Cardiology Critical Care
Heart failure
Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. New Engl J Med 2002;347:161-7. Largest of a series of studies looking at utility of BNP levels in determining cardiac vs. non-cardiac cause of dyspnea. BNP has to be quite low to rule out CHF. For a BNP < 50 pg/ml, the negative predictive value (NPV) was 96% and for BNP < 150 pg/ml, NPV was 85%. Patients with a history of left ventricular dysfunction but with a non-cardiac cause of dyspnea had BNP levels that overlapped considerably with those of CHF patients.
PMID: 12124404
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Forfia PR, Watkins SP, Rame JE, Stewart KJ, Shapiro EP. Relationship between B-type natriuretic peptides and pulmonary capillary wedge pressure in the intensive care unit. J Am Coll Cardiol. 2005; 45:1667-71. BNP and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are highly correlated with left ventricular (LV) filling pressures in patients with depressed LV systolic function but less is known about their utility in ICU patients. This study found peptide levels were approximately four-fold greater in patients with impaired (estimated glomerular filtration rate [eGFR] <60 ml/min) versus normal (eGFR >60 ml/min) renal function, despite similar PCWP, cardiac index, and LV ejection fraction.
PMID: 15893185
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Mebazaa A, Gheorghiade M, Pina IL, et al. Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes. Crit Care Med 2008; 36[Suppl]:S129-139. Intensivists are often involved in the early management of heart failure patients but there are few randomized studies to guide management in this setting. These guidelines are derived primarily from expert opinion and provide recommendations on the use nitrates, intotropes, pressors, diuretics, and fluids based on various clinical scenarios.
PMID: 18158472
Binanay C, Califf RM, Hasselblad V, et al. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA 2005; 294:1625-33. This RCT of 433 patients with acute decompensated CHF (but not shock) found no difference in resolution of symptoms, mortality, or days alive and out of the hospital at 6 months. There was a higher incidence of adverse events in the group randomized to PAC. This data should discourage the use of PAC for the routine management of decompensated CHF.
PMID: 16204662
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Cariogenic shock
DeBacker D, Biston P, Devriendt J, et al. SOAP II Investigators. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362:779-89. Large multicenter RCT of 1679 patients with shock of any etiology, demonstrated equal mortality and significantly fewer arrhythmias with norepinephrine as first line vasopressor. Subgroup of those with cardiogenic shock had higher mortality with dopamine. Concerns raised have included heterogeneity of shock physiologies included, restricted fluid resuscitation protocol, and open label use of norepinephrine after conservative max doses of study drug. However, this study adds valuable evidence to our currently limited understanding of comparative merits of pressors.
PMID: 20200382
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***For therapeutic hypothermia following cardiac arrest, see Neurology Critical Care.
