Hemodynamic Profiles as a Predictor of Mortality and Length Of Stay in ICCU: Insight from Registry of Acute and Intensive Cardiovascular Care Outcome

Aims: The ability to differentiate high risk and low risk patients in ICCU is beneficial. Hemodynamic profiles can be used to describe patient’s condition immediately. Based on the presence of congestion and poor perfusion, patients can be divided into four hemodynamic profiles. We aim to evaluate the prognostic value of hemodynamic profiles for patient’s mortality and length of stay (LOS) in intensive cardiac care unit (ICCU). Methods: In this retrospective cohort study, patients who admitted to ICCU of National Cardiovascular Center Harapan Kita Jakarta, Indonesia, were classified into four hemodynamic profiles: dry-warm, dry-cold, wet-warm, and wet-cold. Bivariate analysis was performed to see the significance between hemodinamic profiles with mortality and LOS, continued with multvariate analysis to evaluate the contribution of other significant factors. Results: Of 742 patients included, the mortality rate was 7.8%. With dry-warm profile as reference, relative risk for mortality was 2.3 (95% CI 1.303-4.076), 5.8 (95% CI 1.992-16.906), and 8.7 (95% CI 3.513-21.567) for wet-warm, dry-cold and wet cold, consecutively. Mean differences of LOS (days) as follows: wet-warm (1.719; 95% CI 1.21-2.23), dry-cold (3.418; 95% CI 1.52-5.32), and wet-cold (4.654; 95% CI 2.64-6.67) compared to dry-warm. Hemodynamic profiles, especially wet-cold profile, consistently predicted mortality and longer LOS in ICCU by multivariable analysis. Conclusion: The presence of “wet” profile double the risk of death, “cold” profile has five fold risk of death, while the presence of both has the highest risk for mortality and longer LOS. Hemodynamic profiles assessme   Abstrak Latar Belakang: Kemampuan untuk membedakan pasien resiko tinggi dan resiko rendah di ICCU sangat penting. Profil hemodinamik dapat digunakan untuk mengenali kondisi pasien secara cepat. Berdasarkan adanya tanda kongesti dan perfusi yang buruk pasien dapat dikelompok­kan ke dalam empat profil hemodinamik. Studi ini bertujuan untuk mengevaluasi nilai prognostik profil hemodinamik terhadap mortalitas dan lama rawat pasien di Intensive Cardiac Care Unit (ICCU). Metode : Studi kohort retrospektif ini dilakukan di Rumah Sakit Pusat Jantung dan Pembuluh Darah Nasional Harapan Kita, Jakarta, Indo­nesia. Pasien yang dirawat di ICCU dikelompokkan ke dalam empat profil hemodinamik: kering-hangat, kering-dingin, basah-hangat dan basah-dingin. Analisis bivariate dilakukan untuk menilai hubungan antara profil hemodinamik dengan mortalitas dan lama rawat di ICCU, dilanjutkan dengan analisis multivariate untuk mengevaluasi kontribusi faktor-faktor lain yang signifikan Hasil : Total pasien yang ikut dalam studi sebanyak 742 pasien dan tingkat mortalitas sebesar 7,8%. Resiko relatif (RR) mortalitas untuk profil basah-hangat, kering-dingin dan basah-dingin berturut-turut sebesar 2.3 (95% CI 1.303-4.076), 5.8 (95% CI 1.992-16.906), dan 8.7 (95% CI 3.513-21.567) bila dibandingkan terhadap profil kering-hangat sebagai referensi. Rerata perbedaan lama rawat sebesar 1.719 (95% CI 1.21-2.23), 3.418 ( 95% CI 1.52-5.32), (4.654 (95% CI 2.64-6.67) untuk profil basah-hangat, kering-dingin, dan basah dingin berturut-turut bila dibandingkan dengan profil kering-hangat. Profil hemodinamik, terutama profil basah-dingin secara konsisten memprediksi mortalitas dan lama rawat yang lebih panjang setelah analisis multivariat. Kesimpulan: Profil “basah” memiliki resiko mortalitas dua kali lipat, profil “dingin” memiliki resiko mortalitas lima kali lipat, sedangkan ked­uanya secara bersamaan memiliki resiko mortalitas dan lama rawat lebih panjang paling tinggi. Profil hemodinamik dapat digunakan sebagai prediktor mortalitas dan lama rawat pasien di ICCU secara efektif.

Characteristics and outcomes of patients with severe COVID-19 in Indonesia: Lessons from the first wave.

BackgroundIndonesia's national response to COVID-19 evolved rapidly throughout 2020. Understanding pandemic response and outcomes is crucial for better mitigation strategies ahead. This study describes the characteristics and outcomes of patients admitted to ICU during the early stages of the pandemic.MethodsThis is a multi-centre prospective observational study including patients from twelve collaborating hospitals in Indonesia. All patients were clinically suspected or laboratory-confirmed COVID-19 cases admitted to ICU between January 2020 and March 2021. The primary outcome was monthly ICU mortality. Descriptive statistics of patient characteristics and treatment were generated as secondary outcomes.ResultsFrom 559 subjects, the overall mortality was 68% and decreased over the study period, while the mortality of patients that received mechanical ventilation was 92%, consistently high over the study period. Fatal cases showed 2- and 4-day delays from symptoms onset to hospital admissions and ICU admissions, respectively. Evidence-backed approaches which could influence patient outcome, such as extracorporeal membrane oxygenation, prone positioning, renal replacement therapy, and neuromuscular blockade were scarcely administered.ConclusionsThe mortality rate of COVID-19 patients in Indonesia was extremely high during the first major outbreak of disease, particularly in those mechanically ventilated. Delayed admission and unavailability of evidence-based approaches due to high burden on health facility during COVID-19 crisis could be addressed by efficient public health measures and enhancing health infrastructure to improve the future pandemic response

Impact of chronic obstructive pulmonary disease on short-term outcome in patients with ST-elevation myocardial infarction during COVID-19 pandemic: insights from the international multicenter ISACS-STEMI registry

Background Chronic obstructive pulmonary disease (COPD) is projected to become the third cause of mortality worldwide. COPD shares several pathophysiological mechanisms with cardiovascular disease, especially atherosclerosis. However, no definite answers are available on the prognostic role of COPD in the setting of ST elevation myocardial infarction (STEMI), especially during COVID-19 pandemic, among patients undergoing primary angioplasty, that is therefore the aim of the current study. Methods In the ISACS-STEMI COVID-19 registry we included retrospectively patients with STEMI treated with primary percutaneous coronary intervention (PCI) between March and June of 2019 and 2020 from 109 high-volume primary PCI centers in 4 continents. Results A total of 15,686 patients were included in this analysis. Of them, 810 (5.2%) subjects had a COPD diagnosis. They were more often elderly and with a more pronounced cardiovascular risk profile. No preminent procedural dissimilarities were noticed except for a lower proportion of dual antiplatelet therapy at discharge among COPD patients (98.9% vs. 98.1%, P = 0.038). With regards to short-term fatal outcomes, both in-hospital and 30-days mortality occurred more frequently among COPD patients, similarly in pre-COVID-19 and COVID-19 era. However, after adjustment for main baseline differences, COPD did not result as independent predictor for in-hospital death (adjusted OR [95% CI] = 0.913[0.658-1.266], P = 0.585) nor for 30-days mortality (adjusted OR [95% CI] = 0.850 [0.620-1.164], P = 0.310). No significant differences were detected in terms of SARS-CoV-2 positivity between the two groups. Conclusion This is one of the largest studies investigating characteristics and outcome of COPD patients with STEMI undergoing primary angioplasty, especially during COVID pandemic. COPD was associated with significantly higher rates of in-hospital and 30-days mortality. However, this association disappeared after adjustment for baseline characteristics. Furthermore, COPD did not significantly affect SARS-CoV-2 positivity. Trial registration number: NCT 04412655 (2nd June 2020)

Management of Acute Coronary Syndrome Indonesia : Insight from One ACS Multicenter Registry

Background Acute coronary syndrome (ACS) is a life-threatening disorder which contributes to high morbidity and mortality in the world. Registry of ACS offers a great guidance for improvement and research. We collated a multicentre registry to gain information about demographic, management, and outcomes of ACS in Indonesia. Methods IndONEsia Acute Coronary Syndrome Registry (One ACS Registry) was a prospective nationwide multicenter registry with 14 hospitals participating in submitting data of ACS  via standardized electronic case report form (eCRF). Between July 2018 and June 2019, 7634 patients with ACS were registered. This registry recorded baseline characteristics; onset, awareness, and transfer time; physical examination and additional test; diagnosis; in-hospital medications and intervention; complications; and in-hospital outcomes. Results Nearly half of patients (48.8%) were diagnosed with STE-ACS. Most prevalent risk factors were male gender, smoking, hypertension. Patients with NSTE-ACS tended to have more concomitant diseases including diabetes mellitus, dyslipidemia, prior AMI, HF, PCI, and CABG. Majority of ACS patients in our registry (89.4%) were funded by national health coverage. Antiplatelet, anticoagulant, antihypertensive, and statins were prescribed as 24-hours therapy and discharge therapy; however presription of potent P2Y12 inhibitor was low. More STE-ACS patients underwent reperfusion therapy than non-reperfusion (65.2% vs. 34.8%), and primary PCI was the most common method (45.7%). Only 21.8% STE-ACS patients underwent reperfusion strategy within 0-3 hours of onset. Invasive strategy performed in 17.6% of NSTE-ACS patients, and only 6.7% performed early (within <24 hours). Patients underwent early invasive strategy had a shorter median LoS than late invasive strategy (P<0.001). A shorter median LoS also found in intermediate and low risk patients.  Mortality rate in our ACS patients was 8.9%; STE-ACS patients showed higher mortality than NSTE-ACS (11.7 vs. 6.2%). Conclusion Our registry showed a comparable proportion between STE- and NSTE-ACS patients, with male gender predominant in middle age. Both STE- and NSTE-ACS sharing the same risk factors. We need an improvement in referral time, especially in patients with STE-ACS. Evidence from our registry showed that there are two issues that need to be addressed in order to improve ACS outcomes: optimal and adequate medical treatment and invasive strategy

Impact of renin-angiotensin-aldosterone system inhibition on mortality in critically ill COVID-19 patients with pre-existing hypertension : a prospective cohort study

BACKGROUND: The influence of renin-angiotensin-aldosterone system (RAAS) inhibitors on the critically ill COVID-19 patients with pre-existing hypertension remains uncertain. This study examined the impact of previous use of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) on the critically ill COVID-19 patients. METHODS: Data from an international, prospective, observational cohort study involving 354 hospitals spanning 54 countries were included. A cohort of 737 COVID-19 patients with pre-existing hypertension admitted to intensive care units (ICUs) in 2020 were targeted. Multi-state survival analysis was performed to evaluate in-hospital mortality and hospital length of stay up to 90 days following ICU admission. RESULTS: A total of 737 patients were included-538 (73%) with pre-existing hypertension had received ACEi/ARBs before ICU admission, while 199 (27%) had not. Cox proportional hazards model showed that previous ACEi/ARB use was associated with a decreased hazard of in-hospital death (HR, 0.74, 95% CI 0.58-0.94). Sensitivity analysis adjusted for propensity scores showed similar results for hazards of death. The average length of hospital stay was longer in ACEi/ARB group with 21.2 days (95% CI 19.7-22.8 days) in ICU and 6.7 days (5.9-7.6 days) in general ward compared to non-ACEi/ARB group with 16.2 days (14.1-18.6 days) and 6.4 days (5.1-7.9 days), respectively. When analysed separately, results for ACEi or ARB patient groups were similar for both death and discharge. CONCLUSIONS: In critically ill COVID-19 patients with comorbid hypertension, use of ACEi/ARBs prior to ICU admission was associated with a reduced risk of in-hospital mortality following adjustment for baseline characteristics although patients with ACEi/ARB showed longer length of hospital stay. Clinical trial registration The registration number: ACTRN12620000421932; The date of registration: 30, March 2020; The URL of the registration: https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12620000421932 .</p

Number of cases and their outcome by month.

(A) Overall in-hospital mortality. (B) In-hospital mortality of mechanically ventilated patients; The bar graphs show the number of cases, and the line graphs show mortality (percentage).</p

Baseline characteristics.

BackgroundIndonesia’s national response to COVID-19 evolved rapidly throughout 2020. Understanding pandemic response and outcomes is crucial for better mitigation strategies ahead. This study describes the characteristics and outcomes of patients admitted to ICU during the early stages of the pandemic.MethodsThis is a multi-centre prospective observational study including patients from twelve collaborating hospitals in Indonesia. All patients were clinically suspected or laboratory-confirmed COVID-19 cases admitted to ICU between January 2020 and March 2021. The primary outcome was monthly ICU mortality. Descriptive statistics of patient characteristics and treatment were generated as secondary outcomes.ResultsFrom 559 subjects, the overall mortality was 68% and decreased over the study period, while the mortality of patients that received mechanical ventilation was 92%, consistently high over the study period. Fatal cases showed 2- and 4-day delays from symptoms onset to hospital admissions and ICU admissions, respectively. Evidence-backed approaches which could influence patient outcome, such as extracorporeal membrane oxygenation, prone positioning, renal replacement therapy, and neuromuscular blockade were scarcely administered.ConclusionsThe mortality rate of COVID-19 patients in Indonesia was extremely high during the first major outbreak of disease, particularly in those mechanically ventilated. Delayed admission and unavailability of evidence-based approaches due to high burden on health facility during COVID-19 crisis could be addressed by efficient public health measures and enhancing health infrastructure to improve the future pandemic response.</div

Complications during ICU stay.

BackgroundIndonesia’s national response to COVID-19 evolved rapidly throughout 2020. Understanding pandemic response and outcomes is crucial for better mitigation strategies ahead. This study describes the characteristics and outcomes of patients admitted to ICU during the early stages of the pandemic.MethodsThis is a multi-centre prospective observational study including patients from twelve collaborating hospitals in Indonesia. All patients were clinically suspected or laboratory-confirmed COVID-19 cases admitted to ICU between January 2020 and March 2021. The primary outcome was monthly ICU mortality. Descriptive statistics of patient characteristics and treatment were generated as secondary outcomes.ResultsFrom 559 subjects, the overall mortality was 68% and decreased over the study period, while the mortality of patients that received mechanical ventilation was 92%, consistently high over the study period. Fatal cases showed 2- and 4-day delays from symptoms onset to hospital admissions and ICU admissions, respectively. Evidence-backed approaches which could influence patient outcome, such as extracorporeal membrane oxygenation, prone positioning, renal replacement therapy, and neuromuscular blockade were scarcely administered.ConclusionsThe mortality rate of COVID-19 patients in Indonesia was extremely high during the first major outbreak of disease, particularly in those mechanically ventilated. Delayed admission and unavailability of evidence-based approaches due to high burden on health facility during COVID-19 crisis could be addressed by efficient public health measures and enhancing health infrastructure to improve the future pandemic response.</div

Differences in the time course from symptom onset between survivors and deaths.

(A) Overall patients, (B) Patients who underwent mechanical ventilation during their ICU stays.</p