Tabi, Meir

Abstract Aims Acute myocardial infarction (AMI) patients face a substantial risk of cardiovascular events and rehospitalization. The impact of the SmartHeart 12-lead electrocardiogram (ECG) telemedicine device on healthcare utilization has not been tested in a US randomized trial. Methods and results Patients with AMI were randomized at discharge to standard of care without (control group) or with the SmartHeart 12-lead ECG device (intervention group). The primary endpoint was the rate of emergency department (ED) visits, hospital readmissions, and any cardiovascular testing from discharge to 90 days of follow-up. The primary endpoint was reached in 57 (59%) patients in the control group and 53 (63%) patients in the intervention group (P = 0.61). However, in the intervention group, only 30% of patients complied with two follow-up training SmartHeart 12-lead ECG transmissions after discharge, and only 24% used the device thereafter. Among device users, ED presentations were lower in the intervention group than in the control group (8.0% vs. 29%, P = 0.04). In all patients advised to present to the ED upon device use (38%), a clinically relevant cardiovascular diagnosis was made. One patient survived a ventricular fibrillation cardiac arrest as advised to present to ED urgently after device use. Conclusion In this US-based RCT, there were no significant differences in the primary outcome in the intention-to-treat analysis. However, according to per-protocol analysis, proper use of the SmartHeart ECG device with 24/7 telemedicine support reduced inappropriate and increased appropriate ED presentations after hospitalization for AMI.

Abstract Background Pulmonary Hypertension (PH) is a diverse condition associated with elevated mortality. We sought to determine the association of Transthoracic Echocardiography (TTE) parameters with in-hospital mortality in patients with PH admitted to Cardiac Intensive Care Unit (CICU). Methods We included 1 Clinic CICU admissions from 2007 to 2018, with available TTE parameters within the first day of CICU admission who had PH defined as an estimated right ventricular systolic pressure (RVSP) ≥36 mmHg. The primary outcome was in-hospital mortality, evaluated using logistic regression. Results We included 3085 unique CICU patients with PH, predominantly WHO group 2 and 3. Median age was 73.7 (63.8, 82.4) years, and 1343 (43.5%) were females. Heart failure (65.6%) and respiratory failure (34.0%) were the most common admission diagnoses. The median RVSP was 47 (41, 56) mmHg, and 1314 (42.6%) had RVSP ≥50 mmHg. A total of 337 (10.9%) patients died during hospitalization. In-hospital deaths had higher RVSP (51 versus 47 mmHg, p <0.001), reflecting higher right atrial (RA) pressure (14 versus 10 mmHg, p <0.001) (Figure). In-hospital mortality increased with worse TTE parameters reflecting Right Ventricle-Pulmonary Artery (RV-PA) coupling, such as Tricuspid Annular Plane Systolic Excursion/ Right Ventricular Systolic Pressure (RVSP), Tricuspid Annular Systolic Velocity (TASV)/RVSP and TASV/ Tricuspid Regurgitation velocity ratios. Conclusion In CICU patients with PH, we have identified the specific Doppler TTE parameters with strong associations with outcomes. Specifically, RA pressure and parameters of RV-PA coupling had the highest discrimination for in-hospital mortality. Comprehensive Doppler TTE is valuable for identification of high-risk PH patients to facilitate further investigation plans, management, and prognostication. Figure: In-hospital mortality in association with right ventricular (RV) function and right atrial pressure (RAP).In-hospital mortality in association wit

Introduction: An elevated shock index (SI) predicts worse outcomes in multiple clinical arenas. We aimed to determine whether the SI can aid in mortality risk stratification in unselected CICU patients. Methods: We included admissions to the Mayo Clinic from 2007 to 2015 and stratified them based on admission SI, defined as heart rate divided by systolic blood pressure. The primary outcome was in-hospital mortality, and predictors of in-hospital mortality were analyzed using multivariable logistic regression. Results: We included 9,939 unique CICU patients with available data for SI. The mean age was 69 years old (37% female). Median HR, SBP, and shock index for our cohort were 79 beats per minute (BPM), 121 mmHg, and 0.65 BPM/mmHg, respectively. Patients were grouped by SI as follows: < 0.6, 3,973 (40%); 0.6-0.99, 4,810 (48%); and ≥ 1.0, 1,156 (12%). After multivariable adjustment, both HR (adjusted OR 1.06 per 10 BPM higher; CI 1.02-1.10; p-value 0.005) and SBP (adjusted OR 0.94 per 10 mmHg higher; CI 0.90-0.97; p-value < 0.001) remained associated with higher in-hospital mortality. As SI increased there was an incremental increase in in-hospital mortality (adjusted OR 1.07 per 0.1 BPM/mmHg higher, CI 1.04-1.10, p-Value < 0.001). A higher SI was associated with increased mortality across all examined admission diagnoses, including acute coronary syndromes, heart failure, and cardiogenic shock. Conclusions: The SI is a simple and universally available bedside marker that can be used at the time of admission to predict in-hospital mortality in CICU patients across a variety of cardiac conditions.

Background: Acute kidney injury (AKI) is associated with significant short- and long-term morbidity and mortality. In critically ill patients with sepsis, AKI tends to be more severe, more likely to require kidney replacement therapy (KRT), with less chance of recovery. Consequently, critically ill patients with sepsis-associated AKI (SA-AKI) have extended intensive care unit (ICU) stays and higher mortality rates. This study evaluated the predictive value of clinical and transthoracic echocardiographic (TTE) parameters for recovery from moderate-to-severe SA-AKI in critically ill patients. Methods: This single-center historical cohort study was conducted at a tertiary academic medical center. We analyzed the data of all adults (age ≥ 18 years) admitted to the ICU at Mayo Clinic, Rochester, MN, from June 1, 2018, to December 31, 2020. We included all patients who developed sepsis within the initial 24 h of their ICU stay. Results: We identified 2,919 eligible septic patients with available TTE, among which 1,431 patients (49%) had moderate-to-severe SA-AKI. The mean age of the patients was 68 ± 15 years, and the male-to-female ratio was 1.3:1. The most common comorbidities were diabetes mellitus and chronic lung and kidney diseases. Clinical predictors associated with SA-AKI non-recovery were the presence of stage III AKI (HR 1.5, 95% CI 1.0-2.1, p = 0.03) and utilization of kidney replacement therapy (KRT) (HR 6.8, 95% CI 3.6-12.4, p = 0.01). On the other hand, higher TAPSE was the only TTE variable associated with SA-AKI recovery (HR 1.1; 95% CI 1.08-1.15; p = 0.01). Conclusion: Our data from a single-center provide new information on the clinical (AKI stage, utilization of KRT, BMI, and peak serum creatinine) and echocardiographic features (TAPSE) associated with improved recovery in SA-AKI. There is a definite knowledge gap in the current literature regarding optimizing recovery in moderate-to-severe SA-AKI. Larger, multi-center studies are required to confirm these findings.

Background Limited data exist regarding urine output (UO) as a prognostic marker in out-of-hospital-cardiac-arrest (OHCA) survivors undergoing targeted temperature management (TTM). Methods We included 247 comatose adult patients who underwent TTM after OHCA between 2007 and 2017, excluding patients with end-stage renal disease. Three groups were defined based on mean hourly UO during the first 24 h: Group 1 (<0.5 mL/kg/h, n = 73), Group 2 (0.5−1 mL/kg/h, n = 81) and Group 3 (>1 mL/kg/h, n = 93). Serum creatinine was used to classify acute kidney injury (AKI). The primary and secondary outcomes respectively were in-hospital mortality and favorable neurological outcome at hospital discharge (modified Rankin Scale [mRS]<3). Results In-hospital mortality decreased incrementally as UO increased (adjusted OR 0.9 per 0.1 mL/kg/h higher; p = 0.002). UO < 0.5 mL/kg/h was strongly associated with higher in-hospital mortality (adjusted OR 4.2 [1.6−10.8], p = 0.003) and less favorable neurological outcomes (adjusted OR 0.4 [0.2−0.8], p = 0.007). Even among patients without AKI, lower UO portended higher mortality (40% vs 15% vs 9% for UO groups 1, 2, and 3 respectively, p < 0.001). Conclusion Higher UO is incrementally associated with lower in-hospital mortality and better neurological outcomes. Oliguria may be a more sensitive early prognostic marker than creatinine-based AKI after OHCA.

Exercise intolerance, measured by peak oxygen consumption (V̇O2), is a hallmark feature of heart failure (HF). The effect is compounded in the elderly HF patient by aging-associated changes such as a reduction in lean muscle mass, an increase in adiposity, and a reduction in maximal heart rate and peripheral blood flow with exercise. There is a non-linear reduction in peak V̇O2 with age that accelerates in the later decades of life. Peak V̇O2 is further reduced due to central and peripheral maladaptation from HF. Central mechanisms include impaired peak heart rate, stroke volume, contractility, increased filling pressures, and a blunted vasodilatory response. Peripheral mechanisms include endothelial dysfunction, reduced blood flow to muscles, and impaired skeletal muscle oxidative capacity. This review presents a focused update on mechanisms leading to impaired aerobic capacity in older HF patients.

Abstract Aims Cardiac point-of-care ultrasound (CV-POCUS) has become a fundamental part for the assessment of patients admitted to cardiac intensive care units (CICU). We sought to refine the practice of CV-POCUS by identifying 2D and Doppler-derived measurements from bedside transthoracic echocardiograms (TTEs) performed in the CICU that are associated with mortality. Methods and results We retrospectively included Mayo Clinic CICU patients admitted from 2007 to 2018 and assessed the TTEs performed within 1 day of CICU admission, including Doppler and 2D measurements of left and right ventricular function. Logistic regression and classification and regression tree (CART) analysis were used to determine the association between TTE variables with in-hospital mortality. A total of 6957 patients were included with a mean age of 68.0 ± 14.9 years (37.0% females). A total of 609 (8.8%) patients died in the hospital. Inpatient deaths group had worse biventricular systolic function [left ventricular ejection fraction (LVEF) 48.2 ± 16.0% vs. 38.7 ± 18.2%, P &lt; 0.0001], higher filling pressures, and lower forward flow. The strongest TTE predictors of hospital mortality were left ventricular outflow tract velocity–time integral [LVOT VTI, adjusted OR 0.912 per 1 cm higher, 95% confidence interval (CI) 0.883–0.942, P &lt; 0.0001] followed by medial mitral E/e′ ratio (adjusted OR 1.024 per 1 unit higher, 95% CI 1.010–1.039, P = 0.0011). Classification and regression tree analysis identified LVOT VTI &lt;16 cm as the most important TTE predictor of mortality. Conclusions Doppler-derived haemodynamic TTE parameters have a strong association with mortality in the CICU, particularly LVOT VTI &lt;16 cm or mitral E/e′ ratio &gt;15. The incorporation of these simplified Doppler-derived haemodynamics into admission CV-POCUS facilitates early risk stratification and strengthens the clinical yield of the ultrasound exam.

Background Cardiac arrest (CA) is associated with worse outcomes in patients with cardiogenic shock (CS). To better understand the contribution of CA on CS, we evaluated transthoracic echocardiography (TTE) parameters in CS patients with and without CA. Methods We retrospectively identified CS patients with a TTE performed near cardiac intensive care unit admission between 2007 to 2018. We compared TTE measurements of left ventricular (LV) and right ventricular (RV) function in patients with and without CA. The primary outcome was all-cause in-hospital mortality, as determined using multivariable logistic regression. Results We included 1085 patients, 35% of whom had CA. Median age was 70 years and 37% were females. CA patients had higher severity of illness, more invasive mechanical ventilation and greater vasopressor/inotrope use. In-hospital mortality was 31% and was higher in CA patients (45% vs. 23%, p <0.001). Although LV ejection fraction (LVEF) was similar (35% vs. 37%, p = 0.05), CA patients had lower cardiac index, mitral valve E wave peak velocity, E/A ratio and E/e' ratio. TTE variables that were associated with hospital mortality varied, among patients with CA, these included measures of RV pressure and function and among patients without CA, these included parameters reflecting LV systolic function. Conclusions Doppler assessments of RV systolic dysfunction were the strongest TTE predictors of hospital mortality in CS patients with CA, unlike CS patients without CA in whom LV systolic function was more important. This emphasizes the importance of RV assessment for mortality risk stratification after CA.

Background: Post-arrest hypotension is common after out of hospital cardiac arrest (OHCA) and many patients resuscitated after OHCA will require vasopressors. We sought to determine the associations between echocardiographic parameters and vasopressor requirements in OHCA patients. Methods: We retrospectively analyzed adult patients with OHCA treated with targeted temperature management between December 2005 and September 2016 who underwent a transthoracic echocardiogram (TTE). Categorical variables were compared using 2-tailed Fisher’s exact and Pearson’s correlation coefficients and variance (r 2 ) values were used to assess relationships between continuous variables. Results: Among 217 included patients, the mean age was 62 ± 12 years, including 74% males. The arrest was witnessed in 90%, the initial rhythm was shockable in 88%, and 58% received bystander CPR. At the time of TTE, 41% of patients were receiving vasopressors; this group of patients was older, had greater severity of illness, higher inpatient mortality and left ventricular ejection fraction (LVEF) was modestly lower (36.8 ± 17.1% vs. 41.4 ± 16.4%, P = 0.04). Stroke volume, cardiac power output and left ventricular stroke work index correlated with number of vasopressors (Pearson r −0.24 to −0.34, all P < 0.002), but the correlation with LVEF was weak (Pearson r −0.13, P = 0.06). Conclusions: In patients after OHCA, left ventricular systolic dysfunction was associated with the need for vasopressors, and Doppler TTE hemodynamic parameters had higher correlation coefficients compared with vasopressor requirements than LVEF. This emphasizes the complex nature of shock after OHCA, including pathophysiologic processes not captured by TTE assessment alone.