Faculty Bibliography

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.

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.

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).

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.

BACKGROUND:Mixed cardiogenic and septic shock has been shown to have a higher mortality than cardiogenic shock alone and presents a unique hemodynamic phenotype. OBJECTIVES/OBJECTIVE:This study aimed to evaluate whether higher circulatory support with veno-arterial extracorporeal life support (VA-ECLS) was associated with increased survival to discharge in patients with mixed shock. METHODS:flow) circulatory support on VA-ECLS at 24 hours post-ECLS initiation. RESULTS:A total of 452 patients supported with VA-ECLS with mixed shock were identified. Overall mortality was 63% (n = 285). Older age (adjusted OR [aOR]: 1.02; 95% CI: 1.01-1.04; P < 0.001), pre-extracorporeal membrane oxygenation cardiac arrest (aOR: 1.71; 95% CI: 1.11-2.65; P = 0.016), and baseline Charlson Comorbidity Index (aOR: 1.13; 95% CI: 1.01-1.28; P = 0.043) were associated with increased mortality. Patients receiving higher VA-ECLS support at 24 hours were numerically more likely to survive to discharge (42.6% vs 33.8%, P = 0.063). When evaluated as a continuous variable, higher VA-ECLS flow at 24 hours was associated with an aOR of 1.31 (95% CI: 0.87-1.97; P = 0.19) for survival to discharge. CONCLUSIONS:Patients with mixed shock requiring VA-ECLS have a high mortality. Patients with mixed shock receiving higher support at 24 hours had a trend toward increased survival to discharge compared to those with lower support. These results are hypothesis-generating, and further studies are needed.

BACKGROUND:Acute decompensated heart failure (HF) can progress to cardiogenic shock, and patients with cancer are at an increased risk of HF compared to patients without cancer. However, limited data exist on outcomes of patients admitted for HF-related cardiogenic shock (HF-CS) with cancer versus without cancer. METHODS:Adult patients admitted for HF-CS between 2014-2020 were identified using the National Readmission Database. Propensity score matching (PSM) was used to match 1 patient with cancer to 10 patients without cancer. Primary outcomes were in-hospital death, major bleeding, and thrombotic complications. Exploratory outcomes were 90-day readmission rates among patients who survived initial hospitalization. Temporal trends were also explored. RESULTS:Of 137,316 admissions for HF-CS, 7,306 (5.3%) had active cancer. After PSM, patients with cancer had increased odds of in-hospital death (OR 1.12, 95% CI 1.06 - 1.18), thrombotic complications (OR 1.12, 95% CI 1.03 - 1.21), and major bleeding (OR 1.23, 95% CI 1.17 - 1.31) compared to patients without cancer, with risks differing by cancer type. In exploratory analyses, rates of readmission were similar for patients with and without cancer. From 2014-2020, patients with cancer had no significant change in in-hospital mortality (ptrend = 0.43), while patients without cancer had decreased mortality over time (ptrend < 0.001). CONCLUSIONS:Among patients admitted for HF-CS, patients with cancer are at increased risk of in-hospital death, thrombotic complications, and major bleeding compared to patients without cancer. Future studies are needed to guide nuanced evaluation and management of this population to improve outcomes.