Jentzer, Jacob C.

Background The cardiac intensive care unit ( CICU ) population is no longer composed of only patients with acute coronary syndromes, and includes those with acute heart failure and multiple comorbidities. We hypothesized that the GWTG ‐ HF (Get With The Guidelines–Heart Failure) risk score that predicts inpatient mortality in hospitalized patients with heart failure would predict mortality in CICU patients. Methods and Results We retrospectively analyzed CICU patients at a tertiary care hospital from 2007 to 2015. The GWTG ‐ HF risk score was calculated at CICU admission. As a secondary analysis, the EFFECT (Enhanced Feedback for Effective Cardiac Treatment) , OPTIMIZE‐HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure), and ADHERE (Acute Decompensated Heart Failure National Registry) risk scores were calculated. Kaplan–Meier survival analysis and the area under the receiver operating characteristic curve value were determined for inpatient and 1‐year mortality. The GWTG ‐ HF risk score was calculated in 9532 (95%) patients, with a median value of 40 (interquartile range, 35–47). Inpatient mortality occurred in 824 (8.6%) patients, and 2075 (21.8%) patients died by 1 year. Patients who died in hospital had a significantly higher mean GWTG ‐ HF score (47.7 versus 40.2; P <0.001). Inpatient and 1‐year mortality increased in each GWTG ‐ HF risk score quartile ( P <0.0001). Discrimination of the GWTG ‐ HF , EFFECT, OPTIMIZE‐HF, and ADHERE risk scores was assessed using area under the receiver operating characteristic curve values for hospital mortality, and were similar for all risk scores (0.72–0.74; P >0.05). The Hosmer–Lemeshow statistic suggested poor calibration for hospital mortality by the GWTG ‐ HF risk score ( P <0.001). Conclusions The GWTG ‐ HF risk score and other heart failure prediction tools demonstrate good discrimination for inpatient and 1‐year mortality in a heterogeneous cohort of CICU patients. Our study emphasizes that prognostic variables overlap in cardiac patients, regardless of the admission diagnosis.

Background Abnormal serum sodium levels have been associated with higher mortality among patients with acute coronary syndromes and heart failure. We sought to describe the association between sodium levels and mortality among unselected cardiac intensive care unit ( CICU ) patients. Methods and Results We retrospectively reviewed consecutive adult patients admitted to our cardiac intensive care unit from 2007 to 2015. Hyponatremia and hypernatremia were defined as admission serum sodium <135 and >145 mE q/L, respectively. In‐hospital mortality was assessed by multivariable regression, and postdischarge mortality was evaluated by Cox proportional‐hazards analysis. We included 9676 patients with a mean age of 68±15 years (37.5% females). Hyponatremia occurred in 1706 (17.6%) patients, and hypernatremia occurred in 322 (3.3%) patients; these groups had higher illness severity and a greater number of comorbidities. Risk of hospital mortality was higher with hyponatremia (15.5% versus 7.5%; unadjusted odds ratio, 2.41; 95% CI , 2.06–2.82; P <0.001) or hypernatremia (17.7% versus 8.6%; unadjusted odds ratio, 2.82; 95% CI , 2.09–3.80; P <0.001), with a J‐shaped relationship between admission sodium and mortality. After multivariate adjustment, only hyponatremia was significantly associated with in‐hospital mortality (adjusted odds ratio, 1.42; 95% CI, 1.14–1.76; P =0.002). Among hospital survivors, risk of postdischarge mortality was higher in patients with hyponatremia (adjusted hazard ratio, 1.28; 95% CI , 1.17–1.41; P <0.001) or hypernatremia (adjusted hazard ratio, 1.36; 95% CI, 1.12–1.64; P =0.002). Conclusions Hyponatremia and hypernatremia on admission to the cardiac intensive care unit are associated with increased unadjusted short‐ and long‐term mortality. Further studies are needed to determine whether correcting abnormal sodium levels can improve outcomes in cardiac intensive care unit patients.

Background: Emerging evidence suggests that coronary intensive care units are evolving into intensive care environments with an increasing burden of non-cardiovascular illness, but previous studies have been limited to older populations or single center experiences. Methods: Canadian national health-care data was used to identify all patients ≥18 years admitted to dedicated coronary intensive care units (2005–2015) and admissions were categorized as primary cardiac or non-cardiac. The outcomes of interest included longitudinal trends in admission diagnoses, critical care therapies, and all-cause in-hospital mortality. Results: Among the 373,992 patients admitted to a coronary intensive care unit, minimal changes in the proportion of patients admitted with a primary cardiac (88.2% to 86.9%; p&lt;0.001) and non-cardiac diagnoses (11.8% to 13.1%; p&lt;0.001) were observed. Among cardiac admissions, a temporal increase in the proportion of ST-segment elevation myocardial infarction (19.4% to 24.1%, p&lt;0.001), non-ST-segment elevation myocardial infarction (14.6% to 16.2%, p&lt;0.001), heart failure (7.3% to 8.4%, p&lt;0.001), shock (4.9% to 5.7%, p&lt;0.001), and decline in unstable angina (4.9% to 4.0%, p&lt;0.001) and stable coronary diseases (21.3% to 12.4%, p&lt;0.001) was observed. The proportion of patients requiring critical care therapies (57.8% to 63.5%, p&lt;0.001) including mechanical ventilation (9.6% to 13.1%, p&lt;0.001) increased. In-hospital mortality rates for patients with primary cardiac (4.9% to 4.4%; adjusted odds ratio 0.71, 95% confidence interval 0.63–0.79) and non-cardiac (17.8% to 16.1%; adjusted odds ratio 0.84, 0.73–0.97) declined; results were consistent when stratified by academic vs community hospital, and by the presence of on-site percutaneous coronary intervention. Conclusion: In a national dataset we observed a changing case-mix among patients admitted to a coronary intensive care unit, though the proportion of patients with a primary cardiac diagnosis remained stable. There was an increase in clinical acuity highlighted by critical care therapies, but in-hospital mortality rates for both primary cardiac and non-cardiac conditions declined across all hospitals. Our findings confirm the changing coronary intensive care unit case-mix and have implications for future coronary intensive care unit training and staffing.

Background There are no risk scores designed specifically for mortality risk prediction in unselected cardiac intensive care unit ( CICU ) patients. We sought to develop a novel CICU ‐specific risk score for prediction of hospital mortality using variables available at the time of CICU admission. Methods and Results A database of CICU patients admitted from January 1, 2007 to April 30, 2018 was divided into derivation and validation cohorts. The top 7 predictors of hospital mortality were identified using stepwise backward regression, then used to develop the Mayo CICU Admission Risk Score (M‐ CARS ), with integer scores ranging from 0 to 10. Discrimination was assessed using area under the receiver‐operator curve analysis. Calibration was assessed using the Hosmer–Lemeshow statistic. The derivation cohort included 10 004 patients and the validation cohort included 2634 patients (mean age 67.6 years, 37.7% females). Hospital mortality was 9.2%. Predictor variables included in the M‐ CARS were cardiac arrest, shock, respiratory failure, Braden skin score, blood urea nitrogen, anion gap and red blood cell distribution width at the time of CICU admission. The M‐ CARS showed a graded relationship with hospital mortality (odds ratio 1.84 for each 1‐point increase in M‐ CARS , 95% CI 1.78–1.89). In the validation cohort, the M‐ CARS had an area under the receiver‐operator curve of 0.86 for hospital mortality, with good calibration ( P =0.21). The 47.1% of patients with M‐ CARS <2 had hospital mortality of 0.8%, and the 5.2% of patients with M‐ CARS >6 had hospital mortality of 51.6%. Conclusions Using 7 variables available at the time of CICU admission, the M‐ CARS can predict hospital mortality in unselected CICU patients with excellent discrimination.

ABSTRACT Background: The use of norepinephrine may be associated with better outcomes in some patients with shock. We sought to determine whether norepinephrine was associated with lower mortality in unselected cardiac intensive care unit (CICU) patients compared with other vasopressors, and whether patterns of vasopressor and inotrope usage in the CICU have changed over time. Methods: We retrospectively evaluated consecutive adult patients admitted to a tertiary care hospital CICU from January 1, 2007 to December 31, 2015. Vasoactive drug doses were quantified using the peak Vasoactive-Inotropic Score (VIS). Temporal trends were assessed using the Cochran–Armitage trends test and multivariable logistic regression was used to determine predictors of hospital mortality. Results: We included 10,004 patients with a mean age of 67 ± 15 years; vasoactive drugs were used in 2,468 (24.7%) patients. Use of norepinephrine increased over time, whereas dopamine utilization decreased ( P < 0.001 for trends). After adjustment for illness severity and other variables, the peak VIS was a predictor of hospital mortality across the entire population (unit odds ratio [OR] 1.013, 95% confidence interval [CI], 1.009–1.017, P < 0.001) and among patients receiving vasoactive drugs (OR 1.018, 95% CI, 1.013–1.022, P < 0.001). Among patients receiving vasoactive drugs, norepinephrine was associated with a lower risk of hospital mortality (OR 0.66, 95% CI, 0.49–0.90, P = 0.008) after adjustment for illness severity and peak VIS. Conclusions: Vasoactive drug use in CICU patients has a dose-dependent association with short-term mortality. Use of norepinephrine in CICU patients is associated with decreased odds of death when compared with other vasoactive drugs.

Background Hyperkalemia has been associated with increased mortality in patients with myocardial infarction, but few data exist regarding hyperkalemia in cardiac intensive care unit ( CICU ) patients. We hypothesize that hyperkalemia is associated with increased mortality in unselected CICU patients. Methods and Results We retrospectively reviewed a historical cohort of 9681 CICU patients admitted from January 2007 to December 2015. Hyperkalemia was defined as admission potassium ≥5.0 mEq/L and hypokalemia as admission potassium <3.5 mEq/L. Multivariate logistic regression was used to determine predictors of in‐hospital mortality. Postdischarge survival was assessed using Kaplan–Meier analysis and Cox proportional hazards models. The mean age of included patients was 67±15 years, with 36% females, and in‐hospital mortality was 9%. Hyperkalemia occurred in 1187 (12.3%) and hypokalemia occurred in 719 (7.4%) patients. Both patients with hyperkalemia (unadjusted odds ratio, 2.85; 95% CI, 2.40–3.39; P <0.001) and patients with hypokalemia (unadjusted odds ratio, 2.31; 95% CI, 1.85–2.88; P <0.001) were at increased risk of unadjusted in‐hospital mortality. After adjustment for illness severity and renal function, only patients with hyperkalemia demonstrated increased risk of in‐hospital death (adjusted odds ratio, 1.44; 95% CI, 1.11–1.87; P =0.006). Among hospital survivors, only patients with hyperkalemia had lower postdischarge survival by Kaplan–Meier analysis ( P <0.001). After adjustment for illness severity and renal function, hospital survivors with admission hyperkalemia remained at increased risk for postdischarge mortality (adjusted hazard ratio, 1.20; 95% CI, 1.08–1.34; P <0.001). Conclusions Hyperkalemia on CICU admission is associated with higher in‐hospital and postdischarge mortality, independent of renal function and illness severity. These findings emphasize the importance of potassium abnormalities as a risk predictor in patients admitted to the CICU .

Sepsis continues to be a leading cause of mortality and morbidity in the intensive care unit. Cardiovascular dysfunction in sepsis is associated with worse short- and long-term outcomes. Sepsis-related myocardial dysfunction is noted in 20%–65% of these patients and manifests as isolated or combined left or right ventricular systolic or diastolic dysfunction Echocardiography is the most commonly used modality for the diagnosis of sepsis-related myocardial dysfunction. With the increasing use of ultrasonography in the intensive care unit, there is a renewed interest in sepsis-related myocardial dysfunction. This review summarises the current scope of literature focused on sepsis-related myocardial dysfunction and highlights the use of basic and advanced echocardiographic techniques for the diagnosis of sepsis-related myocardial dysfunction and the management of sepsis and septic shock.