Faculty Bibliography

BACKGROUND:Hospital ownership type may influence acute cardiovascular disease disparities that persist across the U.S. We examined associations between hospital ownership type and in-hospital and readmission outcomes for STEMI hospitalizations. METHODS:We performed a retrospective cohort study of hospitalizations for STEMI using the National Readmissions Database (2016-2022). Hospitals were categorized as nonprofit, for-profit, or public. Outcomes included in-hospital mortality and 90-day readmission for acute coronary syndrome, heart failure, cardiovascular, and all causes. Associations were assessed using multivariable logistic and Cox proportional hazards regression, adjusting for patient, hospitalization, and hospital-level characteristics. RESULTS:Of 610,427 STEMI hospitalizations, 460,451 (75.4%) were at nonprofit, 88,965 (14.6%) at for-profit, and 61,011 (10.0%) at public hospitals. Compared with nonprofit hospitals, for-profit hospitals (aOR 1.09, 95% CI 1.05-1.13) and public hospitals (aOR 1.17, 95% CI 1.12-1.22) were each associated with higher odds of in-hospital mortality. For-profit hospitals were associated with higher risk of 90-day readmission for acute coronary syndrome (aHR 1.15, 95% CI 1.10-1.21), heart failure (aHR 1.08, 95% CI 1.03-1.13), cardiovascular (aHR 1.08, 95% CI 1.05-1.12), and all causes (aHR 1.13, 95% CI 1.10-1.16) relative to nonprofit hospitals. Public hospitals were associated with higher risk of 90-day readmission for heart failure (aHR 1.08, 95% CI 1.02-1.13) relative to nonprofit hospitals. CONCLUSIONS:For-profit and public hospitals were associated with higher in-hospital mortality and 90-day readmission for various causes compared with nonprofit hospitals. These findings suggest that hospital-level factors may contribute to disparities in STEMI outcomes and warrant further investigation.

BACKGROUND/UNASSIGNED:The paucity of data to guide selection of specific vasoactive agents in patients with cardiogenic shock (CS) may lead to variability in practice patterns. The level of variability and specific factors that are associated with the use of vasoactive medications and inodilators have not been previously described. METHODS/UNASSIGNED:The CCCTN (Critical Care Cardiology Trials Network) is an international, multicenter network of cardiac intensive care units (CICUs) coordinated by the TIMI Study Group. This analysis included CICU admissions for CS from 2019 to 2023. Variation in the use of inodilator treatment (dobutamine/milrinone) was assessed with multivariable mixed-effects logistic modeling. RESULTS/UNASSIGNED:increase). No individual measurable institution-level factors (eg, transplant center) were associated with variability in inodilator use. In mixed-effects logistic modeling, 45.7% of variation in inodilator use was attributed to patient-level factors and 22.7% to the random effect of individual CICU centers. Similarly, 35.3% of variation in the use of dobutamine versus milrinone was attributed to patient-level factors and 32.6% to the random effect of individual CICU centers. CONCLUSIONS/UNASSIGNED:There is significant variation in vasoactive treatment and inodilator use in CS. Variation in inodilator use was associated with patient-level factors and with substantial individual CICU practice variation. Such variability underscores the need for additional high-quality evidence to guide vasoactive treatment strategies in CS.

BACKGROUND:In patients with intermediate-risk pulmonary embolism (PE), there are limited tools to assess therapeutic response following catheter-based intervention. This study evaluates pulmonary vascular resistance (PVR), an invasive marker of right ventricular (RV) afterload, and its prognostic significance in acute PE. METHODS:This single-center retrospective study included patients from October 2020-May 2025 with intermediate-high risk PE undergoing large bore mechanical thrombectomy (LBMT) with pulmonary artery catheter-derived hemodynamic indices obtained pre- and post-procedure. The primary objective was to evaluate the effect of LBMT on PVR. Secondary objective was to evaluate the predictors of post procedure elevated PVR (defined as PVR >2 Wood units, WU) and its effect on clinical composite outcome (PE mortality, resuscitated cardiac arrest, hemodynamic instability and 90-day hospital readmission) and hospital length of stay (LOS). RESULTS:A total of 131 patients were included. Following LBMT, median PVR decreased significantly from 2.9 to 1.8 WU (p < 0.001), with greater reduction in patients with higher baseline PVR (baseline PVR tertile 3 to 1: 50% vs. 40% vs. 20%; p < 0.001). Persistently elevated post procedure PVR (>2 WU) was seen in 43.6% of patients. However, the incidence of post-procedure severe PVR >5 WU was extremely low (11.5% pre-procedure, 0.8% post-procedure). Multivariable predictors of elevated post-procedural PVR were pre-procedural mean pulmonary artery pressure (OR: 1.07, 95% CI 1.01-1.14, p = 0.026) and pre-procedural PVR (OR 2.20, 95% CI: 1.20-4.04, p = 0.011). In an age and sex adjusted model, elevated post-procedure PVR was associated with a longer in-hospital LOS of 4.2 days (95% CI: 0.60-7.88; p = 0.023) and a 4-fold higher risk of the composite outcome (20.7% vs 5.3%, adjusted hazard ratio: 4.02, 95% CI: 1.28-12.61, p = 0.017). CONCLUSIONS:In patients with intermediate-high risk PE, LBMT significantly reduced PVR and may be a valuable hemodynamic marker of disease severity and treatment response. Elevated post-procedural PVR identified patients at increased risk of adverse outcomes.

BACKGROUND:Cardiogenic shock (CS) can be complicated by severe valvular heart disease (VHD). We analyzed cardiac intensive care unit (CICU) admissions according to VHD status. METHODS AND RESULTS/RESULTS:The Critical Care Cardiology Trials Network is a multicenter network of tertiary CICUs. Centers contributed data from consecutive admissions during 2-month annual snapshots from 2017-2023. CS admissions were classified as having CS attributed to VHD, CS with noncausative VHD or CS without severe VHD. Demographics and therapies were compared. Unadjusted and adjusted odds ratios for in-hospital mortality were calculated. We analyzed 5242 admissions with CS (4.1% attributed to VHD, 18.8% with noncausative VHD, 77.1% without severe VHD). Mitral regurgitation (32.1%) and aortic stenosis (27.9%) were the most common pathologies in CS attributed to VHD. Admissions with CS attributed to VHD more commonly had LVEF ≥ 40% on admission (present in 62.8%, 22.6% and 15.1%, respectively; P < 0.001). Valve intervention was performed in 32.1% of those with CS attributed to VHD. Unadjusted in-hospital mortality in admissions with CS attributed to VHD was 40.0%, compared to 33.4% and 30.3% in the other groups. CONCLUSIONS:VHD is the underlying cause of CS in a minority of CICU admissions but is associated with high in-hospital mortality rates.

Suboptimal care for ST-elevation myocardial infarction (STEMI) in low- and middle-income countries is a significant problem. Registries from Latin America, Africa, and Asia show that <65% of patients receive reperfusion therapy, and widespread treatment delays and a lack of access to optimal therapies lead to preventable deaths and complications. While current guidelines provide a blueprint for care, their implementation in low-resource settings requires specific guidance that considers geographical, logistical, and economic realities. This clinical consensus offers a new framework for developing STEMI care systems in these countries. We propose a flexible, three-model pathway, based on the initiatives such as STEMI India and Stent - Save a Life. The models include a fibrinolysis model, a pharmaco-invasive strategy model, and a primary percutaneous coronary intervention (PCI) model. This approach emphasizes adaptability, allowing local STEMI systems to be tailored to specific circumstances. The framework also addresses specific, common challenges, such as delayed access to primary PCI, reperfusion in patients with cardiogenic shock and expected delayed PCI, fibrinolysis in patients with a high risk of bleeding, and the absence of fibrin-specific fibrinolytics, catheterization labs, or reperfusion therapies at all. The consensus also highlights the importance of continuous improvement, patient education, and adopting secondary prevention strategies. Ultimately, this framework is designed to help healthcare providers and leaders in developing countries improve their regional STEMI care systems.

BACKGROUND/UNASSIGNED:The Society for Cardiovascular Angiography & Intervention (SCAI) SHOCK stages classification schema risk-stratifies patients with cardiogenic shock (CS). The updated 2022 SCAI SHOCK stages removed the use of respiratory support, either noninvasive (NIV) or invasive mechanical ventilation (IMV), as a criterion. We sought to investigate the impact of receiving respiratory support on in-hospital mortality for patients with CS stratified by SCAI SHOCK stages. METHODS/UNASSIGNED:Utilizing a nationally representative database, adults aged ≥18 years admitted from 2015 to 2023 with a diagnosis of CS were used to assess for the association between respiratory support, either NIV or IMV, on the first day of admission, with in-hospital mortality stratified by SCAI SHOCK stages B through E. We utilized inverse probability treatment weighting, adjusting for demographic characteristics, comorbidities, hospital characteristics, and vasoactive/mechanical circulatory support. RESULTS/UNASSIGNED:We identified 317,325 patients with CS, including 2.4%, 39.0%, 34.2%, and 24.5% with SCAI stages B through E, respectively. Respiratory support was utilized in 38.0% (n = 120,594) of patients, with 5.4% receiving NIV, 33.8% receiving IMV, and 1.1% receiving both on the first day of admission. After inverse probability treatment weighting, respiratory support use remained associated with an increased mortality overall (weighted mean mortality increase of 18.3%; 95% CI, 17.9%-18.7%), when stratified by each SCAI SHOCK stage and in several key sensitivity analyses. CONCLUSIONS/UNASSIGNED:Compared with patients not receiving respiratory support, the use of respiratory support was associated with an increased mortality for each SCAI stage of CS and could be a simple, easily identifiable CS risk modifier.

In patients experiencing acute heart failure, acute cardiogenic pulmonary edema (ACPE) can emerge due to a surge in pulmonary capillary hydrostatic pressure. This escalation triggers a fluid build-up beyond the lymphatic interstitial drainage system's ability to eliminate, leading to a swift increase in interstitial and alveolar fluid volumes. Such accumulation subsequently results in intrapulmonary shunting and an advancing state of respiratory failure. Contemporary evidence hints at the potential of non-invasive ventilation (NIV) to cut back on the reintubation rate, along with the reduction of ICU and hospital mortality rates, particularly among patients scheduled for extubation. The aim of this review is to critically analyze the existent body of evidence concerning the application of NIV in managing ACPE. It seeks to explore the practical aspects of utilizing NIV within an emergency department environment, addressing crucial considerations such as patient selection, commencement of treatment, monitoring protocols, problem-solving strategies, and weaning processes. In addition, our review will also explore the data available on high flow nasal cannula, a relatively recent therapeutic intervention, discussing its role and effectiveness in treating respiratory insufficiency associated with ACPE.

BACKGROUND:This study evaluates the prognostic utility of the RV/LV diameter ratio in predicting low cardiac index (CI) in patients with acute intermediate-risk PE. METHODS:We conducted a retrospective analysis of 112 patients with acute PE who underwent catheter-based therapies. The RV/LV diameter ratio was measured from standard axial views on computed tomography pulmonary angiogram (CTPA). Multivariable regression models were used to assess the relationship between the RV/LV diameter ratio and invasive hemodynamic parameters. RESULTS:lower cardiac index (p = 0.002). The RV/LV ratio demonstrated moderate sensitivity (64.5 %) and high specificity (84.2 %) for predicting low cardiac index. CONCLUSION/CONCLUSIONS:The RV/LV diameter ratio offers real-time risk stratification and is a predictor of low cardiac index in patients with acute PE.