Faculty Bibliography

Patients admitted to contemporary cardiac intensive care units (ICUs) increasingly present with complex low-flow states and multisystem organ dysfunction, particularly in the perioperative cardiac surgery setting. This article outlines a systematic, organ-based approach to optimizing extracardiac organ function in patients with shock, emphasizing respiratory, renal, vascular, neurologic, hematologic, gastrointestinal, and endocrine management. Key principles include understanding cardiopulmonary interactions, minimizing secondary organ injury, tailoring supportive therapies to physiologic profiles, and applying ICU best practices. Coordinated, multidisciplinary optimization of noncardiac organ systems is essential to improve surgical candidacy, reduce complications, and enhance outcomes in this high-risk population.

IMPORTANCE/OBJECTIVE:Since the cardiac intensive care unit (CICU) was first introduced into to the medical landscape, patient complexity, comorbidity, and illness severity have increased substantially over time. This evolution has required and informed the cultivation of new tools and an expanding skill set for those who deliver care in these units, and has paved the way for the emergence and growth of a distinct discipline-Critical Care Cardiology. With the genesis of this field and the need to care for comorbid and critically ill patients, numerous questions have been posed, including those related to optimal staffing models, appropriate training pathways, and the development of best practice principles to guide patient management. To address these and other challenges, to foster necessary collaborations, and to galvanize a maturing field, the Society of Critical Care Cardiology (SoCCC) was born. OBSERVATIONS/METHODS:SoCCC was created to provide an independent, yet complementary home for stakeholders within this rapidly growing discipline. Its mission is to address the unique needs and concerns of Critical Care Cardiology through an inclusive approach that prioritizes the development of early career faculty, actively engaging them to help to shape the field and to strengthen its unique practice environment - the CICU. While collaborations with larger professional societies remain essential, an independent subspecialty society like SoCCC intends to capitalize on the historical precedent and experiences shared by other successful organizations, while leveraging its nimble structure to advocate for and advance the needs of its constituency. CONCLUSIONS/RELEVANCE/CONCLUSIONS:While this document primarily details the history and rationale that led to the establishment of SoCCC, it also endeavors to be a practical blueprint to support future leaders who might be considering a new society for their own subspecialty.

BACKGROUND:Contemporary data characterizing older adults admitted to cardiac intensive care units (CICUs) across diverse indications are limited. OBJECTIVES/OBJECTIVE:The objective of the study was to describe the clinical characteristics, critical care therapies, and in-hospital outcomes of older patients admitted to the CICU compared with younger adults. METHODS:The Critical Care Cardiology Trials Network is a multicenter, international registry of CICUs. Between 2017 and 2024, participating centers contributed annual ≥2-month snapshots of consecutive medical CICU admissions. Admissions were categorized into 4 age groups: <65, 65-<75, 75-<85, and ≥85 years. Outcomes included CICU and in-hospital mortality and length of stay. Multivariable models adjusted for sex, illness severity (SOFA score), lactate, and kidney function. RESULTS:Among 35,265 admissions from 50 sites, 44%, 27%, 21%, and 9% were aged <65, 65-<75, 75-<85, and ≥85 years, respectively. Acute coronary syndrome was the most common admission diagnosis among all age groups. Patients aged ≥85 years had the lowest use of mechanical circulatory support (5.5%), which consisted exclusively of intra-aortic balloon pumps. Relative to patients <65 years, adjusted ORs of in-hospital mortality were 1.53 (1.40-1.67) for 65-<75 years, 1.83 (1.67-2.01) for 75-<85 years, and 1.95 (1.72-2.22) for ≥85 years. Among cardiac arrest patients the increase in mortality with age was steeper, reaching 3.09 (2.24-4.26) for patients ≥85 years. CONCLUSIONS:Patients ≥85 years in contemporary CICUs experience survival comparable to those aged 75-<85 years, except in the setting of cardiac arrest. These findings support consideration of factors beyond chronological age in CICU triage and treatment decisions.

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: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: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.