Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome

Purpose

Pulmonary vascular dysfunction is common during acute respiratory distress syndrome (ARDS), but there is controversy concerning prevalence and prognosis of cor pulmonale during protective ventilation for ARDS.

Methods

This was a prospective observational study in an academic medical intensive care unit in France. Two hundred and twenty-six consecutive patients with moderate to severe ARDS (Berlin definition) ventilated with plateau pressure limited at 30 cmH₂O (mean PEEP of 8.8 ± 3.6 cmH₂O) underwent transesophageal echocardiography (TEE) within the first 3 days after the diagnosis of ARDS. Cor pulmonale was defined as a dilated right ventricle associated with septal dyskinesia.

Results

Cor pulmonale was detected in 49 patients (prevalence of 22 %; 95 % confidence interval, 16–27 %). Multivariate logistic regression identified infectious causes of lung injury and higher driving pressures as independent factors associated with cor pulmonale. Patients with cor pulmonale exhibited a higher incidence of shock (need for vasoactive drug) at the time of TEE and were more often managed with prone positioning and/or nitric oxide as adjunctive therapy for severe hypoxemia during ARDS course. The 28-day mortality rate was significantly higher in the group with cor pulmonale (60 vs. 36 %, p < 0.01). Multivariate logistic regression identified McCabe and Jackson class, lung injury not related to pneumonia, aspiration, or sepsis, lactic acidosis, driving pressure, and cor pulmonale as independent risk factors for 28-day mortality.

Conclusion

Cor pulmonale occurrence is not negligible in ARDS patients ventilated with airway pressure limitation. Cor pulmonale was associated with sepsis and higher values of driving pressure and was an independent risk factor for 28-day mortality in our series.     

Risk factors for carbapenem-resistant Gram-negative bacteremia in intensive care unit patients

Purpose

Carbapenem-resistant (CR) Gram-negative pathogens have increased substantially. This study was performed to identify the risk factors for development of CR Gram-negative bacteremia (GNB) in intensive care unit (ICU) patients.

Methods

Prospective study; risk factors for development of CR-GNB were investigated using two groups of case patients: the first group consisted of patients who acquired carbapenem susceptible (CS) GNB and the second group included patients with CR-GNB. Both case groups were compared to a shared control group defined as patients without bacteremia, hospitalized in the ICU during the same period.

Results

Eighty-five patients with CR- and 84 patients with CS-GNB were compared to 630 control patients, without bacteremia. Presence of VAP (OR 7.59, 95 % CI 4.54–12.69, p < 0.001) and additional intravascular devices (OR 3.69, 95 % CI 2.20–6.20, p < 0.001) were independently associated with CR-GNB. Presence of VAP (OR 2.93, 95 % CI 1.74–4.93, p < 0.001), presence of additional intravascular devices (OR 2.10, 95 % CI 1.23–3.60, p = 0.007) and SOFA score on ICU admission (OR 1.11, 95 % CI 1.03–1.20, p = 0.006) were independently associated with CS-GNB. The duration of exposure to carbapenems (OR 1.079, 95 % CI 1.022–1.139, p = 0.006) and colistin (OR 1.113, 95 % CI 1.046–1.184, p = 0.001) were independent risk factors for acquisition of CR-GNB. When the source of bacteremia was other than VAP, previous administration of carbapenems was the only factor related with the development of CR-GNB (OR 1.086, 95 % CI 1.003–1.177, p = 0.042).

Conclusions

Among ICU patients, VAP development and the presence of additional intravascular devices were the major risk factors for CR-GNB. In the absence of VAP, prior use of carbapenems was the only factor independently related to carbapenem resistance.     

Clinical characteristics, morbidity, and prognostic value of concomitant coronary artery disease in idiopathic dilated cardiomyopathy

Background

Patients with idiopathic dilated cardiomyopathy (dCMP) might present coronary artery disease (CAD) concomitant to dCMP and prognostic differences between ischemic heart disease and non-ischemic cardiomyopathy have been described. Clinical characteristics and prognostic implications of concomitant CAD in patients with dCMP are largely unknown.

Methods

A total of 1,263 patients with chronic systolic dysfunction from dCMP—of these 67.1 % (n = 847; 72.3 % men) without and 32.9 % (n = 416; 80.8 % men) with concomitant CAD were included and baseline clinical characteristics noted. They were followed prospectively for 36.3 (20.8–65.0) months, representing 5,168 patient-years. All-cause mortality was the primary endpoint; and decompensation requiring hospitalisation as well as the combined endpoint thereof were secondary endpoints.

Results

Independent significant predictors of CAD were smoking status (current smoker: OR 2.68, 95 % CI 1.61–4.46; p < 0.001; past smoker: OR 2.52, 95 % CI 1.40–4.52; p < 0.005; each vs. non-smoker), presence of dyslipidemia (OR 3.46, 95 % CI 2.23–5.35; p < 0.001), age (OR 1.06, 95 % CI 1.04–1.08; p < 0.001), and female sex (OR 0.49, 95 % CI 0.29–0.81; p = 0.005). The presence of CAD was not a significant predictor of all-cause mortality (adjusted HR 0.74, 95 % CI 0.36–1.54; p = 0.42), morbidity (adjusted HR 1.48, 95 % CI 0.55–3.99; p = 0.44), or the combined endpoint (HR 0.65, 95 % CI 0.24–1.78; p = 0.40).

Conclusion

Concomitant CAD is common in patients with dCMP. Clinical predictors of its presence are largely coincident with classic risk factors in the general population. The presence of concomitant CAD appears not to be associated with adverse prognosis (morbidity or mortality) in patients with dCMP.     

Critically ill infants and children with influenza A (H1N1) in pediatric intensive care units in Argentina

Objective

To determine the epidemiological features, course, and outcomes of critically ill pediatric patients with Influenza A (H1N1) virus.

Design

Prospective cohort of children in pediatric intensive care units (PICUs) due to Influenza A (H1N1) virus infection.

Setting

Seventeen medical-surgical PICUs in tertiary care hospital in Argentina.

Patients

All consecutive patients admitted to the PICUs with influenza A (H1N1) viral infection from 15 June to 31 July 2009.

Measurements and main results

Of 437 patients with acute lower respiratory infection in PICUs, 147 (34%) were diagnosed with influenza A (H1N1) related to critical illness. The median age of these patients was 10 months (IQR 3–59). Invasive mechanical ventilation was used in 117 (84%) on admission. The rate of acute respiratory distress syndrome (ARDS) was 80% (118 of 147 patients). Initial non-invasive ventilation failed in 19 of 22 attempts (86%). Mortality at 28 days was 39% (n = 57). Chronic complex conditions (CCCs), acute renal dysfunction (ARD) and ratio PaO₂/FiO₂ at day 3 on MV were independently associated with a higher risk of mortality. The odds ratio (OR) for CCCs was 3.06, (CI 95% 1.36–6.84); OR for ARD, 3.38, (CI 95% 1.45–10.33); OR for PaO₂/FiO₂, 4 (CI 95% 1.57–9.59). The administration of oseltamivir within 24 h after admission had a protective effect: OR 0.2 (CI 95% 0.07–0.54).

Conclusions

In children with ARDS, H1N1 as an etiologic agent confers high mortality, and the presence of CCCs in such patients increases the risk of death.     

Enteral omega-3 fatty acid supplementation in adult patients with acute respiratory distress syndrome: a systematic review of randomized controlled trials with meta-analysis and trial sequential analysis

Purpose

Controversy remains as to whether enteral supplementation of ω-3 fatty acids (FA) could improve outcomes in patients with acute respiratory distress syndrome (ARDS). Thus, we did a meta-analysis and aimed to investigate the benefit and harm of enteral ω-3 FA supplementation in adult patients with ARDS.

Methods

Databases including PubMed, Embase, the Cochrane Register of Controlled Trials, and Google Scholar were searched to find relevant articles. Randomized controlled trials (RCTs) comparing enteral ω-3 FA supplementation with a control or placebo intervention in adult patients with ARDS were included. The primary outcome was all-cause 28-day mortality. We used the Cochrane Collaboration methodology.

Results

Seven RCTs with 955 adult patients qualified for inclusion, and all the selected trials were considered as at high risk of bias. The use of enteral ω-3 FA did not significantly reduce all-cause 28-day mortality [relative risk (RR), 0.90; 95 % confidence intervals (CI), 0.68–1.18; p = 0.44; I ² = 31 %; random effects]. Trial sequential analysis indicated lack of firm evidence for a 20 % RR reduction in all-cause 28-day mortality. PaO₂/FiO₂ ratio was significantly increased in the ω-3 FA group on day 4 [weighted mean difference (WMD), 45.14; 95 % CI, 16.77–73.51; p = 0.002; I ² = 86 %; random effects] and day 7 (WMD, 33.10; 95 % CI, 1.67–64.52; p = 0.04; I ² = 88 %; random effects). Meta-analysis using a random effects model showed no significant differences in ventilator-free days (VFD) (WMD, 2.47 days; 95 % CI, ?2.85 to 7.79; p = 0.36; I ² = 91 %) or intensive care unit-free days (ICU) (WMD, 2.31 days; 95 % CI, ?2.34 to 6.97; p = 0.33; I ² = 89 %) between the two groups.

Conclusions

Among patients with ARDS, enteral supplementation of ω-3 FA seemed ineffective regarding all-cause 28-day mortality, VFD, and ICU-free days. Routine use of enteral ω-3 FA cannot be recommended based on the available evidence.     

Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis

Background

Prone position ventilation for acute hypoxemic respiratory failure (AHRF) improves oxygenation but not survival, except possibly when AHRF is severe.

Objective

To determine effects of prone versus supine ventilation in AHRF and severe hypoxemia [partial pressure of arterial oxygen (PaO₂)/inspired fraction of oxygen (FiO₂) <100 mmHg] compared with moderate hypoxemia (100 mmHg ≤ PaO₂/FiO₂ ≤ 300 mmHg).

Design

Systematic review and meta-analysis.

Data Sources

Electronic databases (to November 2009) and conference proceedings.

Methods

Two authors independently selected and extracted data from parallel-group randomized controlled trials comparing prone with supine ventilation in mechanically ventilated adults or children with AHRF. Trialists provided subgroup data. The primary outcome was hospital mortality in patients with AHRF and PaO₂/FiO₂ <100 mmHg. Meta-analyses used study-level random-effects models.

Results

Ten trials (N = 1,867 patients) met inclusion criteria; most patients had acute lung injury. Methodological quality was relatively high. Prone ventilation reduced mortality in patients with PaO₂/FiO₂ <100 mmHg [risk ratio (RR) 0.84, 95% confidence interval (CI) 0.74–0.96; p = 0.01; seven trials, N = 555] but not in patients with PaO₂/FiO₂ ≥100 mmHg (RR 1.07, 95% CI 0.93–1.22; p = 0.36; seven trials, N = 1,169). Risk ratios differed significantly between subgroups (interaction p = 0.012). Post hoc analysis demonstrated statistically significant improved mortality in the more hypoxemic subgroup and significant differences between subgroups using a range of PaO₂/FiO₂ thresholds up to approximately 140 mmHg. Prone ventilation improved oxygenation by 27–39% over the first 3 days of therapy but increased the risks of pressure ulcers (RR 1.29, 95% CI 1.16–1.44), endotracheal tube obstruction (RR 1.58, 95% CI 1.24–2.01), and chest tube dislodgement (RR 3.14, 95% CI 1.02–9.69). There was no statistical between-trial heterogeneity for most clinical outcomes.

Conclusions

Prone ventilation reduces mortality in patients with severe hypoxemia. Given associated risks, this approach should not be routine in all patients with AHRF, but may be considered for severely hypoxemic patients.     

Reducing in-hospital cardiac arrests and hospital mortality by introducing a medical emergency team

Purpose

To prospectively evaluate the implementation of a rapid response team in the form of a medical emergency team (MET) with regard to cardiac arrests and hospital mortality.

Methods

Prospective before-and-after trial of implementation of a MET at the Karolinska University Hospital, Stockholm, Sweden. All adult patients, apart from cardiothoracic, admitted to the hospital were regarded as participants in the study. A control period of 5 years and 203,892 patients preceded the 2-year intervention period of 73,825 patients.

Main results

Number of MET calls was 9.3 per 1,000 hospital admissions. Cardiac arrests per 1,000 admissions decreased from 1.12 to 0.83, OR 0.74 (95% CI 0.55–0.98, p = 0.035). Adjusted for age, sex, hospital length of stay, acute/elective admission as well as co-morbidities, MET implementation was associated with a reduction in total hospital mortality by 10%, OR 0.90 (95% CI 0.84–0.97), p = 0.003. Hospital mortality was also reduced for medical patients by 12%, OR 0.88 (95% CI 0.81–0.96, p = 0.002) and for surgical patients not operated upon by 28%, OR 0.72 (95% CI 0.56–0.92, p = 0.008).

For patients fulfilling the MET criteria

Thirty-day mortality pre-MET was 25% versus 7.9% following MET compared with historical controls. Similarly, 180-day mortality was 37.5% versus 15.8%, respectively.

Conclusions

Implementing the MET team was associated with significant improvement in both cardiac arrest rate and overall adjusted hospital mortality. Significant reductions in hospital mortality for un-operated surgical patients as well as for medical patients were also seen. Thus, introduction of the MET seemed to improve outcome for hospitalized patients.     

One-year mortality and predictors of death among hospital survivors of acute respiratory distress syndrome

Purpose

Advances in supportive care and ventilator management for acute respiratory distress syndrome (ARDS) have resulted in declines in short-term mortality, but risks of death after survival to hospital discharge have not been well described. Our objective was to quantify the difference between short-term and long-term mortality in ARDS and to identify risk factors for death and causes of death at 1 year among hospital survivors.

Methods

This multi-intensive care unit, prospective cohort included patients with ARDS enrolled between January 2006 and February 2010. We determined the clinical characteristics associated with in-hospital and 1-year mortality among hospital survivors and utilized death certificate data to identify causes of death.

Results

Of 646 patients hospitalized with ARDS, mortality at 1 year was substantially higher (41 %, 95 % CI 37–45 %) than in-hospital mortality (24 %, 95 % CI 21–27 %), P < 0.0001. Among 493 patients who survived to hospital discharge, the 110 (22 %) who died in the subsequent year were older (P < 0.001) and more likely to have been discharged to a nursing home, other hospital, or hospice compared to patients alive at 1 year (P < 0.001). Important predictors of death among hospital survivors were comorbidities present at the time of ARDS, and not living at home prior to admission. ARDS-related measures of severity of illness did not emerge as independent predictors of mortality in hospital survivors.

Conclusions

Despite improvements in short-term ARDS outcomes, 1-year mortality is high, mostly because of the large burden of comorbidities, which are prevalent in patients with ARDS.     

The use of the Berlin definition for acute respiratory distress syndrome during infancy and early childhood: multicenter evaluation and expert consensus

Purpose

A new acute respiratory distress syndrome (ARDS) definition has been recently issued: the so-called Berlin definition (BD) has some characteristics that could make it suitable for pediatrics. The European Society for Pediatric Neonatal Intensive Care (ESPNIC) Respiratory Section started a project to evaluate BD validity in early childhood. A secondary aim was reaching a consensus on clinical tools (risk factors list and illustrative radiographs) to help the application of BD.

Methods

This was an international, multicenter, retrospective study enrolling 221 children [aged greater than 30 days and less than 18 months; median age 6 (range 2–13) months], admitted to seven European pediatric intensive care units (PICU) with acute lung injury (ALI) or ARDS diagnosed with the earlier definition.

Results

Patients were categorized according to the two definitions, as follows: ALI, 36; ARDS, 185 (for the American–European Consensus Conference (AECC) definition); mild, 36; moderate, 97; severe ARDS, 88 (for BD). Mortality (13.9 % for mild ARDS; 11.3 % for moderate ARDS; 25 % for severe ARDS, p = 0.04) and the composite outcome extracorporeal membrane oxygenation (ECMO)/mortality (13.9 % for mild ARDS; 11.3 % for moderate ARDS; 28.4 % for severe ARDS, p < 0.01) were different across the BD classes, whereas they were similar using the previous definition. Mortality [HR 2.7 (95 % CI 1.1–7.1)] and ECMO/mortality [HR 3 (95 % CI 1.1–7.9)] were increased only for the severe ARDS class and remained significant after adjustment for confounding factors. PICU stay was not different across severity classes, irrespective of the definition used. There was significant concordance between raters evaluating radiographs [ICC 0.6 (95 % CI 0.2–0.8)] and risk factors [ICC 0.92 (95 % CI 0.8–0.97)].

Conclusions

BD validity for children is similar to that already reported in adults and mainly due to the introduction of a “severe ARDS” category. We provided clinical tools to use BD for clinical practice, research, and health services planning in pediatric critical care.     

Neurologic complications in neonates supported with extracorporeal membrane oxygenation. An analysis of ELSO registry data

Background

Neurologic complications in neonates supported with extracorporeal membrane oxygenation (ECMO) are common and diminish their quality of life and survival. An understanding of factors associated with neurologic complications in neonatal ECMO is lacking. The goals of this study were to describe the epidemiology and factors associated with neurologic complications in neonatal ECMO.

Patients and methods

Retrospective cohort study of neonates (age ≤30 days) supported with ECMO using data reported to the Extracorporeal Life Support Organization during 2005–2010.

Results

Of 7,190 neonates supported with ECMO, 1,412 (20 %) had neurologic complications. Birth weight <3 kg [odds ratio (OR): 1.3; 95 % confidence intervals (CI): 1.1–1.5], gestational age (<34 weeks; OR 1.5, 95 % CI 1.1–2.0 and 34–36 weeks: OR 1.4, 95 % CI 1.1–1.7), need for cardiopulmonary resuscitation prior to ECMO (OR 1.7, 95 % CI 1.5–2.0), pre-ECMO blood pH ≤ 7.11 (OR 1.7, 95 % CI 1.4–2.1), pre-ECMO bicarbonate use (OR 1.3, 95 % CI 1.2–1.5), prior ECMO exposure (OR 2.4, 95 % CI 1.6–2.6), and use of veno-arterial ECMO (OR 1.7, 95 % CI 1.4–2.0) increased neurologic complications. Mortality was higher in patients with neurologic complications compared to those without (62 % vs. 36 %; p < 0.001).

Conclusions

Neurologic complications are common in neonatal ECMO and are associated with increased mortality. Patient factors, pre-ECMO severity of illness, and use of veno-arterial ECMO are associated with increased neurologic complications. Patient selection, early ECMO deployment, and refining ECMO management strategies for vulnerable populations could be targeted as areas for improvement in neonatal ECMO.     

The ETHICA study (part II): simulation study of determinants and variability of ICU physician decisions in patients aged 80 or over

Purpose

To assess physician decisions about ICU admission for life-sustaining treatments (LSTs).

Methods

Observational simulation study of physician decisions for patients aged ≥80 years. Each patient was allocated at random to four physicians who made decisions based on actual bed availability and existence of an additional bed before and after obtaining information on patient preferences. The simulations involved non-invasive ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of IMV (RRT after IMV).

Results

The physician participation rate was 100/217 (46 %); males without religious beliefs predominated, and median ICU experience was 9 years. Among participants, 85.7, 78, and 62 % felt that NIV, IMV, or RRT (after IMV) was warranted, respectively. By logistic regression analysis, factors associated with admission were age <85 years, self-sufficiency, and bed availability for NIV and IMV. Factors associated with IMV were previous ICU stay (OR 0.29, 95 % CI 0.13–0.65, p = 0.01) and cancer (OR 0.23, 95 % CI 0.10–0.52, p = 0.003), and factors associated with RRT (after IMV) were living spouse (OR 2.03, 95 % CI 1.04–3.97, p = 0.038) and respiratory disease (OR 0.42, 95 % CI 0.23–0.76, p = 0.004). Agreement among physicians was low for all LSTs. Knowledge of patient preferences changed physician decisions for 39.9, 56, and 57 % of patients who disagreed with the initial physician decisions for NIV, IMV, and RRT (after IMV) respectively. An additional bed increased admissions for NIV and IMV by 38.6 and 13.6 %, respectively.

Conclusions

Physician decisions for elderly patients had low agreement and varied greatly with bed availability and knowledge of patient preferences.     

Prone positioning reduces mortality from acute respiratory distress syndrome in the low tidal volume era: a meta-analysis

Purpose

Prone positioning for ARDS has been performed for decades without definitive evidence of clinical benefit. A recent multicenter trial demonstrated for the first time significantly reduced mortality with prone positioning. This meta-analysis was performed to integrate these findings with existing literature and test whether differences in tidal volume explain conflicting results among randomized trials.

Methods

Studies were identified using MEDLINE, EMBASE, Cochrane Register of Controlled Trials, LILACS, and citation review. Included were randomized trials evaluating the effect on mortality of prone versus supine positioning during conventional ventilation for ARDS. The primary outcome was risk ratio of death at 60 days meta-analyzed using random effects models. Analysis stratified by high (>8 ml/kg predicted body weight) or low (≤8 ml/kg PBW) mean baseline tidal volume was planned a priori.

Results

Seven trials were identified including 2,119 patients, of whom 1,088 received prone positioning. Overall, prone positioning was not significantly associated with the risk ratio of death (RR 0.83; 95 % CI 0.68–1.02; p = 0.073; I ²  = 64 %). When stratified by high or low tidal volume, prone positioning was associated with a significant decrease in RR of death only among studies with low baseline tidal volume (RR 0.66; 95 % CI 0.50–0.86; p = 0.002; I ²  = 25 %). Stratification by tidal volume explained over half the between-study heterogeneity observed in the unstratified analysis.

Conclusions

Prone positioning is associated with significantly reduced mortality from ARDS in the low tidal volume era. Substantial heterogeneity across studies can be explained by differences in tidal volume.     

Severe hypercapnia and outcome of mechanically ventilated patients with moderate or severe acute respiratory distress syndrome

Purpose

To analyze the relationship between hypercapnia developing within the first 48 h after the start of mechanical ventilation and outcome in patients with acute respiratory distress syndrome (ARDS).

Patients and methods

We performed a secondary analysis of three prospective non-interventional cohort studies focusing on ARDS patients from 927 intensive care units (ICUs) in 40 countries. These patients received mechanical ventilation for more than 12 h during 1-month periods in 1998, 2004, and 2010. We used multivariable logistic regression and a propensity score analysis to examine the association between hypercapnia and ICU mortality.

Main outcomes

We included 1899 patients with ARDS in this study. The relationship between maximum PaCO₂ in the first 48 h and mortality suggests higher mortality at or above PaCO₂ of ≥50 mmHg. Patients with severe hypercapnia (PaCO₂ ≥50 mmHg) had higher complication rates, more organ failures, and worse outcomes. After adjusting for age, SAPS II score, respiratory rate, positive end-expiratory pressure, PaO₂/FiO₂ ratio, driving pressure, pressure/volume limitation strategy (PLS), corrected minute ventilation, and presence of acidosis, severe hypercapnia was associated with increased risk of ICU mortality [odds ratio (OR) 1.93, 95% confidence interval (CI) 1.32 to 2.81; p = 0.001]. In patients with severe hypercapnia matched for all other variables, ventilation with PLS was associated with higher ICU mortality (OR 1.58, CI 95% 1.04–2.41; p = 0.032).

Conclusions

Severe hypercapnia appears to be independently associated with higher ICU mortality in patients with ARDS.

Trial registration

Clinicaltrials.gov identifier, NCT01093482.

     

Late-onset moderate to severe acute respiratory distress syndrome is associated with shorter survival and higher mortality: a two-stage association study

Purpose

To evaluate the association between acute respiratory distress syndrome (ARDS) onset time and prognosis.

Methods

Patients with moderate to severe ARDS (N = 876) were randomly assigned into derivation (N = 520) and validation (N = 356) datasets. Both 28-day and 60-day survival times after ARDS onset were analyzed. A data-driven cutoff point between early- and late-onset ARDS was determined on the basis of mortality risk effects of onset times. We estimated the hazard ratio (HR) and odds ratio (OR) of late-onset ARDS using a multivariate Cox proportional hazards model of survival time and a multivariate logistic regression model of mortality rate, respectively.

Results

Late-onset ARDS, defined as onset over 48 h after intensive care unit (ICU) admission (N = 273, 31%), was associated with shorter 28-day survival time: HR = 2.24, 95% CI 1.48–3.39, P = 1.24 × 10^?4 (derivation); HR = 2.16, 95% CI 1.33–3.51, P = 1.95 × 10^?3 (validation); and HR = 2.00, 95% CI 1.47–2.72, P = 1.10 × 10^?5 (combined dataset). Late-onset ARDS was also associated with shorter 60-day survival time: HR = 1.70, 95% CI 1.16–2.48, P = 6.62 × 10^?3 (derivation); HR = 1.78, 95% CI 1.15–2.75, P = 9.80 × 10^?3 (validation); and HR = 1.59, 95% CI 1.20–2.10, P = 1.22 × 10^?3 (combined dataset). Meanwhile, late-onset ARDS was associated with higher 28-day mortality rate (OR = 1.46, 95% CI 1.04–2.06, P = 0.0305) and 60-day mortality rate (OR = 1.44, 95% CI 1.03–2.02, P = 0.0313).

Conclusions

Late-onset moderate to severe ARDS patients had both shorter survival time and higher mortality rate in 28-day and 60-day observations.

     

Tailoring diuretic therapy in acute heart failure: insight into early diuretic response predictors

Background/objectives

Few data exist to help physicians in the use of diuretics to provide the greatest symptomatic benefit with the least adverse effect to patients and to select the subset of patients who require a more aggressive diuretic strategy and monitoring. The aim of this study is to identify early predictors of diuretic response in a selected group of patients with acutely decompensated chronic heart failure (ADCHF).

Methods

This was an observational, retrospective secondary analysis of a study including 100 patients with ADCHF.

Results

The mean ± standard deviation (SD) of age was 76.0 ± 10.9 years. Sixty-one patients were female. After three days of inpatient treatment, 16 (16 %) patients maintained or increased i.v. furosemide dose (slow diuretic response, SDR). This group of patients had more indirect signs of fluid overload, including greater body mass index increment. The other 84 patients had greater congestion relief and had decreased i.v. furosemide dose or were switched furosemide to oral route (fast diuretic response, FDR). Admission day factors predicting SDR were: higher levels of pUr (mean ± SD, 69.6 ± 20.9 vs. 52.5 ± 19.8, p = 0.002), higher levels of pUr/pCr ratio (mean ± SD, 58.3 ± 15.2 vs. 49.6 ± 15.1, p = 0.036), higher levels of albuminuria [median (IQR), 131.5 (396.9) vs. 47.1 (143.6), p = 0,011], higher levels of red cell distribution width (RDW) [median (IQR), 16.0 (1.9) vs. 15.1 (1.5), p = 0.039], lower levels of HgB (mean ± SD, 11.5 ± 1.8 vs. 12.6 ± 2.1, p = 0.04) and higher levels of hsTnT [median (IQR), 0.05 (0.05) vs. 0.03 (0.03), p = 0,026]. By multivariate analysis, the strongest independent early predictors of SDR were: pUr [OR (95 % CI), 1.04 [1.01–1.07], p = 0.006] and RDW [OR (95 % CI), 1.47 (1.07–2.02), p = 0.018]. During the first 3 days of hospitalization, the strongest independent factor associated with SDR was NTproBNP increase or decrease by less than 30 % from day 1 to day 3 [OR (95 % CI), 4.84 (1.14–20.55), p = 0.032]. Use of high-dose spironolactone was associated with FDR [OR (95 % CI), 0.17 (0.03–0.85), p = 0.031].

Conclusions

High RDW and high levels of pUr at admission are strong predictors of slower diuretic response. No change or increase in NTproBNP in the first 3 days of treatment is associated with slower diuretic response. On the other hand, the use of high-dose spironolactone is associated with faster diuretic response.     

Drug-coated balloons in treatment of in-stent restenosis: a meta-analysis of randomised controlled trials

Background

Drug-coated balloons (DCBs) have been developed for the percutaneous treatment of coronary artery disease. An initial focus has been the management of in-stent restenosis (ISR) but randomised controlled trials (RCTs) have been small and powered only for angiographic endpoints.

Objective

The aim of the work was to assess the clinical and angiographic outcomes of patients treated for ISR with DCB versus control (balloon angioplasty or drug-eluting stents) by a meta-analysis of RCTs.

Methods

A comprehensive search was performed of RCTs where patients with ISR were randomly assigned to either DCB or alternative coronary intervention. Outcome measurements were death, myocardial infarction (MI), target lesion revascularisation (TLR), binary definition of restenosis and in-lesion late luminal loss (LLL).

Results

Four studies were identified that fulfilled the inclusion criteria. Pooled odds ratios (ORs) were calculated for patients treated for ISR (n = 399). Mean follow-up duration was 14.5 months. DCBs were associated with lower rates of TLR [8.8 vs. 29.7 % OR (95 % confidence interval, CI) 0.20 (0.11–0.36), p < 0.0001], binary restenosis [10.3 vs. 41.3 % OR (95 % CI) 0.13 (0.07–0.24), p < 0.00001] and MI [0.5 vs. 3.8 %, OR (95 % CI) 0.21 (0.04–1.00), p = 0.05]. No significant heterogeneity was identified.

Conclusion

Drug-coated balloons appear to be effective versus control in reducing TLR and possibly MI versus balloon angioplasty or drug-eluting stents in the management of ISR.     

Prognosis of patients with atrial fibrillation undergoing percutaneous coronary intervention receiving drug eluting stents

Background

Atrial fibrillation (AF) is increasingly prevalent in elderly patients and adversely affects clinical outcomes after coronary artery bypass grafting, non-cardiac surgery or myocardial infarction. Aim of the present analysis was to investigate the prognostic impact of AF in patients undergoing drug eluting stent (DES) implantation during a 1-year follow-up.

Patients and methods

5,772 consecutive patients undergoing percutaneous coronary intervention were enrolled into the German Drug Eluting Stent Registry (DES.DE) and were followed for 12 months. Of these 455 had AF and 5,317 in sinus rhythm served as controls. Univariate and multivariate logistic regression analyses were used to determine the risk of major adverse cardiac and cerebrovascular events (MACCE) and bleeding complications.

Results

Patients with AF were older (71.3 ± 7.6 vs. 64.7 ± 10.5 years) and had a higher prevalence of diabetes, hypertension, renal insufficiency as well as more prior bypass surgery, stroke and peripheral arterial disease. Cardiogenic shock (2.9 vs. 1.4 %; p < 0.05), left ventricular ejection fraction ≤40 % (21.0 vs. 11.4 %; p < 0.0001) and triple vessel disease (44.4 vs. 37.9 %; p < 0.01) were more frequent in patients with AF than in controls. MACCE (OR 2.08, 95 % CI 1.56–2.77), total mortality (OR 3.27, 95 % CI 2.32–4.62) and non-fatal stroke (OR 2.03, 95 % CI 1.03–4.00) as well as bleeding complications (OR 1.88, 95 % CI 1.13–3.12) during the 1-year follow-up were more frequent in patients with AF (univariate analysis). In multivariate analyses adjusting for covariates determined to be relevant at baseline, the risk for total mortality remained elevated (OR 1.63, 95 % CI 1.05–2.52).

Conclusions

AF is an important predictor of long-term mortality in patients undergoing DES implantation.     

Increased pericardial adipose tissue is correlated with atrial fibrillation and left atrial dilatation

Introduction

Pericardial adipose tissue (PAT), a visceral fat depot surrounding the heart, serves as an endocrine active organ and is associated with inflammation. There is growing evidence that atrial fibrillation (AF) is linked with inflammation, which in turn can be a promoter of left atrial remodeling. The aim of this study was to evaluate a potential correlation of PAT to AF and left atrial structural remodeling represented by LA size.

Methods

PAT was measured in 1,288 patients who underwent coronary artery calcium-scanning for coronary risk stratification. LA size was determined by two independent readers. Patients were subdivided into patients without AF, patients with paroxysmal and persistent AF.

Results

PAT was independently correlated with AF, persistent AF, and LA size (all p values <0.001). No association could be observed between paroxysmal AF and PAT. These associations persisted after multivariate adjustment for AF risk factors such as age, hypertension, valvular disease, heart failure, and body mass index (AF: OR 1.52, 95 % CI 1.15–2.00, p = 0.003; persistent AF: OR 2.58, 95 % CI 1.69–3.99, p = 0.001; LA size: regression coefficient 0.15 with 95 % CI 0.10–0.20, p < 0.001).

Conclusion

PAT is associated with AF, in particular with persistent AF and LA size. These findings suggest that PAT could be an independent risk factor for the development of AF and for LA remodeling.     

Trends in admission prevalence,illness severity and survival of haematological patients treated in Dutch intensive care units

Purpose

To explore trends over time in admission prevalence and (risk-adjusted) mortality of critically ill haematological patients and compare these trends to those of several subgroups of patients admitted to the medical intensive care unit (medical ICU patients).

Methods

A total of 1,741 haematological and 60,954 non-haematological patients admitted to the medical ICU were analysed. Trends over time and differences between two subgroups of haematological medical ICU patients and four subgroups of non-haematological medical ICU patients were assessed, as well as the influence of leukocytopenia.

Results

The proportion of haematological patients among all medical ICU patients increased over time [odds ratio (OR) 1.06; 95 % confidence interval (CI) 1.03–1.10 per year; p < 0.001]. Risk-adjusted mortality was significantly higher for haematological patients admitted to the ICU with white blood cell (WBC) counts of <1.0 × 10⁹/L (47 %; 95 % CI 41–54 %) and ≥1.0 × 10⁹/L (45 %; 95 % CI 42–49 %), respectively, than for patients admitted with chronic heart failure (27 %; 95 % CI 26–28 %) and with chronic liver cirrhosis (38 %; 95 % CI 35–42 %), but was not significantly different from patients admitted with solid tumours (40 %; 95 % CI 36–45 %). Over the years, the risk-adjusted hospital mortality rate significantly decreased in both the haematological and non-haematological group with an OR of 0.93 (95 % CI 0.92–0.95) per year. After correction for case-mix using the APACHE-II score (with WBC omitted), a WBC <1.0 × 10⁹/L was not a predictor of mortality in haematological patients (OR 0.86; 95 % CI 0.46–1.64; p = 0.65). We found no case–volume effect on mortality for haematological ICU patients.

Conclusions

An increasing number of haematological patients are being admitted to Dutch ICUs. While mortality is significantly higher in this group of medical ICU patients than in subgroups of non-haematological ones, the former show a similar decrease in raw and risk-adjusted mortality rate over time, while leukocytopenia is not a predictor of mortality. These results suggest that haematological ICU patients have benefitted from improved intensive care support during the last decade.     

Prevalence of cardiovascular diseases in HIV-infected outpatients: results from a prospective, multicenter cohort study

Background

Recent studies suggest a rising rate of cardiovascular disease (CVD) in HIV-infected subjects. Although most countries have an aging HIV-infected population, there remains a lack of knowledge about associated cardiovascular diseases.

Methods

This ongoing prospective multicentre observational cohort study aims to elucidate CVD prevalence in HIV-infected outpatients by standardized non-invasive cardiovascular screening. Cardiovascular and coronary risk was calculated using Framingham risk scores.

Results

803 HIV-infected subjects (mean age 44.2 years, female 16.6 %) were included. The prevalence of CVD in HIV-infected subjects was 10.1 % (95 % CI 8.0–12.2 %). Aging HIV-infected patients (≥45 years, N = 348) exhibited significantly increased rates of CVD, including an elevated frequency of coronary artery disease (7.5 vs. 1.8 %, p < 0.001), myocardial infarction (6.0 vs. 1.8 %, p = 0.002) and peripheral arterial diseases (4.6 vs. 1.5 %, p < 0.017). Furthermore, aging patients exhibited a higher rate of chronic heart failure (5.2 vs. 1.5 %, p < 0.001), predominantly of ischemic etiology. In multivariate analyses, age (OR 2.05 per decade, 95 % CI 1.64–2.56), smoking (OR 5.96 per decade, 95 % CI 2.31–15.38) and advanced symptomatic HIV infection (OR 2.60 per decade, 95 % CI 1.31–5.15), were significantly associated with the prevalence of CVD. Based on the 10-year cardiovascular risk estimation, a disproportionate increase in cardiac events has to be expected in aging HIV-infected subjects in the next decades (≥45 years/<45 years 16.4 vs. 4.2 %, p < 0.001).

Conclusion

CVD in aging HIV-infected population is an increasing medical challenge. In the era of antiretroviral therapy, prevention and diagnostic strategies are essential to reduce the prevalence of CVD in HIV-infected patients.