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Category: Acute Care Cardiology

Authors: Micah Liam Arthur Heldeweg, Nan Liu, Zhi Xiong Koh, Stephanie Fook-Chong, Weng Kit Lye, Mark Harms and Marcus Eng Hock Ong

Reference: Critical Care201620:179


Risk stratification models can be employed at the emergency department (ED) to evaluate patient prognosis and guide choice of treatment. We derived and validated a new cardiovascular risk stratification model comprising vital signs, heart rate variability (HRV) parameters, and demographic and electrocardiogram (ECG) variables.

We conducted a single-center, observational cohort study of patients presenting to the ED with chest pain. All patients above 21 years of age and in sinus rhythm were eligible. ECGs were collected and evaluated for 12-lead ECG abnormalities. Routine monitoring ECG data were processed to obtain HRV parameters. Vital signs and demographic data were obtained from electronic medical records. Thirty-day major adverse cardiac events (MACE) were the primary endpoint, including death, acute myocardial infarction, and revascularization. Candidate variables were identified using univariate analysis; the model for the final risk score was derived by multivariable logistic regression. We compared the performance of the new model with that of the thrombolysis in myocardial infarct (TIMI) score using receiver operating characteristic (ROC) analysis.

In total, 763 patients were included in this study; 254 (33 %) met the primary endpoint, the mean age was 60 (σ = 13) years, and the majority was male (65 %). Nineteen candidate predictors were entered into the multivariable model for backward variable elimination. The final model contained 10 clinical variables, including age, gender, heart rate, three HRV parameters (average R-to-R interval (RR), triangular interpolation of normal-to-normal (NN) intervals, and high-frequency power), and four 12-lead ECG variables (ST elevation, ST depression, Q wave, and QT prolongation). Our proposed model outperformed the TIMI score for prediction of MACE (area under the ROC curve 0.780 versus 0.653). At the cutoff score of 9 (range 0–37), our model had sensitivity of 0.709 (95 % CI 0.653, 0.765), specificity of 0.674 (95 % CI 0.633, 0.715), positive predictive value of 0.520 (95 % CI 0.468, 0.573), and negative predictive value of 0.823 (95 % CI 0.786, 0.859).

A non-invasive and objective ECG- and HRV-based risk stratification tool performed well against the TIMI score, but future research warrants use of an external validation cohort.


Heart rate variability Emergency department Chest pain Risk stratification 12-Lead ECG
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Authors: Shaw R.

Reference: Am J Crit Care. 2016 Mar;25(2):181-4.

Adequate sleep is a critical component of illness recovery. Inadequate sleep contributes to a myriad of physiological problems, including impaired immune response, decline in wound healing, greater insulin resistance, increased perceptions of pain, and an increase in mortality. Sleep problems exacerbate the healing process during hospitalization and can endure beyond hospitalization.13 Researchers in one study4 documented that sleep difficulties may endure beyond hospitalization: 50% of respondents reported moderate to severe sleep problems 1 week after discharge. Other studies have offered evidence that sleep problems experienced during hospitalization increase the risk for development of chronic insomnia.3

Acutely ill patients experience difficulty falling asleep, sleep fragmentation, decreased rapid-eye-movement (REM) sleep, and sleep perceived as poor quality.2,5 In hospitals, many factors can interfere with patients’ sleep. Environmental noise (eg, noisy equipment, alarms, staff interaction) is a pervasive problem. The Environmental Protection Agency recommends that noise levels not exceed 45 decibels during the day and 35 decibels at night. Numerous studies in acute and intensive care settings have documented noise levels regularly exceeding the recommendations.6,7 Other sleep disruption factors include lighting that interferes with sleep-wake cycles, pain, anxiety, and symptoms related to patients’ underlying illness.4 Many of these sleep-disrupting factors are amplified in intensive care units.

Pharmacological interventions, such as sedatives, are often the first response to promoting sleep in hospitalized patients. However, use of sedatives has been linked to such adverse effects as memory loss, disorientation, increased fall risk, and daytime fatigue.3 In recent years, growing emphasis has been placed on exploring the effectiveness of non-pharmacological interventions to promote sleep, such as minimizing nighttime disruptions, decreasing noise and light, increasing meaningful daytime activity, and using relaxation techniques (eg, aromatherapy, massage, guided imagery, ear plugs, and eye masks).3Music is another previously studied technique for promoting sleep. Music is hypothesized to have psychological and physiological effects on the body, including potentially sleep-promoting influences.8 The PICO (patient/problem, intervention, comparison, outcomes) question that this review addresses is, What effect do interventions using music, compared with other methods, or usual care, have on promoting sleep in hospitalized adults?

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A study presented at Euroanaesthesia 2016 shows that noise levels in the Intensive Care Unit (ICU) can go well above recommended levels, disturbing both patients and the medical teams that care for them. The study is by Dr Eveline Claes, Jessa Ziekenhuis Hospital, Hasselt, Belgium and colleagues.

Noise exposure in the intensive care unit can have a negative impact on patients’ well-being as well as on optimal functioning of both nursing and medical staff. WHO recommends average sound levels for hospital wards below 35 decibels (dBA) with a maximum of 40 dBA at night time. Reported sound levels in ICUs are significantly higher with average sound levels always exceeding 45 dBA and for 50% of the time exceeding 52 dBA. After several patient complaints and remarks from the nursing staff as well as the medical staff about noise, the study authors wanted to assess a potential noise problem by measuring sound levels in one ward (12 beds) of their hospital’s ICU (Jessa Hospital).

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Authors: Levitov A, Frankel HL, Blaivas M, Kirkpatrick AW, Su E, Evans D, Summerfield DT, Slonim A, Breitkreutz R, Price S, McLaughlin M, Marik PE, Elbarbary M.

Reference: Crit Care Med. 2016 Jun;44(6):1206-27

To establish evidence-based guidelines for the use of bedside cardiac ultrasound, echocardiography, in the ICU and equivalent care sites.

Grading of Recommendations, Assessment, Development and Evaluation system was used to rank the “levels” of quality of evidence into high (A), moderate (B), or low (C) and to determine the “strength” of recommendations as either strong (strength class 1) or conditional/weak (strength class 2), thus generating six “grades” of recommendations (1A-1B-1C-2A-2B-2C). Grading of Recommendations, Assessment, Development and Evaluation was used for all questions with clinically relevant outcomes. RAND Appropriateness Method, incorporating the modified Delphi technique, was used in formulating recommendations related to terminology or definitions or in those based purely on expert consensus. The process was conducted by teleconference and electronic-based discussion, following clear rules for establishing consensus and agreement/disagreement. Individual panel members provided full disclosure and were judged to be free of any commercial bias.

Forty-five statements were considered. Among these statements, six did not achieve agreement based on RAND appropriateness method rules (majority of at least 70%). Fifteen statements were approved as conditional recommendations (strength class 2). The rest (24 statements) were approved as strong recommendations (strength class 1). Each recommendation was also linked to its level of quality of evidence and the required level of echo expertise of the intensivist. Key recommendations, listed by category, included the use of cardiac ultrasonography to assess preload responsiveness in mechanically ventilated (1B) patients, left ventricular (LV) systolic (1C) and diastolic (2C) function, acute cor pulmonale (ACP) (1C), pulmonary hypertension (1B), symptomatic pulmonary embolism (PE) (1C), right ventricular (RV) infarct (1C), the efficacy of fluid resuscitation (1C) and inotropic therapy (2C), presence of RV dysfunction (2C) in septic shock, the reason for cardiac arrest to assist in cardiopulmonary resuscitation (1B-2C depending on rhythm), status in acute coronary syndromes (ACS) (1C), the presence of pericardial effusion (1C), cardiac tamponade (1B), valvular dysfunction (1C), endocarditis in native (2C) or mechanical valves (1B), great vessel disease and injury (2C), penetrating chest trauma (1C) and for use of contrast (1B-2C depending on indication). Finally, several recommendations were made regarding the use of bedside cardiac ultrasound in pediatric patients ranging from 1B for preload responsiveness to no recommendation for RV dysfunction.

There was strong agreement among a large cohort of international experts regarding several class 1 recommendations for the use of bedside cardiac ultrasound, echocardiography, in the ICU. Evidence-based recommendations regarding the appropriate use of this technology are a step toward improving patient outcomes in relevant patients and guiding appropriate integration of ultrasound into critical care practice.

Authors: John H. Alexander, M.D., M.H.S., and Peter K. Smith, M.D.

Reference: N Engl J Med 2016; 374:1954-1964

Coronary-artery bypass grafting (CABG) is very commonly performed. CABG improves survival among patients with multivessel coronary disease; those with more severe coronary disease, diabetes, or left ventricular dysfunction are especially likely to benefit.

Medical mistakes — from surgical disasters to accidental drug overdoses — are the No. 3 cause of death in the U.S., behind cancer and heart disease, two experts argued Wednesday.

They said a careful count of all deaths from preventable medical errors shows between 200,000 and 400,000 people a year die in the U.S. from these mistakes. The only way to get the country to do something about them is to start counting them, Dr. Martin Makary and Michael Daniel of Johns Hopkins University medical school argued.

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Authors: M.B. Leon

Aortic-Valve Replacement
Transcatheter aortic-valve replacement is a less invasive alternative to open surgery for high-risk patients with severe aortic stenosis. Could TAVR criteria be expanded to include patients at low or intermediate risk? New research findings are summarized in a short video.

Authors: Martin A Makary, professor , Michael Daniel, research fellow

Reference: BMJ 2016;353:i2139


Medical error is not included on death certificates or in rankings of cause of death. Martin Makary and Michael Daniel assess its contribution to mortality and call for better reporting

The annual list of the most common causes of death in the United States, compiled by the Centers for Disease Control and Prevention (CDC), informs public awareness and national research priorities each year. The list is created using death certificates filled out by physicians, funeral directors, medical examiners, and coroners. However, a major limitation of the death certificate is that it relies on assigning an International Classification of Disease (ICD) code to the cause of death.1 As a result, causes of death not associated with an ICD code, such as human and system factors, are not captured. The science of safety has matured to describe how communication breakdowns, diagnostic errors, poor judgment, and inadequate skill can directly result in patient harm and death. We analyzed the scientific literature on medical error to identify its contribution to US deaths in relation to causes listed by the CDC.2
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Authors: Michael W. Donnino, Lars W. Andersen, Katherine M. Berg, Maureen Chase, Robert Sherwin, Howard Smithline, Erin Carney, Long Ngo, Parth V. Patel, Xiaowen Liu, Donald Cutlip, Peter Zimetbaum, Michael N. Cocchi and the collaborating authors from the Beth Israel Deaconess Medical Center’s Center for Resuscitation Science Research Group

Reference: Critical Care201620:82



The purpose of this study was to determine whether the provision of corticosteroids improves time to shock reversal and outcomes in patients with post-cardiac arrest shock.


We conducted a randomized, double-blind trial of post-cardiac arrest patients in shock, defined as vasopressor support for a minimum of 1 hour. Patients were randomized to intravenous hydrocortisone 100 mg or placebo every 8 hours for 7 days or until shock reversal. The primary endpoint was time to shock reversal.


Fifty patients were included with 25 in each group. There was no difference in time to shock reversal between groups (hazard ratio: 0.83 [95 % CI: 0.40-1.75], p = 0.63). We found no difference in secondary outcomes including shock reversal (52 % vs. 60 %, p = 0.57), good neurological outcome (24 % vs. 32 %, p = 0.53) or survival to discharge (28 % vs. 36 %, p = 0.54) between the hydrocortisone and placebo groups. Of the patients with a baseline cortisol < 15 ug/dL, 100 % (6/6) in the hydrocortisone group achieved shock reversal compared to 33 % (1/3) in the placebo group (p = 0.08). All patients in the placebo group died (100 %; 3/3) whereas 50 % (3/6) died in the hydrocortisone group (p = 0.43).


In a population of cardiac arrest patients with vasopressor-dependent shock, treatment with hydrocortisone did not improve time toshock reversal, rate of shock reversal, or clinical outcomes when compared to placebo.

CLINICAL TRIAL REGISTRATION: NCT00676585 , registration date: May 9, 2008.


Adrenal; Cardiac arrest; Hydrocortisone; Shock; Steroids; Vasopressors

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Authors: Mitrić G, Udy A, Bandeshe H, Clement P, Boots R.

Reference: Crit Care. 2016 Apr 2;20(1):90.

Atrial fibrillation is a common rhythm disturbance in the general medical-surgical intensive care unit. Amiodarone is a popular drug in this setting but evidence to inform clinical practice remains scarce. We aimed to identify whether variation in the clinical use of amiodarone was associated with recurrent atrial fibrillation.

This was a retrospective audit of 177 critically ill patients who developed new-onset atrial fibrillation after admission to a tertiary level medical-surgical trauma intensive care unit. Patterns of amiodarone prescription (including dosage schedule and duration) were assessed in relation to recurrence of atrial fibrillation during the intensive care unit stay. Known recurrence risk factors, such as inotrope administration, cardiac disease indices, Charlson Comorbidity Index, magnesium concentrations, fluid balance, and potassium concentrations, were also included in adjusted analysis using forward stepwise logistic regression modelling.

The cohort had a median (interquartile range) age of 69 years (60-75), Acute Physiology and Chronic Health Evalution II score of 22 (17-28) and Charlson Comorbidity Index of 2 (1-4). A bolus dose of amiodarone followed by infusion (P = 0.02), in addition to continuing amiodarone infusion through to discharge from the intensive care unit (P