The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital c...The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient's behavior and health care systems contributed to these changes. Understanding the potential factors offers the opportunity to improve future response and save lives.
Best practices in cardiac arrest depend on continuous high-quality chest compressions, appropriate ventilatory management, early defibrillation of shockable rhythms, and identification and treatment of reversible causes....Best practices in cardiac arrest depend on continuous high-quality chest compressions, appropriate ventilatory management, early defibrillation of shockable rhythms, and identification and treatment of reversible causes. Although most patients can be treated according to highly vetted treatment guidelines, some special situations in cardiac arrest arise where additional skills and preparation can improve outcomes. Situations covered in this section involve cardiac arrest in context of electrical injuries, asthma, allergic reactions, pregnancy, trauma, electrolyte imbalances, toxic exposures, hypothermia, drowning, pulmonary embolism, and left ventricular assist devices.
The effectiveness of pharmacologic management of cardiac arrest patients is widely debated; however, several studies published in the past 5 years have begun to clarify some of these issues. This article covers the curre...The effectiveness of pharmacologic management of cardiac arrest patients is widely debated; however, several studies published in the past 5 years have begun to clarify some of these issues. This article covers the current state of evidence for the effectiveness of the vasopressor epinephrine and the combination of vasopressin-steroids-epinephrine and antiarrhythmic medications amiodarone and lidocaine and reviews the role of other medications such as calcium, sodium bicarbonate, magnesium, and atropine in cardiac arrest care. We additionally review the role of β-blockers for refractory pulseless ventricular tachycardia/ventricular fibrillation and thrombolytics in undifferentiated cardiac arrest and suspected fatal pulmonary embolism.
Pulmonary hypertension is a challenging disease entity with various underlying etiologies. The management of patients with pulmonary arterial hypertension (WHO Group 1) remains challenging especially in the critical care...Pulmonary hypertension is a challenging disease entity with various underlying etiologies. The management of patients with pulmonary arterial hypertension (WHO Group 1) remains challenging especially in the critical care setting. With risk of high morbidity and mortality, these patients require a multidisciplinary team approach at a speciality care facility for pulmonary hypertension for comprehensive evaluation and rapid initiation of treatment. For acute decompensated right heart failure, management should concentrate on optimizing preload and after load with use of pulmonary vasodilator therapy. A careful evaluation of specialized situations is required for appropriate treatment response.
Lopez MP, Applefeld W, Miller PE
… +10 more, Elliott A, Bennett C, Lee B, Barnett C, Solomon MA, Corradi F, Sionis A, Mireles-Cabodevila E, Tavazzi G, Alviar CL
This review aims to enhance the comprehension and management of cardiopulmonary interactions in critically ill patients with cardiovascular disease undergoing mechanical ventilation. Highlighting the significance of main...This review aims to enhance the comprehension and management of cardiopulmonary interactions in critically ill patients with cardiovascular disease undergoing mechanical ventilation. Highlighting the significance of maintaining a delicate balance, this article emphasizes the crucial role of adjusting ventilation parameters based on both invasive and noninvasive monitoring. It provides recommendations for the induction and liberation from mechanical ventilation. Special attention is given to the identification of auto-PEEP (positive end-expiratory pressure) and other situations that may impact hemodynamics and patients' outcomes.
Within the cardiac intensive care unit, prompt recognition of severe acute valvular lesions is essential because hemodynamic collapse can occur rapidly, especially when cardiac chambers have not had time for compensatory...Within the cardiac intensive care unit, prompt recognition of severe acute valvular lesions is essential because hemodynamic collapse can occur rapidly, especially when cardiac chambers have not had time for compensatory remodeling. Within this context, optimal medical management, considerations for temporary mechanical circulatory support and decisive treatments strategies are addressed. Fundamental concepts include an appreciation for how sudden changes in flow and pressure gradients between cardiac chambers can impact hemodynamic and echocardiographic findings differently compared to similarly severe chronic lesions, as well as understanding the main causes for decompensated heart failure and cardiogenic shock for each valvular abnormality.
Cardiol Clin
· 2024 May · PMID 38631791
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Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for di...Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
The acute aortic syndromes (AAS) are life-threatening vascular compromises within the aortic wall. These include aortic dissection (AD), intramural hematoma (IMH), penetrating aortic ulcer (PAU), and blunt traumatic thor...The acute aortic syndromes (AAS) are life-threatening vascular compromises within the aortic wall. These include aortic dissection (AD), intramural hematoma (IMH), penetrating aortic ulcer (PAU), and blunt traumatic thoracic aortic injury (BTTAI). While patients classically present with chest pain, the presentation may be highly variable. Timely diagnosis is critical to initiate definitive treatment and maximize chances of survival. In high-risk patients, treatment should begin immediately, even while diagnostic evaluation proceeds. The mainstay of medical therapy is acute reduction of heart rate and blood pressure. Surgical intervention is often required but is informed by patient anatomy and extent of vascular compromise.
Cardiogenic shock is a lethal condition with significant morbidity, characterized by myocardial insults leading to low cardiac output and ensuing systemic hypoperfusion. While mortality rates remain high, we have improve...Cardiogenic shock is a lethal condition with significant morbidity, characterized by myocardial insults leading to low cardiac output and ensuing systemic hypoperfusion. While mortality rates remain high, we have improved upon our recognition and definition of cardiogenic shock, now with an emphasis on defining stages of shock to help guide effective treatment strategies with either pharmacologic or mechanical circulatory support. In this review, the authors summarize these stages as well as discuss indications, function, selection, and troubleshooting of the various temporary mechanical circulatory support devices.
Cardiol Clin
· 2024 May · PMID 38631788
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Acute heart failure (AHF) is a frequent cause of hospitalization around the world and is associated with high in-hospital and post-discharge morbidity and mortality. This review summarizes data on diagnosis and managemen...Acute heart failure (AHF) is a frequent cause of hospitalization around the world and is associated with high in-hospital and post-discharge morbidity and mortality. This review summarizes data on diagnosis and management of AHF from the emergency department to the intensive care unit. While more evidence is needed to guide risk stratification and care of patients with AHF, hospitalization is a key opportunity to optimize evidence-based medical therapy for heart failure. Close linkage to outpatient care is essential to improve post-hospitalization outcomes.
Pericardiocentesis is an important diagnostic and therapeutic procedure. In the setting of cardiac tamponade, pericardiocentesis can rapidly improve hemodynamics, and in cases of diagnostic uncertainty, pericardiocentesi...Pericardiocentesis is an important diagnostic and therapeutic procedure. In the setting of cardiac tamponade, pericardiocentesis can rapidly improve hemodynamics, and in cases of diagnostic uncertainty, pericardiocentesis allows for fluid analysis to aid in diagnosis. In contemporary practice, the widespread availability of ultrasonography has made echocardiographic guidance the standard of care. Additional tools such as micropuncture technique, live ultrasonographic guidance, and adjunctive tools including fluoroscopy continue to advance and enhance procedural efficiency and safety. When performed by experienced operators, pericardiocentesis is a safe, effective, and potentially life-saving procedure.
Intravascular imaging-derived physiology is emerging as a promising tool allowing simultaneous anatomic and functional lesion assessment. Recently, several optical coherence tomography-based and intravascular ultrasound-...Intravascular imaging-derived physiology is emerging as a promising tool allowing simultaneous anatomic and functional lesion assessment. Recently, several optical coherence tomography-based and intravascular ultrasound-based fractional flow reserve (FFR) indices have been developed that compute FFR through computational fluid dynamics, fluid dynamics equations, or machine-learning methods. This review aims to provide an overview of the currently available intravascular imaging-based physiologic indices, their diagnostic performance, and clinical application.
Percutaneous coronary intervention is increasingly guided by coronary physiology and optimized using intravascular imaging. Pressure-based measurements determine the significance of a stenosis using hyperemic or nonhyper...Percutaneous coronary intervention is increasingly guided by coronary physiology and optimized using intravascular imaging. Pressure-based measurements determine the significance of a stenosis using hyperemic or nonhyperemic pressure ratios (eg, the instantaneous wave-free ratio). Intravascular ultrasound and optical coherence tomography provide cross-sectional and longitudinal detail regarding plaque composition and vessel characteristics. These facilitate lesion preparation and optimization of stent sizing and positioning. This review explores the evidence-base and practical aspects of coregistering pressure gradient assessment and intravascular imaging with angiography. We then discuss gaps in the evidence and what is needed to help integrate these techniques into clinical practice.
Coronary physiologic assessment has become a standard of care for patients with coronary atherosclerotic disease. While most attention has focused on pre-interventional physiologic assessment to aid in revascularization...Coronary physiologic assessment has become a standard of care for patients with coronary atherosclerotic disease. While most attention has focused on pre-interventional physiologic assessment to aid in revascularization decision-making, post-interventional physiologic assessment has not been as widely used, despite evidence supporting its role in assessment and optimization of the revascularization procedure. A thorough understanding of such evidence and ongoing studies would be crucial to incorporate post-interventional physiologic assessment into daily practice. Thus, this review provides a comprehensive overview of current evidence regarding the evolving role of physiologic assessment as a functional optimization tool for the entire revascularization process.
Modern coronary intervention requires integration of angiographic, physiologic, and intravascular imaging. This article describes the use and techniques needed to understand coronary physiology pullback data and how use...Modern coronary intervention requires integration of angiographic, physiologic, and intravascular imaging. This article describes the use and techniques needed to understand coronary physiology pullback data and how use it to make revascularization decisions. The article describes instantaneous wave-free ratio, fractional flow reserve, and the data that support their use and how they differ when used in tandem disease. Common practical mistakes and errors are discussed together with a brief review of the limited published research data.
During the past 30 years, fractional flow reserve (FFR) has moved from animal models to class IA recommendations in guidelines. However, the FLOWER-MI, RIPCORD-2, FUTURE, and FAME 3 trials in 2021 were "negative"-has FFR...During the past 30 years, fractional flow reserve (FFR) has moved from animal models to class IA recommendations in guidelines. However, the FLOWER-MI, RIPCORD-2, FUTURE, and FAME 3 trials in 2021 were "negative"-has FFR exceeded its expiration date? We critically examine these randomized trials in order to draw insights not just about FFR but also about study design and interpretation. Are all randomized trials created equal? No, rather we must focus on discordant decisions between angiography and FFR and highlight clinical endpoints that can be improved by percutaneous coronary intervention instead of medical therapy.
Fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) provide an important clinical tool to evaluate the hemodynamic significance of coronary lesions. However, these indices have major limitations. As th...Fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) provide an important clinical tool to evaluate the hemodynamic significance of coronary lesions. However, these indices have major limitations. As these indices are meant to be surrogates of coronary flow, clinical scenarios such as aortic stenosis (with increased end-systolic and end-diastolic pressures) or atrial fibrillation (with significant beat-to-beat cardiac output variability) can have significant effect on the accuracy and reliability of these hemodynamic indices. Here, we provide a comprehensive evaluation of the pitfalls, limitations, and strengths of FFR and NHPRs in common clinical scenarios paired with coronary artery disease.
The use of coronary physiology allows for rational decision making at the time of PCI, contributing to better patient outcomes. Yet, coronary physiology is only one aspect of optimal revascularization. State-of-the-art P...The use of coronary physiology allows for rational decision making at the time of PCI, contributing to better patient outcomes. Yet, coronary physiology is only one aspect of optimal revascularization. State-of-the-art PCI must also consider other important aspects such as intracoronary imaging guidance and specific procedural expertise, as tested in the SYNTAX II study. In this review, we highlight the technical aspects pertaining to the use of physiology as used in that trial and offer a glimpse into the future with emerging physiologic metrics, including functional coronary angiography, which have already established themselves as useful indices to guide decision making.
Coronary microvascular dysfunction (CMD) is a common cause of ischemia but no obstructive coronary artery disease that results in an inability of the coronary microvasculature to meet myocardial oxygen demand. CMD is cha...Coronary microvascular dysfunction (CMD) is a common cause of ischemia but no obstructive coronary artery disease that results in an inability of the coronary microvasculature to meet myocardial oxygen demand. CMD is challenging to diagnose and manage due to a lack of mechanistic research and targeted therapy. Recent evidence suggests we can improved patient outcomes by stratifying antianginal therapies according to the diagnosis revealed by invasive assessment of the coronary microcirculation. This review article appraises the evidence for management of CMD, which includes treatment of cardiovascular risk, antianginal therapy and therapy for atherosclerosis.