Heart Failure
Forfia PR, Watkins SP, Rame JE, et al. 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.
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, inotropes, pressors, diuretics, and fluids based on various clinical scenarios.
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 suggests the use of PAC is not indicated for the routine management of decompensated CHF.
Cardiogenic 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.
Thiele H, Zeymer U, Neumann FJ, et al. IABP-SHOCK II Trial Investigators. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012; 367 :1287-96. Randomized study of 600 patients with cardiogenic shock complicating acute myocardial infarction found no difference in all-cause 30-day mortality with use of intraaortic balloon counterpulsation (IABP) compared to no IABP. The IABP group had less multiorgan dysfunction at days 2 and 3 but there was no difference by day 4.
Myocardial infarction
Ducrocq G, Gonzalez-Juanatey JR, Puymirat E, et al. Effect of a restrictive vs liberal blood transfusion strategy on major cardiovascular events among patients with acute myocardial infarction and anemia: The REALITY randomized clinical trial. JAMA. 2021; 325:552-560. This trial is noteworthy for finding no difference in major adverse cardiovascular events with using a transfusion threshold of 8 gm/dl compared to 10 gm/dl in the setting of acute myocardial infarction. Outcomes favored the restrictive approach but did not reach statistical significance.
Post cardiac surgery
The following two-part article provides a comprehensive review of postoperative care in adult cardiac surgical patients.
Stephens RS, Whitman GJ. Postoperative critical care of the adult cardiac surgical patient. Part I: routine postoperative care. Crit Care Med. 2015; 43:1477-97.
Stephens RS, Whitman GJ. Postoperative critical care of the adult cardiac surgical patient: Part II: procedure-specific considerations, management of complications, and quality improvement. Crit Care Med. 2015; :1995-2014.
Hajjar LA, Vincent JL, Barbosa Gomes Galas FR et al. Vasopressin versus norepinephrine in patients with vasoplegic shock after cardiac surgery: The VANCS randomized controlled trial. Anesthesiology. 2017;126:85-93. This double-blind trial of 330 patients with vasoplegic shock after cardiac surgery found use of vasopressin reduced the primary endpoint of mortality or severe complications compared to norepinephrine (32% vs 49%). There was less atrial fibrillation in the vasopressin group and no difference in digital ischemia, mesenteric ischemia, hyponatremia or myocardial infarction.
***For therapeutic hypothermia following cardiac arrest, see Neurology Critical Care.
