Palliative care in cardiac intensive care units (CICUs): Insights from the Critical Care Cardiology Trials Network (CCCTN) registry

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf Critical Care Cardiology Trials Network (CCCTN) registry Introduction Palliative care is a practice focused on providing relief of symptoms of illness, while optimizing the quality of life for patients and families. We aimed to quantify palliative care (PC) practices and end-of-life decision-making in critically ill cardiac patients in contemporary CICUs. Methods The CCCTN Registry is a network of tertiary care CICUs in the United States and Canada. Between 2017 and 2020, up to 26 centers contributed an annual 2-month snapshot of all consecutive admissions to the CICU. We captured code status, rates of palliative care consultation, and decisions for comfort measures only (CMO) before all deaths in the CICU.  Results    Of 8231 admissions, 10% ended with death in the CICU and 2.6% were discharges to hospice. Of deceased  patients, 68% were CMO before death. The median age of CMO patients was 70y (25th-75th: 59-78) vs. 67 (56-77) among deaths without CMO. In the CMO group, only 13% were DNR/DNI at admission, and the remainder were full code. Respiratory insufficiency and non-cardiogenic shock were the CICU indications most frequently associated with CMO. The median time from CICU admission to CMO decision was 3.4 days (25th-75th: 1.2-7.7) and was ≥7 days in 27% (Figure). Time from CMO decision to death was &amp;lt;24h in 88%, with a median of 3.8h (25th-75th 1.0-10.3). Before a CMO decision, 73% received mechanical ventilation and 25% mechanical circulatory support. Of total deaths, 34% of intubated patients were palliatively extubated. Formal PC services were engaged in only 28% of deaths. Conclusions In contemporary CICUs, CMO preceded death in 2/3 of cases. The high use of advanced ICU therapies, lengthy times to a CMO decision, and the very short time from CMO to death, highlight a potential opportunity for greater PC consultation, as well as training programs to build skills in PC for practitioners in the CICU. Abstract Figure </jats:sec

Higher CICU mechanical ventilation volumes are associated with lower in-hospital mortality

Abstract Funding Acknowledgements Type of funding sources: None. Background  The incidence of respiratory failure and the provision of invasive and non-invasive mechanical ventilation (MV) in patients admitted to cardiac intensive care units (CICU) are increasing. While institutional MV volumes are associated with reduced mortality in medical and surgical ICUs, this relationship has not been characterized in the CICU population. Purpose  By describing the relationship between institutional MV volume and outcomes in the CICUs, we hope to shed light on minimum volume benchmarks for providing MV. Methods  National Canadian population-based data from 2005 to 2015 was used to identify patients admitted to CICUs requiring MV. CICUs were categorized into low (≤100), intermediate (101-300), and high (&amp;gt;300) volume centers based on spline knots identified in the association between annual MV volume and mortality (Figure). Outcomes of interests included all-cause in-hospital mortality, the proportion of patients requiring prolonged MV (&amp;gt;96 hours) and CICU length of stay (LOS). Results  Among the 47,173 CICU admissions that required MV, 89.5% (42,200) required invasive mechanical ventilation. The median annual CICU MV volume was 127 (range 1-490). In-hospital mortality was lower in intermediate (29.2%, adjusted odds ratio [aOR] 0.84, 95% CI 0.72-0.97, p = 0.019) and high-volume (18.2%; aOR 0.82, 95% CI 0.66-1.02, p = 0.076) centers, compared to low volume centers (35.9%). The proportion of patients requiring prolonged MV was higher in low-volume (29.2%) compared to high-volume (14.8%, OR 0.70, 95% 0.55-0.89, p = 0.003) centers. Point estimates for mortality and prolonged MV were lower in PCI-capable and academic centers (Table). Significantly (p &amp;lt;0.01) lower CICU LOS was observed only in the subgroup of PCI-capable intermediate- and high-volume hospitals. Conclusions  In a national dataset, we observed that higher CICU MV hospital volumes were associated with lower in-hospital mortality, CICU LOS, and fewer episodes of prolonged MV. Pending further validation, these data suggest minimum MV volume benchmarks for CICUs caring for patients with respiratory failure. Further research is warranted to explore these associations in more detail. Unadjusted volume-outcome relationshipsOutcomesGroup 1 Annual Volume ≤100Group 2 Annual Volume 101-300Group 3 Annual Volume &amp;gt;300Totalp-valueTotal N1770224351512047173In-hospital mortality6357 (35.0%)7122 (29.2%)933 (18.2%)14412 (30.6%)p &amp;lt; 0.0001Median CICU LOS(hours)85796679p &amp;lt; 0.0001Episodes of prolonged MV5161 (29.2%)5608 (23.0%)758 (14.8%)11527 (24.4%)p &amp;lt; 0.0001Abbreviations OR (odds ratio), RD (risk difference), CI (confidence interval), PCI (percutaneous coronary intervention), LOS (length of stay)Abstract Figure. Annual CICU MV volume and mortality </jats:sec

COVID-19 and Disruptive Modifications to Cardiac Critical Care Delivery: JACC Review Topic of the Week

The COVID-19 pandemic has presented a major unanticipated stress on our workforce, organizational structure, systems of care, and critical resource supply. In order to ensure provider safety, maximize efficiency, and optimize patient outcomes, health systems need to be agile. Critical care cardiologists may be uniquely positioned to treat the numerous respiratory and cardiovascular complications of the SARS-CoV-2 virus and support clinicians without critical care training who may be suddenly asked to care for critically ill patients. This manuscript draws upon the experiences of colleagues from heavily impacted regions of the United States and Europe as well as lessons learned from military mass casualty medicine. We offer pragmatic suggestions on how to implement scalable models for critical care delivery, cultivate educational tools for team training, and embrace technologies such as telemedicine to enable effective collaboration despite social distancing imperatives

Bacterial Communities Associated with Atherosclerotic Plaques from Russian Individuals with Atherosclerosis

Atherosclerosis is considered a chronic disease of the arterial wall and is the major cause of severe disease and death among individuals all over the world. Some recent studies have established the presence of bacteria in atherosclerotic plaque samples and suggested their possible contribution to the development of cardiovascular disease. The main objective of this preliminary pilot study was to better understand the bacterial diversity and abundance in human atherosclerotic plaques derived from common carotid arteries of individuals with atherosclerosis (Russian nationwide group) and contribute towards the further identification of a main group of atherosclerotic plaque bacteria by 454 pyrosequencing their 16S ribosomal RNA (16S rRNA) genes. The applied approach enabled the detection of bacterial DNA in all atherosclerotic plaques. We found that distinct members of the order Burkholderiales were present at high levels in all atherosclerotic plaques obtained from patients with atherosclerosis with the genus Curvibacter being predominant in all plaque samples. Moreover, unclassified Burkholderiales as well as members of the genera Propionibacterium and Ralstonia were typically the most significant taxa for all atherosclerotic plaques. Other genera such as Burkholderia, Corynebacterium and Sediminibacterium as well as unclassified Comamonadaceae, Oxalobacteraceae, Rhodospirillaceae, Bradyrhizobiaceae and Burkholderiaceae were always found but at low relative abundances of the total 16S rRNA gene population derived from all samples. Also, we found that some bacteria found in plaque samples correlated with some clinical parameters, including total cholesterol, alanine aminotransferase and fibrinogen levels. Finally, our study indicates that some bacterial agents at least partially may be involved in affecting the development of cardiovascular disease through different mechanisms