Faculty Bibliography

Cardiogenic shock (CS) remains a high-mortality condition that demands rapid diagnosis, coordinated multidisciplinary management, and timely initiation of mechanical circulatory support. As more institutions implement dedicated CS teams, substantial heterogeneity has emerged in how these teams are structured, activated, and sustained. To better characterize this variability and begin defining the components of an optimal CS team, the Society of Critical Care Cardiology (SoCCC), in partnership with the Society for Cardiovascular Angiography and Interventions (SCAI), convened the Inaugural Cardiogenic Shock Teams Think Tank. Held on October 17, 2024, as a pre-conference program to SCAI SHOCK 2024 in Washington, DC, the meeting brought together national leaders in CS care, mechanical circulatory support, and resuscitation to identify shared challenges and propose practical solutions. This manuscript summarizes key insights from this inaugural Think Tank, which represents the first in an ongoing series of collaborative efforts aimed at informing the standardization and optimization of CS teams nationwide. Specifically, we review the ideal composition and core competencies of a CS team; the rationale and emerging evidence supporting dedicated team-based CS care; activation algorithms and operational workflows; and common barriers to establishing and sustaining such teams. We also outline future directions and opportunities to strengthen collaborative infrastructure, refine clinical pathways, and enhance the reliability, responsiveness, and effectiveness of cardiogenic shock teams across diverse healthcare settings.

BACKGROUND:The cardiac intensive care unit (CICU) has evolved into a complex care environment for critically ill patients with cardiac and noncardiac diseases. OBJECTIVES/OBJECTIVE:Our goal was to describe contemporary CICU care delivery and the role of cardiologists therein. METHODS:The American College of Cardiology administered a 42-item survey to U.S. and Canadian CICU-focused cardiologists designed to capture models of care delivery and workforce demographics. RESULTS:The survey was distributed by email to 1,085 U.S. and Canadian CICU cardiologists. The response rate was 20%, yielding a final sample of 166 after excluding trainees and those not board-certified or board-eligible in cardiology. The majority were from medium (34%) or large (64%) academic (81%) medical centers. Fifty-three percent reported working in high-intensity care models and 61% reported that their CICU was dedicated exclusively to medical cardiology patients. Critical care medicine-boarded physicians contributed to care through consultative (53%), comanagement (29%), and/or primary roles (44%). Subspecialization beyond cardiology was common (82%), with critical care medicine being most frequent (46%), followed by echocardiography (37%), advanced heart failure (21%), and interventional cardiology (16%). Limitations include the low survey response rate, which raises the risk of selection bias. CONCLUSIONS:This study provides insight into the current landscape of cardiac critical care delivery in North America, highlighting wide variation in staffing models, subspecialty training, and clinical practice. Our findings highlight growing trends toward high-intensity staffing models that incorporate critical care medicine-boarded physicians in consultative, comanagement, and or primary roles.

BACKGROUND:The ARIES-HM3 trial demonstrated the safety and effectiveness of aspirin elimination from the antithrombotic regimen after HeartMate 3 (HM3) LVAD implantation. We explored the interaction of atrial fibrillation, diabetes mellitus and obesity [AF/DM/Ob] with aspirin elimination on hemocompatibility-related adverse events (HRAE) at 1 year post-implant. METHODS:level suppression. RESULTS:levels. CONCLUSION/CONCLUSIONS:Among ARIES-HM3 trial patients with AF/DM/Ob, either comorbidity alone or in combination, did not alter the safety or observed effect size on bleeding reduction with aspirin elimination in patients implanted with the HM3 LVAD.

BACKGROUND:Patients with cardiohepatic syndrome are at higher risk of adverse outcomes in the cardiac intensive care unit. We hypothesized that cardiohepatic syndrome phenotypes would exhibit differences in their clinical and transthoracic echocardiogram hemodynamic profiles, portending a higher risk of mortality. METHODS:We included unique CICU patients with an admission diagnosis of heart failure from 2007 to 2018 with available data for 1 or more admission liver function tests. Echocardiographic variables were extracted from patients who had a transthoracic echocardiogram within 1 day of admission. We assigned patients to 1 of 4 mutually exclusive cardiohepatic syndrome phenotype groups: normal, hepatocellular, cholestasis, and combined. RESULTS:=0.002). CONCLUSIONS:Cardiohepatic syndrome phenotypes are associated with distinct echocardiographic profiles. Patients with the combined cardiohepatic syndrome phenotype were at highest risk of mortality, particularly if this was combined with poor cardiac function.

Patients hospitalized with acute heart failure (HF) may experience diuretic resistance and require an add-on agent despite increasing loop diuretic dosage. While randomized controlled trials (RCTs) have compared add-on therapy to loop diuretics only, sparse literature exists on direct comparisons between various add-on therapies. We performed a systematic review and network meta-analysis of RCTs to assess the efficacy and safety of different diuretic add-on therapies in patients hospitalized with acute HF. Any RCT evaluating the effect of add-on diuretic therapy in patients hospitalized with acute HF was eligible for inclusion. A complete search of EMBASE and PubMed was conducted until March 29, 2024. The primary outcome was the hospital length of stay. Data was pooled using a random-effects model for direct comparisons. A network meta-analysis using frequentist methods was performed under random-effects multiple treatment comparisons. We assessed ranking probability by surface under the cumulative ranking curve (SUCRA). Of the 1,103 references, 29 RCTs enrolling 8,362 patients met the eligibility and were included. For the direct comparisons, there was no significant difference in hospital length of stay (MD -0.42, 95% CI= -0.87,0.02). Ranking probability based on SUCRA indicated that acetazolamide had the highest likelihood of being the best treatment for shorter hospital length of stay (SUCRA, 0.89), followed by SGLT2i (SUCRA, 0.70). The certainty of estimates for all outcomes ranged from moderate to very low. In conclusion, the efficacy of add-on therapy was associated with reduced hospital length of stay. Albeit uncertain, the results from NMA provide initial evidence suggesting there may be optimal treatment strategies to decongest patients with heart failure to achieve and maintain euvolemia. However, well-designed direct comparison RCTs are needed to increase the certainty of the estimates. Protocol registered in PROSPERO (CRD42023476669).

The contemporary cardiac intensive care unit (CICU) serves as a dynamic educational environment for postgraduate physicians and advanced practice provider trainees. This educational experience, however, can vary substantially between institutions. Specific learning objectives are needed to standardize the educational experience for trainees rotating through the contemporary CICU. We provide a structured, CICU-based curriculum emphasizing exposure to a wide spectrum of cardiovascular pathologies and incorporating learner progression from early to advanced stages, adaptable to a variety of training pathways. Prioritizing standardized educational objectives during training will better prepare learners for further subspecialty training programs and the complexities of modern CICU-based practice.

BACKGROUND:Cardiac intensive care units (CICUs) typically manage critically ill patients with acute cardiovascular (CV) conditions but may serve patients with non-CV critical illness when medical ICU (MICU) beds are unavailable. OBJECTIVES/OBJECTIVE:The purpose of this study was to characterize the clinical profiles and outcomes of "MICU overflow" admissions to the CICU. METHODS:We used the Critical Care Cardiology Trials Network registry to compare CICU admissions without acute or major cardiac issues (MICU overflow) vs those with acute CV illness. RESULTS:Among 19,912 CICU admissions (2018-2023), 923 (4.6%) were MICU overflow, ranging from 0% to 26% across centers. MICU overflow admissions had higher median Sequential Organ Failure Assessment scores than CV admissions (5 vs 3; P < 0.001) and more commonly presented with respiratory failure (50.5% vs 24.6%; P < 0.001) and noncardiogenic shock (30.9% vs 8.0%; P < 0.001). MICU overflow status was associated with similar ICU mortality (adjusted OR: 1.13; 95% CI: 0.90-1.43; P = 0.28) but higher hospital mortality (adjusted OR: 1.80; 95% CI: 1.48-2.19; P < 0.001) vs CV illness. In units where the CICU team managed all admissions, ICU mortality was higher among MICU overflow admissions than CV admissions (adjusted OR: 1.35; 95% CI: 1.02-1.80; P = 0.04), whereas in CICUs where off-unit MICU teams managed MICU overflow admissions, this mortality imbalance was not present (adjusted OR: 0.72; 95% CI: 0.47-1.11; P = 0.14; P interaction = 0.02). CONCLUSIONS:MICU overflow admissions constitute a meaningful proportion of the CICU population and present with more multisystem disease and experience higher hospital mortality compared with acute CV admissions, underscoring the need for multidisciplinary CICU teams with broad critical care expertise.