Contemporary Review of Hemodynamic Monitoring in the Critical Care Setting

Hemodynamic assessment remains the most valuable adjunct to physical examination and laboratory assessment in the diagnosis and management of shock. Through the years, multiple modalities to measure and trend hemodynamic indices have evolved with varying degrees of invasiveness. Pulmonary artery catheter (PAC) has long been considered the gold standard of hemodynamic assessment in critically ill patients and in recent years has been shown to improve clinical outcomes among patients in cardiogenic shock. The invasive nature of PAC is often cited as its major limitation and has encouraged development of less invasive technologies. In this review, the authors summarize the literature on the mechanism and validation of several minimally invasive and noninvasive modalities available in the contemporary intensive care unit. They also provide an update on the use of focused bedside echocardiography

Remnant cholesterol and risk of premature mortality: An analysis from a nationwide prospective cohort study

AIMS: To explore the relationship between remnant cholesterol (RC) and risk of premature mortality as well as life expectancy in the general population.METHODS: We included a total of 428,804 participants from the UK Biobank for analyses. Equivalent population percentiles approach based on the low-density lipoprotein cholesterol (LDL-C) cut-off points was performed to categorize participants into three RC groups: low (with a mean RC of 0.34 mmol/L), moderate (0.53 mmol/L), and high (1.02 mmol/L). We used multivariable Cox proportional hazards models to evaluate the relationship between RC groups and risk of premature mortality (defined as death before age 75 years). Life table methods were used to estimate life expectancy by RC groups.RESULTS: During a median follow-up of 12.1 years (Q1 - Q3: 11.0 - 13.0), there were 23,693 all-cause premature deaths documented with an incidence of 4.83 events per 1,000 person-years (95% confidence interval [CI]: 4.77 - 4.89). Compared with low RC group, the moderate RC group was associated with a 9% increased risk of all-cause premature mortality (hazard ratio [HR] = 1.09, 95% CI: 1.05 - 1.14), while the high RC group had an 11% higher risk (HR = 1.11, 95% CI: 1.07 - 1.16). At the age of 50 years, high RC group was associated with an average 2.2 lower years of life expectancy for females, and an average 0.1 lower years of life expectancy for males when compared to their counterparts in low RC group.CONCLUSIONS: Elevated RC was significantly related to increased risk of premature mortality and reduced life expectancy. Premature death in the general population would benefit from measurement to aid risk stratification and proactive management of RC to improved cardiovascular risk prevention efforts.</p

Ethnic disparities in care and outcomes of non-ST-segment elevation myocardial infarction:a nationwide cohort study

BACKGROUND: Little is known about ethnic disparities in care and clinical outcomes of patients admitted with non-ST-segment elevation myocardial infarction (NSTEMI) in national cohorts from universal healthcare systems derived from Europe. METHODS & RESULTS: We identified 280,588 admissions with NSTEMI in the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP), 2010-2017, including White patients (n = 258,364) and Black, Asian and Minority Ethnic (BAME) patients (n = 22,194). BAME patients were younger (66 years vs. 73 years, P < 0.001) and more frequently had hypertension (66% vs 54%, P < 0.001), hypercholesterolemia (49% vs 34%, P < 0.001) and diabetes (48% vs 24%, P < 0.001). BAME patients more frequently received invasive coronary angiography (80% vs 68%, P < 0.001), percutaneous coronary intervention (PCI) (52% vs 43%, P < 0.001) and coronary artery bypass graft surgery (9% vs 7%, P < 0.001). Following propensity score matching, BAME compared with White patients had similar in-hospital all-cause mortality (OR:0.91, CI: 0.76-1.06, P = 0.23), major bleeding (OR: 0.99, CI: 0.75 - 1.25, P = 0.95), reinfarction (OR: 1.15, CI: 0.84 - 1.46, P = 0.34) and major adverse cardiovascular events (MACE) (OR:0.94, CI: 0.80-1.07, P = 0.35). CONCLUSION: BAME patients with NSTEMI had higher cardiometabolic risk profiles and were more likely to undergo invasive angiography and revascularization, with similar clinical outcomes as those of their White counterparts. Among the quality indicators assessed, there is no evidence of care disparities among BAME patients presenting with NSTEMI

The need for increased pragmatism in cardiovascular clinical trials.

The majority of cardiovascular randomized controlled trials (RCTs) test interventions in selected patient populations under explicitly protocol-defined settings. Although these 'explanatory' trial designs optimize conditions to test the efficacy and safety of an intervention, they limit the generalizability of trial findings in broader clinical settings. The concept of 'pragmatism' in RCTs addresses this concern by providing counterbalance to the more idealized situation underpinning explanatory RCTs and optimizing effectiveness over efficacy. The central tenets of pragmatism in RCTs are to test interventions in routine clinical settings, with patients who are representative of broad clinical practice, and to reduce the burden on investigators and participants by minimizing the number of trial visits and the intensity of trial-based testing. Pragmatic evaluation of interventions is particularly important in cardiovascular diseases, where the risk of death among patients has remained fairly stable over the past few decades despite the development of new therapeutic interventions. Pragmatic RCTs can help to reveal the 'real-world' effectiveness of therapeutic interventions and elucidate barriers to their implementation. In this Review, we discuss the attributes of pragmatism in RCT design, conduct and interpretation as well as the general need for increased pragmatism in cardiovascular RCTs. We also summarize current challenges and potential solutions to the implementation of pragmatism in RCTs and highlight selected ongoing and completed cardiovascular RCTs with pragmatic trial designs