Faculty Bibliography

OBJECTIVE:Patients with primary cardiovascular disorders and comorbidities are commonly admitted to ICUs; however, little is known about the current state of cardiac research being conducted in these adult ICU patients. DESIGN/METHODS:Retrospective analysis. PATIENTS OR SUBJECTS/METHODS:None. SETTING/METHODS:In separate searches of ongoing phase II-IV clinical trials registered with ClinicalTrials.gov and funding grants available in the Canadian Institutes for Health Research funding decision database between 1999 and 2012, we identified all research initiatives focused on adult ICU patients. INTERVENTIONS/METHODS:None. MEASUREMENTS AND MAIN RESULTS/RESULTS:The primary outcome of interest was the proportion of cardiac-specific ICU studies, defined as any involving a cardiac population with a cardiac intervention (or observation for observational analyses) and/or a cardiac outcome. A total of 192 unique studies including adult ICU patients were identified from the ClinicalTrials.gov database. These were most commonly classified as respiratory or ventilation (19%), infectious (14.1%), or neurologic (12.0%) in focus. A total of 105 grants were identified in the Canadian Institutes for Health Research database. Funded studies most commonly addressed respiratory or ventilator questions (18.1%), infectious disease issues (12.4%), or hematological/thrombosis questions (9.5%). Only 4.6% of all ICU studies in ClinicalTrials.gov and 1.9% of all Canadian Institutes for Health Research grants could be considered cardiac. CONCLUSIONS:These findings highlight the relative paucity of cardiac-specific research in the intensive care setting relative to the high prevalence of acute cardiac diseases and comorbidities. This observed disparity warrants timely attention and should lead to meaningful research opportunities aimed at improving the outcomes of critically ill cardiac patients.

Management of the advanced heart failure patient can be complex. Therapies include cardiac transplantation and mechanical circulatory support, as well inotropic agents for the short-term. Despite a growing armamentarium of resources, the clinician must carefully weigh the risks and benefits of each therapy to develop an optimal treatment strategy. While cardiac transplantation remains the only true "cure" for end-stage disease, this resource is limited and the demand continues to far outpace the supply. For patients who are transplant-ineligible or likely to succumb to their illness prior to transplant, ventricular assist device therapy has now become a viable option for improving morbidity and mortality. Particularly for the non-operative patient, intravenous inotropes can be utilized for symptom control. Regardless of the treatments considered, care of the heart failure patient requires thoughtful dialogue, multidisciplinary collaboration, and individualized care. While survival is important, most patients covet quality of life above all outcomes. An often overlooked component is the patient's control over the dying process. It is vital that clinicians make goals-of-care discussions a priority when seeing patients with advanced heart failure. The use of palliative care consultation is well-validated and facilitates these difficult conversations to ensure that all patient needs are ultimately met.

Few innovations in medicine have so convincingly and expeditiously improved patient outcomes more than the development of the left ventricular assist device (LVAD). Where optimal pharmacotherapy once routinely failed those with end-stage disease, the LVAD now offers considerable hope for the growing advanced heart failure population. Despite improvements in mortality, however, mechanical circulatory support is not without its limitations. Those supported with an LVAD are at increased risk of several complications, including infection, bleeding, stroke and arrhythmic events. While once considered benign, ventricular arrhythmias in the LVAD patient are being increasingly recognised for their deleterious influence on patient morbidity and quality of life. In addition, the often multifactorial aetiology to these episodes makes treatment difficult and optimal therapeutic management controversial. Novel strategies are clearly needed to better predict, prevent, and eradicate these arrhythmias in order to allow future generations of heart failure patients to reap the full benefits of LVAD implantation.

Left ventricular assist devices (LVADs) are an increasingly common treatment for end-stage systolic heart failure. However, there are limited data on how to best treat patients pharmacologically after LVAD implantation, resulting in uncertainty about which heart failure medications provide the most benefit. Still, some evidence exists that certain medical therapies can prevent remodeling and improve right ventricular and, possibly, left ventricular function. This article reviews the current literature for medical heart failure therapy in LVAD patients, and possible future treatment strategies.

BACKGROUND:The focused ultrasound examination has become increasingly recognized as a safe and valuable diagnostic tool for the bedside assessment of the critically ill patient. We implemented a dedicated on-site critical care ultrasonography curriculum with the goal of developing a model for teaching ultrasound skills to pulmonary and critical care medicine fellows. METHODS:The program was comprised of blended didactic and bedside sessions in the following topic domains: fundamentals; vascular access and diagnosis; and abdominal, thoracic, and cardiac ultrasonography. Formal knowledge and image acquisition assessments were performed before and after the program to assess success in meeting predefined learning objectives. Participants completed surveys (on Likert scale 1-5) before and after the program to assess their confidence in ultrasonography knowledge and skills as well as their perception as to training effectiveness. RESULTS:The preintervention knowledge and bedside image acquisition scores were 71 and 32%, respectively. The global preintervention score was 51%. All postintervention measures demonstrated significant improvement: 89% (P < 0.01), 86% (P < 0.0001), and 87% (P < 0.0001). Preintervention participant confidence in their ultrasound knowledge and skill was 2.9/5, which improved to 4.3/5 (P = 0.007) after intervention. Participants rated the curriculum as meeting course objectives at a mean of 4.8/5. CONCLUSIONS:At one academic medical center, the knowledge of eight adult pulmonary and critical care fellowship trainees regarding critical care ultrasound was high at baseline; however, bedside image acquisition skills were poor. A dedicated 6-week educational intervention resulted in highly significant improvements in subject knowledge and image acquisition skills. These preliminary results warrant validation studies at other medical centers.

Therapeutic hypothermia (TH) and targeted temperature management improve neurologic recovery, and survival for patients resuscitated from witnessed out-of-hospital ventricular tachycardia (VT) and ventricular fibrillation (VF) cardiac arrest. The American Heart Association recently gave a class IIb recommendation for the use of TH for non-VT/VF and unwitnessed arrests. We explored changes in baseline characteristics, resource use, and outcomes after expanding indications for TH at our institution based on these guidelines. Fifty-six consecutive patients treated with TH for out-of-hospital cardiac arrest were retrospectively evaluated based on whether they received treatment before (protocol 1) or after (protocol 2) broadening inclusion criteria. In protocol 1, TH was indicated after a witnessed VT/VF arrest. In protocol 2, TH was indicated for unwitnessed arrests, pulseless electrical activity, or asystole. Both populations undergoing TH had similarly extensive medical comorbidities and consumed considerable hospital resources. Overall, 64% of the patients from both protocols died in the hospital, although nominally lower mortality was seen in patients treated under protocol 1 compared with protocol 2 (59% vs. 67%, P = 0.57). Lower mortality was observed after VT/VF than after pulseless electrical activity or asystole (47% vs. 93% vs. 56%, P = 0.017). No patient survived following an unwitnessed arrest, and age (odds ratio per 10 years = 2.59; 95% confidence interval, 1.34-4.81) was independently associated with increased mortality. In an evolving field where best practice is still poorly defined, these data, along with future prospective studies in larger populations, should help to enhance care delivery and optimize cost-effectiveness strategies.

BACKGROUND:The cardiac intensive care unit (CICU) has evolved into a complex patient-care environment with escalating acuity and increasing utilization of advanced technologies. These changing demographics of care may require greater clinical expertise among physician providers. Despite these changes, little is known about present-day staffing practices in US CICUs. METHODS AND RESULTS/RESULTS:We conducted a survey of 178 medical directors of ICUs caring for cardiac patients to assess unit structure and physician staffing practices. Data were obtained from 123 CICUs (69% response rate) that were mostly from academic medical centres. A majority of hospitals utilized a dedicated CICU (68%) and approximately half of those hospitals employed a 'closed' unit model. In 46% of CICUs, an intensivist consult was available, but not routinely involved in care of critically ill cardiovascular patients, while 11% did not have a board-certified intensivist available for consultation. Most CICU directors (87%) surveyed agreed that a closed ICU structure provided better care than an open ICU and 81% of respondents identified an unmet need for cardiologists with critical care training. CONCLUSIONS:We report contemporary structural models and staffing practices in a sample of US ICUs caring for critically ill cardiovascular patients. Although most hospitals surveyed had dedicated CICUs, a minority of CICUs employed a 'closed' CICU model and few had routine intensivist staffing. Most CICU directors agree that there is a need for cardiologists with intensivist training and expertise. These survey data reveal potential areas for continued improvement in US CICU organizational structure and physician staffing.