Cardiovascular Critical Care

Hill, Terence E.; Means, G R D Jeanne; Diepen, Sean van; Paul, Timir K.; Katz, Jason N.

doi:10.1097/ccm.0000000000001074

Cited by 13 publications

(6 citation statements)

References 22 publications

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“…Third, another reason may be that current non-cardiovascular critical care providers may feel unprepared in the management of complex cardiovascular critical illness in medical ICUs leading to a greater proportion of these patients being managed in the CICU. 10 Fourth, the shift in coding toward primary non-cardiac diagnoses may reflect changes in reimbursement that encourage ‘up-coding’ or shifting of diagnoses toward higher categories of complex conditions. The fact that we found greater rates of co-morbidities despite stable-to-improving risk adjusted outcomes suggests this possibility.…”

Section: Discussionmentioning

confidence: 99%

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Changes in Primary Noncardiac Diagnoses Over Time Among Elderly Cardiac Intensive Care Unit Patients in the United States

Sinha

Sjoding

Sukul

et al. 2017

Circ: Cardiovascular Quality and Outcomes

102

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Background Early reports suggest the number of CICU patients with primary non-cardiac diagnoses is rising in the U.S., but no national data currently exist. We examined changes in primary non-cardiac diagnoses among elderly patients admitted to a cardiac intensive care unit (CICU) over the last decade. Methods and Results Using 2003–2013 Medicare data, we grouped elderly patients admitted to CICUs into two categories based on principal diagnosis at discharge: 1) primary non-cardiac diagnoses and 2) primary cardiac diagnoses. We examined changes in patient demographics, comorbidities, procedure use, and risk-adjusted in-hospital mortality. Among 3.4 million admissions with a CICU stay, primary non-cardiac diagnoses rose in prevalence from 38.0% to 51.7% between 2003 and 2013. The fastest rising primary non-cardiac diagnoses were infectious diseases (7.8% to 15.1%) and respiratory diseases (6.0% to 7.6%) (p < 0.001 for both), while the fastest declining primary cardiac diagnosis was coronary artery disease (32.3% to 19.0%) (p < 0.001). Simultaneously, the prevalence of both cardiovascular and non-cardiovascular comorbidities rose: heart failure (13.9% to 34.4%), pulmonary vascular disease (1.2% to 7.1%), valvular heart disease (5.0% to 9.8%) and renal failure (7.1% to 19.6%) (p < 0.001 for all). As compared with those with primary cardiac diagnoses, elderly CICU patients with primary non-cardiac diagnoses had higher rates of non-cardiac procedure use and risk-adjusted in-hospital mortality (p < 0.001 for all). Risk-adjusted in-hospital mortality declined slightly in the overall cohort from 9.3% to 8.9% (p < 0.001). Conclusions More than half of all elderly patients with a CICU stay across the U.S. now have primary non-cardiac diagnoses at discharge. These patients receive different types of care and have worse outcomes than patients with primary cardiac diagnoses. Our work has important implications for the development of appropriate training and staffing models for the future critical care workforce.

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Section: Discussionmentioning

confidence: 99%

“…7–9 This latest trend has raised some concern among cardiologists, as caring for these groups of patients may require expertise in critical care and non-cardiac procedures that fall beyond the purview of typical general cardiology training. 6, 10 …”

mentioning

confidence: 99%

Changes in Primary Noncardiac Diagnoses Over Time Among Elderly Cardiac Intensive Care Unit Patients in the United States

Sinha

Sjoding

Sukul

et al. 2017

Circ: Cardiovascular Quality and Outcomes

102

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“…142 Conversely, although the ICU may be well suited to manage noncardiac organ failure, surveys have reported that ICU trainees may be unprepared to manage cardiovascular illness and to perform common cardiovascular procedures. 148 ICU-based observational studies have reported improved outcomes in a closed unit staffing model. 149 In addition, in the CICU, there is emerging evidence from a before-and-after study that transition from an open low-intensity care model to a closed unit model with care led by a dual-trained cardiologist-intensivist may improve outcomes; however, further studies are required to evaluate the independent influence of staffing and physician training.…”

Section: Cicu Versus Icu Admissionmentioning

confidence: 99%

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

Diepen¹,

Katz²,

Albert³

et al. 2017

Circulation

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1,343

1,165

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Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities. Cardiogenic shock (CS) is a low-cardiac-output state resulting in life-threatening end-organ hypoperfusion and hypoxia.1,2 Acute myocardial infarction (MI) with left ventricular (LV) dysfunction remains the most frequent cause of CS. 1,3 Advances in reperfusion therapy have been associated with improvements in survival, but significant regional disparities in evidence-based care have been reported, and in-hospital mortality remains high (27%-51%).1,4-9 Management recommendations are distributed between disease-specific statements and guidelines, and a dedicated and comprehensive clinical resource in this area is lacking. Thus, consolidating the evidence to define contemporary best medical and surgical CS practices for both MI-associated CS and other types of CS may be an important step in knowledge translation to help attenuate disparities in evidence-based care.Regional systems of care coupled with treatment algorithms have improved survival in high-acuity time-sensitive conditions such as MI, out-of-hospital cardiac arrest (OHCA), and trauma.10-12 Applying a similar framework to CS management may lead to similar improvements in survival, and CS systems of care are emerging within existing regional cardiovascular emergency care networks; however, guidance from a national expert group on structure and systems of care has not been available. 13,14 Accordingly, the purposes of this American Heart Association (AHA) scientific statement on CS are to summarize our contemporary understanding of the epidemiology, pathophysiology, and in-hospital best care practices into a single clinical resource document; to suggest a stepwise management algorithm that integrates medical, surgical, and mechanical circulatory support (MCS) therapies; and to propose a Mission: Lifelinesupported pathway for the development of integrated regionalized CS systems of care. DEFINITION OF CSAcute cardiac hemodynamic instability may result from disorders that impair function of the myocardium, valves, conduction system, or pericardium, either in isolation HISTORICAL PERSPECTIVESBefore the routine use of early revascularization, MIassociated CS had an in-hospital mortality exceeding 80%. A registry trial of 250 patients with acute MI described the association between bedside physical examination (Killip classification) for the as...

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“…En cambio, las unidades de tipo "cerrado" están dotadas de un equipo médico estable que toma la gran mayoría de las decisiones, más allá de un mayor o menor grado de interacción con el médico tratante. Existe un cuerpo de evidencia importante que favorece al modelo "cerrado", con un equipo médico presente en régimen de 24 horas, en términos de resultados (incluyendo mortalidad), lo que es aplicable tanto a las unidades generales como a las especializadas en el área cardiovascular (11) . Es interesante que esta discusión no se aplicaría en Uruguay, y probablemente en otros países de Latinoamérica, dado que en la mayoría de ellos las unidades de cuidados intensivos se desarrollaron con un modelo "cerrado" desde su origen.…”

Section: Problemas De Organizaciónunclassified

“…Si bien en la literatura científica hay detallada discusión sobre estos temas organizacionales, no se cuestiona la importancia de la existencia de UCIC con médicos cardiólogos participando activamente de la organización y operación de estos centros y se establecen variados esquemas de formación curricular de acuerdo con las diferentes organizaciones y medios académicos (11) . Existe más de un camino para obtener una especialización que contemple la formación en cardiología y en cuidado intensivo, lo que también dependerá de la comunidad médica que se trate y para qué tipo de complejidad de UCIC.…”

Section: Formación Curricularunclassified

De las unidades de cuidado coronario a las unidades de cuidado intensivo cardiovascular: una evolución inevitable

Arrarte

2017

Rev. Urug. Cardiol.

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Cardiovascular Critical Care

Cited by 13 publications

References 22 publications

Changes in Primary Noncardiac Diagnoses Over Time Among Elderly Cardiac Intensive Care Unit Patients in the United States

Changes in Primary Noncardiac Diagnoses Over Time Among Elderly Cardiac Intensive Care Unit Patients in the United States

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

De las unidades de cuidado coronario a las unidades de cuidado intensivo cardiovascular: una evolución inevitable

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