Vallabhajosyula, Saraschandra

Despite advances in drug and device technology, health care delivery, and research infrastructure, cardiogenic shock (CS) continues to have nearly 50% in‐hospital mortality. In patients with CS, both the initial severity of Society for Cardiovascular Angiography and Intervention CS and its subsequent trajectory predicts the clinical outcomes. Accordingly, delayed initial recognition and failure to escalate or deescalate treatment can significantly affect the outcomes of CS. Traditional assessment methods, with the exception of blood pressure measurement, require a high index of suspicion and frequent reassessment by the clinical team. Electronic medical record‐based detection has been successfully implemented in acute and critical care patients with septic shock and acute kidney injury. In CS, electronic medical record‐based studies have largely focused on using models to predict outcomes in patients with CS, with limited data on electronic medical record‐based tools to assist with either predicting CS or providing real time alerts when escalation or de‐escalation might be indicated. Early detection of CS may be associated with detection of earlier Society for Cardiovascular Angiography and Intervention stages of CS and potentially prevent deterioration to higher stages. In this review, we seek to highlight a blueprint for electronic medical record‐based detection of CS that focuses on reproducibility, convenience, clinical decision support, and research aspects.

ABSTRACT Background Acute pulmonary embolism (PE) is one of the most common causes of cardiovascular mortality in the United States. Significant variations in the management of various cardiovascular conditions have previously been reported, but this has been poorly elucidated for pulmonary embolism. Methods During 2016–2020, adult (≥ 18 years) nonelective admissions with PE, admitted to Northeast, Midwest, South, and West geographic regions were identified using the National Inpatient Sample. Outcomes of interest included in‐hospital mortality, utilization of PE therapies, non‐cardiac organ support, total hospitalization costs, and hospitalization duration. Results In this 5‐year duration, 904,260 admissions were identified ‐ Northeast, Midwest, South, and West had 166,050 (18.3%), 225,680 (24.9%), 350,160 (38.7%), and 162,370 (17.9%) admissions, respectively. On average, admissions to the Northeast were less comorbid, from a higher socioeconomic status, privately insured, and more commonly admitted to urban teaching and medium‐sized hospitals (all p < 0.001). The Northeast region also had the lowest rates of definitive PE therapies except surgical thrombectomy. In comparison to the Northeast, the in‐hospital mortality was higher in the South and West and lower in the Midwest region (3.1% vs 2.8% vs 3.2% vs 3.3%, p < 0.001). However, on adjusted analysis with Northeast as a reference, in‐hospital mortality was noted to be lower in the Midwest (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.67−0.84; p < 0.001), South (aOR 0.89, 95% CI 0.80−0.98; p < 0.05), and the West (aOR 0.88, 95% CI 0.78−0.99; p < 0.05). Conclusion In this study, we noted significant heterogeneity in the management and outcome of pulmonary embolism across various regions of the United States.

ABSTRACT There are limited and conflicting data on sex and urban‐rural disparities in outcomes of patients with pulmonary embolism (PE) in the reproductive age group. Our object was to assess sex disparities in the reproductive age group cohort. All adult non‐elective admissions in the reproductive age group (18−49 years) with a primary diagnosis of PE and with no missing sex/age data were identified using the National Inpatient Sample. Females and males were stratified into rural and urban location based on hospital information. Outcomes of interest included in‐hospital mortality, complication rates, variations in management, total hospitalization costs, and length of stay. During 01/01/2016 to 12/31/2020, 180,898 PE admissions aged 18−49 years were identified (rural—12,319 [6.8%]). Females comprised 54.8% and 55.1% of the rural and urban cohorts, respectively. Overall, compared to males, females in urban and rural regions had largely comparable rates of definitive PE interventions, except lower rates of catheter directed therapy (4.7 vs. 3.6%, p < 0.001) in females admitted to urban hospitals. Despite younger age, higher comorbidity, and lower utilization of PE interventions, females in both regions had similar unadjusted in‐hospital mortality (rural 1.1% vs. 1.0%; p = 0.93 and urban 1.8% vs. 1.7%; p = 0.78) and hospitalization costs compared to males. In conclusion, females of reproductive age group had comparable in‐hospital outcomes to males in both urban and rural areas. Females in urban areas had lower utilization of advanced PE interventions, potentially indicating selective management strategies in different settings.

Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time‐sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well‐resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team‐based approach to care (the “shock team”) has been advocated by professional societies and implemented at select high‐volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative—akin to the successful Pulmonary Embolism Response Team Consortium—with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.

OBJECTIVES: A number of trials related to critical care pharmacotherapy were published in 2022. We aimed to summarize the most influential publications related to the pharmacotherapeutic care of critically ill patients in 2022. DATA SOURCES: PubMed/Medical Literature Analysis and Retrieval System Online and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update. STUDY SELECTION: Randomized controlled trials, prospective studies, or systematic review/meta-analyses of adult critically ill patients assessing a pharmacotherapeutic intervention and reporting clinical endpoints published between January 1, 2022, and December 31, 2022, were included in this article. DATA EXTRACTION: Articles from a systematic search and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update were included and stratified into clinical domains based upon consistent themes. Consensus was obtained on the most influential publication within each clinical domain utilizing an a priori defined three-round modified Delphi process with the following considerations: 1) overall contribution to scientific knowledge and 2) novelty to the literature. DATA SYNTHESIS: The systematic search and Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update yielded a total of 704 articles, of which 660 were excluded. The remaining 44 articles were stratified into the following clinical domains: emergency/neurology, cardiovascular, gastroenterology/fluids/nutrition, hematology, infectious diseases/immunomodulation, and endocrine/metabolic. The final article selected from each clinical domain was summarized following a three-round modified Delphi process and included three randomized controlled trials and three systematic review/meta-analyses. Article topics summarized included dexmedetomidine versus other sedatives during mechanical ventilation, beta-blocker treatment in the critically ill, restriction of IV fluids in septic shock, venous thromboembolism prophylaxis in critically ill adults, duration of antibiotic therapy for Pseudomonas aeruginosa ventilator-associated pneumonia, and low-dose methylprednisolone treatment in severe community-acquired pneumonia. CONCLUSIONS: This concise review provides a perspective on articles published in 2022 that are relevant to the pharmacotherapeutic care of critically ill patients and their potential impact on clinical practice.

Background: Transcatheter pulmonary valve implantation (TPVI) is an effective non-surgical treatment method for patients with right ventricle outflow tract dysfunction. The Medtronic Melody and the Edwards Sapien are the two valves approved for use in TPVI. Since TPVI patients are typically younger, even a modest annual incidence of infective endocarditis (IE) is significant. Several previous studies have shown a growing risk of IE after TPVI. There is uncertainty regarding the overall incidence of IE and differences in the risk of IE between the valves. Methods: A systematic search was conducted in the MEDLINE, EMBASE, PubMed, and Cochrane databases from inception to 1 January 2023 using the search terms ‘pulmonary valve implantation’, ‘TPVI’, or ‘PPVI’. The primary outcome was the pooled incidence of IE following TPVI in Melody and Sapien valves and the difference in incidence between Sapien and Melody valves. Fixed effect and random effect models were used depending on the valve. Meta-regression with random effects was conducted to test the difference in the incidence of IE between the two valves. Results: A total of 22 studies (including 10 Melody valve studies, 8 Sapien valve studies, and 4 studies that included both valves (572 patients that used the Sapien valve and 1395 patients that used the Melody valve)) were used for the final analysis. Zero IE incidence following TPVI was reported by eight studies (66.7%) that utilized Sapien valves compared to two studies (14.3%) that utilized Melody valves. The pooled incidence of IE following TPVI with Sapien valves was 2.1% (95% CI: 0.9% to 5.13%) compared to 8.5% (95% CI: 4.8% to 15.2%) following TPVI with Melody valves. Results of meta-regression indicated that the Sapien valve had a 79.6% (95% CI: 24.2% to 94.4%, p = 0.019; R2 = 34.4) lower risk of IE incidence compared to the Melody valve. Conclusions: The risk of IE following TPVI differs significantly. A prudent valve choice in favor of Sapien valves to lower the risk of post-TPVI endocarditis may be beneficial.

AbstractBackgroundThere are limited national‐level data on the contemporary practices of mechanical circulatory support (MCS) use in acute myocardial infarction‐cardiogenic shock (AMI‐CS).MethodsWe utilized the Healthcare Cost and Utilization Project‐National/Nationwide Inpatient Sample data (2005–2017) to identify adult admissions (>18 years) with AMI‐CS. MCS devices were classified as intra‐aortic balloon pump (IABP), percutaneous left ventricular assist devices (pLVAD), or extracorporeal membrane oxygenation (ECMO). We evaluated trends in the initial device used (IABP alone, pLVAD alone or ≥2 MCS devices), device escalation, bridging to durable LVAD/heart transplantation, and predictors of in‐hospital mortality and device escalation.ResultsAmong 327,283 AMI‐CS admissions, 131,435 (40.2%) had an MCS device placed with available information on timing of placement. IABP, pLVAD, and ≥2 MCS devices were used as initial device in 120,928 (92.0%), 8202 (6.2%), and 2305 (1.7%) admissions, respectively. Most admissions were maintained on the initial MCS device with 1%–1.5% being escalated (IABP to pLVAD/ECMO, pLVAD to ECMO). Urban, medium, and large‐sized hospitals and acute multiorgan failure were significant independent predictors of MCS escalation. In admissions receiving MCS, escalation of MCS device was associated with higher in‐hospital mortality (adjusted odds ratio: 1.56, 95% confidence interval: 1.38–1.75; p < 0.001). Admissions receiving durable LVAD/heart transplantation increased over time in those initiated on pLVAD and ≥2 MCS devices, resulting in lower in‐hospital mortality.ConclusionsIn this 13‐year study, escalation of MCS in AMI‐CS was associated with higher in‐hospital mortality suggestive of higher acuity of illness. The increase in number of durable LVAD/heart transplantations alludes to the role of MCS as successful bridge strategies.

ABSTRACT Sepsis is a multisystem disease process, which constitutes a significant public health challenge and is associated with high morbidity and mortality. Among other systems, sepsis is known to affect the cardiovascular system, which may manifest as myocardial injury, arrhythmias, refractory shock, and/or septic cardiomyopathy. Septic cardiomyopathy is defined as the reversible systolic and/or diastolic dysfunction of one or both ventricles. Left ventricle dysfunction has been extensively studied in the past, and its prognostic role in patients with sepsis is well documented. However, there is relatively scarce literature on right ventricle (RV) dysfunction and its role. Given the importance of timely detection of septic cardiomyopathy and its bearing on prognosis of patients, the role of RV dysfunction has come into renewed focus. Hence, through this review, we sought to describe the pathophysiology of RV dysfunction in sepsis and what have we learnt so far about its multifactorial nature. We also elucidate the roles of different biomarkers for its detection and prognosis, along with appropriate management of such patient population.