ESC core curriculum for the general cardiologist (2013)

[No abstract available

Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest - implementation and clinical management

Background: With the publication of two randomized controlled trials (RCTs) in 2002, therapeutic hypothermia (TH) was re-introduced in postresuscitation care of comatose out-of-hospital cardiac arrest (OHCA) patients. Many issues, however, were unresolved, including implementation protocol, cooling technique, clinical management, implications of TH treatment on prognostic accuracy and therapeutic benefit in subgroups of OHCA excluded from the initial RCTs. Objectives: We wanted to study the implementation of therapeutic hypothermia into daily practice, provide information on clinical management, including differences in cooling techniques and test application in elderly OHCA patients excluded in earlier trials. Subjects: We evaluated the clinical management of adult comatose OHCA patients who were treated in our ICU (paper I and IV). In paper II we surveyed our intensive care nursing staff with regard to key nursing aspects of different cooling methods and devices. In paper III, ICU consultants were assessed on their prognostic approach in OHCA patients treated with TH. Methods: In paper I we retrospectively compared OHCA patients treated with TH with a historic control group of OHCA patients fulfilling the TH inclusion criteria. We collected Utstein template data, as well as data on ICU-and hospital length of stay (LOS), incidence of adverse events, and outcome at hospital discharge and after one year. In paper II an anonymous survey was conducted with our intensive care nursing (ICN) staff, assessing ease of application, hygiene, work load, noise level and visual patient monitoring of four different cooling methods. In paper III we used a semi-structured telephone interview to conduct a nation-wide survey of the prognostication approach of comatose OHCA patients involving timing, methods, involved specialties and rating of prognostic methods. In paper IV we retrospectively studied outcome variables in all adult OHCA patients treated with TH in our ICU over a six-year period, who fulfilled the Hypothermia After Cardiac Arrest study (HACA) criteria with exception of the upper age limit. Results: With our simple cooling protocol we achieved 100% implementation and successful attainment of target temperature (TT) in 89% of patients (paper I). However, it took median 7, 5 hours (1-10 h) to reach TT, which was maintained for median 10 hours (6-19h). Demographics, Utstein template data, ICU and hospital LOS did not differ significantly between the two groups. Insulin resistance and hypokalemia were significantly more frequent in the TH group, whereas seizures were observed more frequent in the normothermia group. The TH group showed significantly higher rates of survival to hospital discharge (59% vs. 32%, p = 0, 05). In paper IV we found that although older age influenced outcome, over half of OHCA patients older than 75 years showed favorable outcome at hospital discharge. The four cooling methods used in our department differed significantly regarding key nursing aspects (paper II). Our simple cooling method scored high regarding ease of application and noise level, but low in work load and hygiene. The CoolGard and ArticSun systems scored highest in work load and hygiene. Only 53% of ICNs were satisfied with their initial training and merely 10% felt adequately prepared at the time when TH was introduced. In paper III we found that even after introduction of TH, prognostication after OHCA was performed within 48 hours in the majority of patients. More than one specialty was involved, using mainly clinical neurological examination (100%), prehospital data (76%), cerebral computer tomography (CCT) (58%) and electroencephalography (EEG) (52%) findings. Somatosensory evoked potentials (SSEP) (8%), biochemical markers (8%) and magnetic resonance imaging (MRI) (8%) only played a minor role. Only one ICU used a standardized protocol. Conclusions: Our simple external cooling protocol could be rapidly implemented, was safe, cheap and feasible, but not optimal with regard to accurate temperature management (paper I). Key nursing elements differed significantly among available cooling methods (paper II). Even though age influences outcome, more than half of our OHCA population older than 75 years showed good outcome. The limitation of patient eligibility for TH treatment should not be based on age alone (paper IV). Despite frequent use of TH, prognostication after OHCA was executed early, mainly based on clinical examination, prehospital data, CCT and EEG results. SSEP seems to be underused and underrated, whereas the clinical accuracy of CCT, prehospital data and EEG seems to be overrated (paper III)

Acute lung injury in paediatric intensive care: course and outcome

Introduction: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) carry a high morbidity and mortality (10-90%). ALI is characterised by non-cardiogenic pulmonary oedema and refractory hypoxaemia of multifactorial aetiology [1]. There is limited data about outcome particularly in children. Methods This retrospective cohort study of 85 randomly selected patients with respiratory failure recruited from a prospectively collected database represents 7.1% of 1187 admissions. They include those treated with High Frequency Oscillation Ventilation (HFOV). The patients were admitted between 1 November 1998 and 31 October 2000. Results: Of the 85, 49 developed acute lung injury and 47 had ARDS. There were 26 males and 23 females with a median age and weight of 7.7 months (range 1 day-12.8 years) and 8 kg (range 0.8-40 kg). There were 7 deaths giving a crude mortality of 14.3%, all of which fulfilled the Consensus I [1] criteria for ARDS. Pulmonary occlusion pressures were not routinely measured. The A-a gradient and PaO2/FiO2 ratio (median + [95% CI]) were 37.46 [31.82-43.1] kPa and 19.12 [15.26-22.98] kPa respectively. The non-survivors had a significantly lower PaO2/FiO2 ratio (13 [6.07-19.93] kPa) compared to survivors (23.85 [19.57-28.13] kPa) (P = 0.03) and had a higher A-a gradient (51.05 [35.68-66.42] kPa) compared to survivors (36.07 [30.2-41.94]) kPa though not significant (P = 0.06). Twenty-nine patients (59.2%) were oscillated (Sensormedics 3100A) including all 7 non-survivors. There was no difference in ventilation requirements for CMV prior to oscillation. Seventeen of the 49 (34.7%) were treated with Nitric Oxide including 5 out of 7 non-survivors (71.4%). The median (95% CI) number of failed organs was 3 (1.96-4.04) for non-survivors compared to 1 (0.62-1.62) for survivors (P = 0.03). There were 27 patients with isolated respiratory failure all of whom survived. Six (85.7%) of the non-survivors also required cardiovascular support.Conclusion: A crude mortality of 14.3% compares favourably to published data. The A-a gradient and PaO2/FiO2 ratio may be of help in morbidity scoring in paediatric ARDS. Use of Nitric Oxide and HFOV is associated with increased mortality, which probably relates to the severity of disease. Multiple organ failure particularly respiratory and cardiac disease is associated with increased mortality. ARDS with isolated respiratory failure carries a good prognosis in children

Decision support continuum paradigm for cardiovascular disease: Towards personalized predictive models

Clinical decision making is a ubiquitous and frequent task physicians make in their daily clinical practice. Conventionally, physicians adopt a cognitive predictive modelling process (i.e. knowledge and experience learnt from past lecture, research, literature, patients, etc.) for anticipating or ascertaining clinical problems based on clinical risk factors that they deemed to be most salient. However, with the inundation of health data and the confounding characteristics of diseases, more effective clinical prediction approaches are required to address these challenges. Approximately a few century ago, the first major transformation of medical practice took place as science-based approaches emerged with compelling results. Now, in the 21st century, new advances in science will once again transform healthcare. Data science has been postulated as an important component in this healthcare reform and has received escalating interests for its potential for ‘personalizing’ medicine. The key advantages of having personalized medicine include, but not limited to, (1) more effective methods for disease prevention, management and treatment, (2) improved accuracy for clinical diagnosis and prognosis, (3) provide patient-oriented personal health plan, and (4) cost containment. In view of the paramount importance of personalized predictive models, this thesis proposes 2 novel learning algorithms (i.e. an immune-inspired algorithm called the Evolutionary Data-Conscious Artificial Immune Recognition System, and a neural-inspired algorithm called the Artificial Neural Cell System for classification) and 3 continuum-based paradigms (i.e. biological, time and age continuum) for enhancing clinical prediction. Cardiovascular disease has been selected as the disease under investigation as it is an epidemic and major health concern in today’s world. We believe that our work has a meaningful and significant impact to the development of future healthcare system and we look forward to the wide adoption of advanced medical technologies by all care centres in the near future.Open Acces

Prognostication in acute heart failure and cardiogenic shock : focus on electrocardiography and biomarkers

Acute heart failure (AHF) is a leading cause of hospitalizations in patients over the age of 65 worldwide, and is associated with high mortality. Cardiogenic shock (CS), the most severe form of AHF, is characterized by hypotension and end-organ hypoperfusion. Acute coronary syndrome (ACS) precipitates a third of all cases of AHF, and up to 80% of CS. Objective and timely risk assessment in AHF is challenging due to the heterogeneity in its pathophysiology and clinical picture. Risk assessment has traditionally relied on clinical parameters, which may remain subjective or become evident too late, after end-organ dysfunction has become irreversible. Considering the costs and possible adverse effects, application of the most aggressive therapies should be limited to those that most likely procure benefit. The aim of this thesis is to evaluate the prognostic value of electrocardiographic changes and biomarkers in AHF and CS. The patient data come from three cohorts of AHF and two cohorts of CS. All cohorts are independent, prospective, observational, investigator-initiated European cohorts. Study I compared the prognostic value of ventricular conduction blocks (VCB) in patients with new-onset (de novo) AHF and in patients with acutely decompensated chronic heart failure (ADCHF). Study II investigated the role of VCBs in ACS-related CS. Half the patients had a VCB in their baseline ECG, and the presence of any VCB predicted mortality independently of baseline clinical variables or angiographic findings. Studies III-IV investigated the role of two novel biomarkers, sST2 and bio-ADM, in cariogenic shock. Study III showed that sST2 provide strong and complementary prognostic value to NT-proBNP in ACS-related CS, and can help in stratification of patients into low, intermediate and high-risk groups as early as 12 hours after detection of shock. Study IV evaluated in CS patients the prognostic value and association with haemodynamic parameters of bio-ADM compared to lactate. Whereas lactate had good prognostic value in the early phase, its levels normalized during the first 24 hours in the majority of patients, with a decreasing prognostic value thereafter. In contrast, levels of bio-ADM stayed elevated in non-survivors during the first 4 days of intensive care, and bio-ADM had good prognostic value when measured on days 2 to 4. In conclusion, in patients with AHF or CS, electrocardiographic alterations may prove useful in early risk assessment on top of clinical parameters. In addition, biomarkers provide a novel approach in CS risk assessment.Akuutti sydämen vajaatoiminta on yksi yleisimmistä sairaalahoitoon johtavista sairauksista, ja siihen liittyy merkittävä kuolleisuus. Sydänperäinen sokki on akuutin vajaatoiminnan vaikein muoto; sille on tunnusomaista matala verenpaine ja yleinen elimistön verenkierron vajaus. Sepelvaltimotautikohtaus on akuutin vajaatoiminnan taustalla noin kolmasosassa tapauksista, mutta jopa 80 %:ssa tapauksista sydänperäisessä sokissa. Johtuen akuutin vajaatoiminnan kliinisen kuvan ja taustalla vaikuttavien patofysiologisten mekanismien moninaisuudesta objektiivinen ja oikea-aikainen riskinarvio on haastavaa. Varhainen riskinarvio on kuitenkin tärkeää hoitomuotojen valintaa ja ajoitusta ajatellen erityisesti sokkipotilailla. Perinteisesti riskinarvio on perustunut kliinisiin löydöksiin, joiden tulkinnassa voi kuitenkin olla subjektiivisuutta ja ne voivat ilmetä sairauden liian myöhäisessä vaiheessa, kun peruuttamattomia elinvaurioita on jo ehtinyt kehittyä. Huomioiden raskaimpien hoitomuotojen, kuten sydämen apupumppujen, korkea komplikaatioriski ja hinta, niiden käyttö tulisi rajata potilaille jotka todennäköisimmin niistä hyötyvät. Tämän väitöskirjatyön tavoitteena on määrittää sydänsähkökäyrä (EKG) –muutosten sekä uusien biomerkkiaineiden ennustearvo akuutissa sydämen vajaatoiminnassa ja sydänperäisessä sokissa. Väitöskirjatyön potilasmateriaali on peräisin kolmesta akuutin sydämen vajaatoiminnan sekä kahdesta sydänperäisen sokin potilaskohortista. Kaikki aineistot ovat eteneviä, havainnoivia, tutkijalähtöisiä eurooppalaisia potilasaineistoja. Osatyössä I tutkittiin EKG:ssa nähtävien kammiojohtumishäiriöiden yhteyttä kuolleisuuteen potilailla joilla akuutti vajaatoiminta ilmeni ensimmäistä kertaa (de novo) verrattuna potilaisiin joilla oli kroonisen sydämen vajaatoiminnan pahenemisvaihe. Osatyössä II tutkittiin kammiojohtumishäiriöitä äkillisestä sepelvaltimokohtauksesta johtuvassa sydänperäisessä sokissa. Puolella potilaista alkuvaiheen EKG:ssa oli jokin kammiojohtumishäiriö, ja kammiojohtumishäiriöt ennustivat suurempaa kuolleisuutta kliinisistä piirteistä ja sepelvaltimotaudin vaikeusasteesta riippumatta. Osatöissä III ja IV tutkittiin kahden uuden biomerkkiaineen, sST2:n ja bio-ADM:n, ennustearvoa kardiogeenisessä sokissa. Osatyö III osoitti, että sST2:lla ja NT-proBNP:llä on vahva itsenäinen ja toisiaan tukeva ennustearvo sydänperäisessä sokissa, ja niiden yhteismäärityksellä potilaat voidaan jakaa matalan, keskisuuren ja suuren riskin ryhmiin jo 12 tuntia sokin toteamisesta. Osatyö IV määritti bio-ADM:n ennustearvoa sekä yhteyttä hemodynaamisiin muuttujiin verrattuna laktaattiin sydänperäisessä sokissa. Laktaatilla oli hyvä ennustearvo ensimmäisten 24 tunnin aikana sokin toteamisesta, mutta sen pitoisuus normaalistui valtaosalla potilaista 24 tunnissa ja sen ennustearvo väheni sen jälkeen. Korkea bio-ADM pitoisuus heijasti matalaa verenpainetta ja sydämen minuuttivoluumia sekä korkeaa keskuslaskimo- ja keuhkovaltimopainetta, ja bio-ADM:n ennustearvo oli parhaimmillaan kun se mitattiin 2.-4. päivänä sokin toteamisesta. Yhteenvetona voidaan todeta, että EKG-muutoksia voidaan hyödyntää kliinisten muutosten rinnalla varhaisessa riskinarviossa akuuttia sydämen vajaatoimintaa tai sydänperäistä sokkia sairastavilla potilailla. Lisäksi uudet biomerkkiaineet mahdollistavat täysin uuden lähestymistavan sydänperäisen sokin riskinarviossa

Big data from electronic health records for early and late translational cardiovascular research: challenges and potential.

AIMS: Cohorts of millions of people's health records, whole genome sequencing, imaging, sensor, societal and publicly available data present a rapidly expanding digital trace of health. We aimed to critically review, for the first time, the challenges and potential of big data across early and late stages of translational cardiovascular disease research. METHODS AND RESULTS: We sought exemplars based on literature reviews and expertise across the BigData@Heart Consortium. We identified formidable challenges including: data quality, knowing what data exist, the legal and ethical framework for their use, data sharing, building and maintaining public trust, developing standards for defining disease, developing tools for scalable, replicable science and equipping the clinical and scientific work force with new inter-disciplinary skills. Opportunities claimed for big health record data include: richer profiles of health and disease from birth to death and from the molecular to the societal scale; accelerated understanding of disease causation and progression, discovery of new mechanisms and treatment-relevant disease sub-phenotypes, understanding health and diseases in whole populations and whole health systems and returning actionable feedback loops to improve (and potentially disrupt) existing models of research and care, with greater efficiency. In early translational research we identified exemplars including: discovery of fundamental biological processes e.g. linking exome sequences to lifelong electronic health records (EHR) (e.g. human knockout experiments); drug development: genomic approaches to drug target validation; precision medicine: e.g. DNA integrated into hospital EHR for pre-emptive pharmacogenomics. In late translational research we identified exemplars including: learning health systems with outcome trials integrated into clinical care; citizen driven health with 24/7 multi-parameter patient monitoring to improve outcomes and population-based linkages of multiple EHR sources for higher resolution clinical epidemiology and public health. CONCLUSION: High volumes of inherently diverse ('big') EHR data are beginning to disrupt the nature of cardiovascular research and care. Such big data have the potential to improve our understanding of disease causation and classification relevant for early translation and to contribute actionable analytics to improve health and healthcare

2023 ESC Guidelines for the management of acute coronary syndromes.

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