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. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12124404

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. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15893185&query_hl=1&itool=pubmed_docsum 

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.
http://www.ncbi.nlm.nih.gov/pubmed/18158472?ordinalpos=11&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Binanay C, Califf RM, Hasselblad V, et al. Evaluation study of congestive heart failure and pulumonary 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.
http://www.ncbi.nlm.nih.gov/pubmed/16204662?ordinalpos=11&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Hypothermia in post cardiac arrest

The following simultaneously-published studies found reducing core body temperature to 32°C to 34°C improved neurologic outcomes in comatose survivors of cardiac arrest:

Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.  N Engl J Med 2002; 346:557-63. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11856794&query_hl=9&itool=pubmed_docsum

The Hypothermia After Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest.  http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11856793&query_hl=9&itool=pubmed_docsum N Engl J Med 2002; 346:549-56.