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Background: The efficacy and safety of prophylactic full-dose anticoagulation and antiplatelet therapy in critically ill COVID-19 patients remain uncertain. Methods: COVID-PACT (Prevention of Arteriovenous Thrombotic Events in Critically-ill COVID-19 Patients Trial) was a multicenter, 2×2 factorial, open-label, randomized-controlled trial with blinded end point adjudication in intensive care unit–level patients with COVID-19. Patients were randomly assigned to a strategy of full-dose anticoagulation or standard-dose prophylactic anticoagulation. Absent an indication for antiplatelet therapy, patients were additionally randomly assigned to either clopidogrel or no antiplatelet therapy. The primary efficacy outcome was the hierarchical composite of death attributable to venous or arterial thrombosis, pulmonary embolism, clinically evident deep venous thrombosis, type 1 myocardial infarction, ischemic stroke, systemic embolic event or acute limb ischemia, or clinically silent deep venous thrombosis, through hospital discharge or 28 days. The primary efficacy analyses included an unmatched win ratio and time-to-first event analysis while patients were on treatment. The primary safety outcome was fatal or life-threatening bleeding. The secondary safety outcome was moderate to severe bleeding. Recruitment was stopped early in March 2022 (≈50% planned recruitment) because of waning intensive care unit–level COVID-19 rates. Results: At 34 centers in the United States, 390 patients were randomly assigned between anticoagulation strategies and 292 between antiplatelet strategies (382 and 290 in the on-treatment analyses). At randomization, 99% of patients required advanced respiratory therapy, including 15% requiring invasive mechanical ventilation; 40% required invasive ventilation during hospitalization. Comparing anticoagulation strategies, a greater proportion of wins occurred with full-dose anticoagulation (12.3%) versus standard-dose prophylactic anticoagulation (6.4%; win ratio, 1.95 [95% CI, 1.08–3.55]; P =0.028). Results were consistent in time-to-event analysis for the primary efficacy end point (full-dose versus standard-dose incidence 19/191 [9.9%] versus 29/191 [15.2%]; hazard ratio, 0.56 [95% CI, 0.32–0.99]; P =0.046). The primary safety end point occurred in 4 (2.1%) on full dose and in 1 (0.5%) on standard dose ( P =0.19); the secondary safety end point occurred in 15 (7.9%) versus 1 (0.5%; P =0.002). There was no difference in all-cause mortality (hazard ratio, 0.91 [95% CI, 0.56–1.48]; P =0.70). There were no differences in the primary efficacy or safety end points with clopidogrel versus no antiplatelet therapy. Conclusions: In critically ill patients with COVID-19, full-dose anticoagulation, but not clopidogrel, reduced thrombotic complications with an increase in bleeding, driven primarily by transfusions in hemodynamically stable patients, and no apparent excess in mortality. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04409834.

Despite advances in early revascularization, percutaneous hemodynamic support platforms, and systems of care, cardiogenic shock (CS) remains associated with a mortality rate higher than 50%. Several risk stratification models have been derived since the 1990 s to identify patients at high risk of adverse outcomes. Still, limited information is available on the differences between scoring systems and their relative applicability to both acute myocardial infarction and advanced decompensated heart failure CS. Thus, we reviewed the similarities, differences, and limitations of published CS risk prediction models and herein discuss their suitability to the contemporary management of CS care.

Background: Algorithmic application of the 2019 Society of Cardiovascular Angiography and Intervention (SCAI) shock stages effectively stratifies mortality risk for patients with cardiogenic shock. However, clinician assessment of SCAI staging may differ. Moreover, the implications of the 2022 SCAI criteria update remain incompletely defined. Methods: The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units (CICUs). Between 2019 and 2021, participating centers (n=32) contributed at least a 2-month snapshot of consecutive medical CICU admissions. In-hospital mortality was assessed across 3 separate staging methods: clinician assessment, Critical Care Cardiology Trials Network algorithmic application of the 2019 SCAI criteria, and a revision of the Critical Care Cardiology Trials Network application using the 2022 SCAI criteria. Results: Of 9612 admissions, 1340 (13.9%) presented with cardiogenic shock with in-hospital mortality of 35.2%. Both clinician and algorithm-based staging using the 2019 SCAI criteria identified a stepwise gradient of mortality risk (stage C–E: 19.0% to 83.7% and 14.6% to 52.2%, respectively; P trend P trend Conclusions: Both clinician and algorithm-based application of the 2019 SCAI stages identify a stepwise gradient of mortality risk, although clinician-staging may better allocate higher risk patients into advanced SCAI stages. Updated algorithmic staging using the 2022 SCAI criteria and vasoactive-inotropic score further refines risk stratification.

Extracorporeal membrane oxygenation has evolved, from a therapy that was selectively applied in the pediatric population in tertiary centers, to more widespread use in diverse forms of cardiopulmonary failure in all ages. We provide a practical review for cardiovascular clinicians on the application of veno-arterial extracorporeal membrane oxygenation in adult patients with cardiogenic shock, including epidemiology of cardiogenic shock, indications, contraindications, and the extracorporeal membrane oxygenation circuit. We also summarize cannulation techniques, practical management and troubleshooting, prognosis, and weaning and exit strategies, with attention to end of life and ethical considerations.

Over the past few decades, advances in pharmacological, catheter-based, and surgical reperfusion have improved outcomes for patients with acute myocardial infarctions. However, patients with large infarcts or those who do not receive timely revascularization remain at risk for mechanical complications of acute myocardial infarction. The most commonly encountered mechanical complications are acute mitral regurgitation secondary to papillary muscle rupture, ventricular septal defect, pseudoaneurysm, and free wall rupture; each complication is associated with a significant risk of morbidity, mortality, and hospital resource utilization. The care for patients with mechanical complications is complex and requires a multidisciplinary collaboration for prompt recognition, diagnosis, hemodynamic stabilization, and decision support to assist patients and families in the selection of definitive therapies or palliation. However, because of the relatively small number of high-quality studies that exist to guide clinical practice, there is significant variability in care that mainly depends on local expertise and available resources.

Background Several studies have shown improved outcomes in closed compared with open medical and surgical intensive care units. However, very little is known about the ideal organizational structure in the modern cardiac intensive care unit (CICU). Methods and Results We retrospectively reviewed consecutive unique admissions (n=3996) to our tertiary care CICU from September 2013 to October 2017. The aim of our study was to assess for differences in clinical outcomes between an open compared with a closed CICU. We used multivariable logistic regression adjusting for demographics, comorbidities, and severity of illness. The primary outcome was in‐hospital mortality. We identified 2226 patients in the open unit and 1770 in the closed CICU. The unadjusted in‐hospital mortality in the open compared with closed unit was 9.6% and 8.9%, respectively ( P =0.42). After multivariable adjustment, admission to the closed unit was associated with a lower in‐hospital mortality (odds ratio [OR], 0.69; 95% CI: 0.53–0.90, P =0.007) and CICU mortality (OR, 0.70; 95% CI, 0.52–0.94, P =0.02). In subgroup analysis, admissions for cardiac arrest (OR, 0.42; 95% CI, 0.20–0.88, P =0.02) and respiratory insufficiency (OR, 0.43; 95% CI, 0.22–0.82, P =0.01) were also associated with a lower in‐hospital mortality in the closed unit. We did not find a difference in CICU length of stay or total hospital charges ( P >0.05). Conclusions We found an association between lower in‐hospital and CICU mortality after the transition to a closed CICU. These results may help guide the ongoing redesign in other tertiary care CICUs.

Contemporary cardiac intensive care units (CICUs) have an increasing prevalence of noncardiovascular comorbidities and multisystem organ dysfunction. However, little guidance exists to support the development of best-practice principles specific to the CICU. This scientific statement evaluates strategies to avoid the potentially preventable complications encountered within contemporary CICUs, focusing on those that are most applicable to the CICU environment. This scientific statement reviews evidence-based practices derived in non–CICU populations, assesses their relevance to CICU practice, and highlights key knowledge gaps warranting further investigation to attenuate patient risk.

Background: Cardiac arrest (CA) is a common reason for cardiac intensive care unit (CICU) admission and is associated with considerable morbidity, mortality, and resource use. Aim: To describe characteristics and outcomes of pts presenting to contemporary CICUs with in-hospital (IH) or out-of-hospital (OH) CA. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multicenter network of tertiary CICUs in North America (n=25). Participating centers contributed data from consecutive admissions during 2-month annual snapshots between 9/2017 and 8/2019 (n=8240). We analyzed characteristics and outcomes of pts with CA by IHCA vs OHCA. Results: Of 975 admissions with CA (48.9% OHCA), most were male (64.7%), Caucasian (63.4%) and smokers (60.6%). Acute coronary syndrome (ACS) was present in 30.6% and cardiomyopathy in 21.8%. Shockable rhythm was present in 54.1%, more commonly among those with reduced ejection fraction, ischemic cardiomyopathy, or ACS (pFig ] and CICU length of stay was longer for pts with OHCA (median 3.4 vs 3.1 days; p=0.049). In-hospital mortality was 41.2% and was higher in OHCA (44.7%) compared with IHCA (38.0%), p=0.03 [ Fig ]. Eventual discharge home or to rehab was more common among pts with IHCA (51.6% vs 49.1% for OHCA; p Conclusion: Despite advances in pre- and in-hospital care, pts presenting to contemporary CICUs with CA have high in-hospital mortality, with IHCA mortality only modestly lower than in OHCA. A better understanding of patterns may guide new approaches to improve patient outcomes.

Introduction: Acute coronary syndrome (ACS) complicated by cardiac arrest (CA) has a heterogeneous presentation, and risk can be challenging to stratify. This study aimed to apply the SCAI cardiogenic shock stages to patients with ACS complicated by CA at early pivotal time intervals when prompt interventions may have a greater impact. Methods: Patients undergoing PCI presenting with CA were stratified according to the SCAI shock classification, retrospectively, on arrival to the cardiac catheterization laboratory (CCL) and on arrival to the intensive care unit (ICU). The primary end-point was in-hospital mortality. Secondary end-points were mortality stratified by the use of mechanical circulatory support or the level of vasopressor support used. Results: Between 01/2014 -08/2018, seventy-nine patients presented with ACS complicated by a CA. The mean age was 70 (SD ± 12) years, and 19 (24%) were females. On arrival to the CCL 17 (22%) were stage A, 6 (8%) were stage B, 31 (40%) were stage C, 19 (24%) were stage D, and 6 (8%) were stage E. In general, there was a stepwise increase in mortality with increasing stage (A 35% vs. B 16% vs. C 48% vs. D 68% vs. E 83%; p=0.05). There was a similar trend when stratified on arrival to the ICU (Figure 1), although of marginal statistical significance (P = 0.07). Presentation with shock stage D or E to the CCL was predictive of mortality (OR 3.7 CI 1.3-10.5; p=0.01) on logistic regression models. The use of mechanical support was not associated with increased mortality. However, the use of an Impella in patients requiring high vasopressor support at arrival to the CCL was associated with a trend towards decreased mortality (25% vs. 61%, p=0.18). Conclusion: Increasing SCAI shock stages on arrival to the CCL and ICU is associated with increased in-hospital mortality among patients who presented after a CA and underwent PCI. The SCAI classification at defined time points has the potential to serve as an important research tool.

Introduction: Early identification of cardiac decompensation remains critical for improved patient outcomes. Digital phenotypes using real-time electronic health record (EHR) data offer an unbiased method to detect decompensation in at-risk individuals. Methods: Phenotypes designed to detect cardiac decompensation and its sequelae were retrospectively evaluated in 108,697 adult patient hospitalizations at a single center from October 2015-August 2018. The 6 phenotypes included hypotension, end organ dysfunction (EOD), hypoperfusion (concomitant hypotension and EOD), escalating vasoactive medication use (vasoactive meds), respiratory decline, and respiratory intervention. Median time from admission to phenotype development was measured in hours. In-hospital mortality and unanticipated ICU transfers were determined across all phenotypes and phenotype combinations. Results: Prevalence and time to detection varied across all six phenotypes (Table 1), with EOD found most frequently (35.7%) and detected earliest (3.4h, IQR 0.9-26.2h). Among individual phenotypes, patients with hypoperfusion had the highest rates of unanticipated ICU transfer (20.62%) and in-hospital mortality (20.99%). Patients meeting at least one phenotype had a 5.90% ICU transfer rate and 5.04% in-hospital mortality rate, compared to 0.62% mortality and 2.19% ICU transfer rates for patients meeting zero phenotypes. Among the 41 measured phenotype combinations, patients meeting all 6 phenotypes had the highest rates of unanticipated ICU transfer (28.75%) and in-hospital mortality (36.45%). Conclusions: Digital phenotypes of decompensation using real-world EHR data identify patients at higher risk of unexpected ICU transfer and in-hospital mortality at early times points in the hospitalization. Further studies will evaluate if implementation of a digital phenotype detection tool can improve care pathways and outcomes.

Introduction: Although sex-specific differences in treatment and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) have been described, little is known about sex-specific differences in acute decompensated heart failure-related CS (ADHF-CS). Methods: The CCCTN is an investigator-initiated multicenter network of cardiac intensive care units (CICUs) in North America. Consecutive admissions (n=8240) to the CICU during annual snapshots (mostly 2 months) were submitted to the coordinating center (TIMI Study Group, Boston, MA). Patients were stratified by sex and type of CS. Adjustments were made for age and SOFA score. Results: Between 2017 and 2019, 1487 admissions were for CS of which 879 (33% women) were for ADHF-CS. In this cohort, age (median 62 y), race, and BMI (median 28 kg/m 2 ) did not differ by sex. Women and men also had similar SOFA and IABP-SHOCK II scores. Women were less likely to have CKD (28% vs 42%, p= Conclusions: Compared to men, women admitted to the CICU with ADHF-CS had higher mortality despite similar indices of illness severity. The reason(s) behind this difference merit further study.

Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.

Organizational models in the intensive care unit (ICU) have classically been described as either closed or open, depending on the presence or absence of a dedicated ICU team. Although a closed model has been shown to improve patient outcomes in medical and surgical ICUs, the merits of various care models have not been previously explored in the cardiac ICU (CICU) setting.From November 2012 to March 2014, data were prospectively collected on all admissions before and after transition from an open to closed CICU at our institution. Baseline clinical variables, illness severity, admission and discharge diagnoses, resource use, and outcomes were recorded. Anonymous surveys were also collected from nursing and resident trainee participants to evaluate the influence of unit structure on perceptions of care. Descriptive statistics were used, and logistic regression modeling was performed to examine the impact of unit structure on mortality.The study consisted of 670 patients, 332 (49.6%) of whom were admitted to the open CICU model and 338 (50.4%) of whom were admitted to the closed model. Neither CICU nor hospital mortality differed between the open and closed units, though length of stay was shorter in the closed CICU. Additionally, nurses and resident trainees reported that the closed CICU allowed for better communication, collaboration, and education.Although there was no significant impact of unit structure on patient outcomes in this single-center study, the closed CICU model was associated with better perceptions of care.

Background Cardiovascular intensive care units ( CICUs ) have evolved from coronary care wards into distinct units for critically ill patients with primary cardiac diseases, often suffering from illnesses that cross multiple disciplines. Mounting evidence has demonstrated improved survival with the incorporation of dedicated CICU providers with expertise in critical care medicine ( CCM ). This is the first study to systematically survey dual certified physicians in order to assess the relevance of CCM training to contemporary CICU care. Methods and Results Utilizing American Board of Internal Medicine data through 2014, 397 eligible physicians had obtained initial certification in both cardiovascular disease and CCM . A survey to delineate the role of critical care training in the CICU was provided to these physicians. Among those surveyed, 120 physicians (30%) responded. Dual certified physicians reported frequent use of their CCM skills in the CICU , highlighting ventilator management, multiorgan dysfunction management, end‐of‐life care, and airway management. The majority (85%) cited these skills as the reason CCM training should be prioritized by future CICU providers. Few (17%) agreed that general cardiology fellowship alone is currently sufficient to care for patients in the modern CICU . Furthermore, there was a consensus that there is an unmet need for cardiologists trained in CCM (70%) and that CICU s should adopt a level system similar to trauma centers (61%). Conclusions Citing specific skills acquired during CCM training, dual certified critical care cardiologists reported that their additional critical care experience was necessary in their practice to effectively deliver care in the modern CICU .

Background Clinical investigations of shock in cardiac intensive care units (CICUs) have primarily focused on acute myocardial infarction (AMI) complicated by cardiogenic shock (AMICS). Few studies have evaluated the full spectrum of shock in contemporary CICUs. Methods and Results The Critical Care Cardiology Trials Network is a multicenter network of advanced CICUs in North America. Anytime between September 2017 and September 2018, each center (n=16) contributed a 2-month snap-shot of all consecutive medical admissions to the CICU. Data were submitted to the central coordinating center (TIMI Study Group, Boston, MA). Shock was defined as sustained systolic blood pressure P P Conclusions The epidemiology of shock in contemporary advanced CICUs is varied, and AMICS now represents less than one-third of all CS. Despite advanced therapies, mortality in CS and mixed shock remains high. Investigation of management strategies and new therapies to treat shock in the CICU should take this epidemiology into account.

There is insufficient data on patients with small body size to determine if this should be considered a risk factor for continuous-flow left ventricular assist device (CF-LVAD) support. We sought to evaluate survival outcomes, adverse events, and functional status of CF-LVAD patients with body surface area (BSA)

Objective: Acute and chronic cardiovascular comorbidities are common among critically ill individuals. It is unclear if current critical care fellowship trainees feel adequately prepared to manage these conditions. Design: Prospective, cross-sectional survey. Patients or Subjects: Trainees enrolled in U.S. critical care training programs. Setting: Accredited pulmonary/critical care, surgery/critical care, anesthesiology/critical care, and stand-alone critical care training programs. Interventions: None. Measurements and Main Results: A 19-item survey assessing trainee confidence in the management of cardiac critical illness and the performance of cardiac-specific critical care interventions was constructed using Accreditation Council for Graduate Medical Education recommendations as a reference. After validation, the survey was electronically sent to all training programs for dissemination to their trainees. Confidence scores were measured on a Likert scale from 1 to 5. A total of 134 completed surveys were analyzed. Overall, respondents reported lower confidence in managing cardiovascular compared with noncardiovascular diseases in the ICU (4.0 vs 4.6 out of 5). Likewise, they reported lower perceived competence in performing cardiovascular procedures specific to the ICU (2.9 vs 4.5 out of 5). The majority (88%) of those surveyed felt that they would benefit from increased didactic and clinical experience in the management of cardiovascular critical illness. Conclusions: Current critical care fellows may be unprepared to deal with the increasing prevalence of cardiovascular illness in the ICU. This potential educational gap warrants timely attention to ensure that future graduates have the requisite skills necessary to manage these critically ill patients and presents a unique opportunity to develop multidisciplinary partnerships for enhancing training.

Left ventricular assist devices (LVADs) improve longevity, as well as functional capacity and quality of life in patients with medically refractory heart failure.1–5 During the 6 years since the US Food and Drug Administration approval of the first commercially available continuous flow LVAD in 2008, the number of patients supported by these devices has grown exponentially. The most recent report from the Interagency Registry for Mechanically Assisted Circulatory Support recorded nearly 2500 North American LVAD implants in 2013 at >150 implanting centers.6 Approximately 40% of LVADs are implanted as an indefinite form of support (ie, destination therapy [DT]), and nearly half of patients are surviving >4 years.6 This combination of improved survival and evolving implant strategies has led to an increasing number of LVAD recipients being integrated into the community and we are observing the growth of an ambulatory LVAD population with a unique set of clinical needs. There are 2 predominant strategies of LVAD implantation. Patients who are not eligible for transplantation because of issues such as advanced age may be considered for an LVAD as DT, implying that they will live the rest of their lives with the LVAD. This is in contrast to patients who undergo LVAD implantation as a temporary support device, to support them while awaiting transplantation. This later strategy is defined as a bridge-to-transplantation, following which, the device will be explanted. Centers implanting LVADs without concomitant transplant programs (designated DT centers) have emerged to provide this therapy, averting the need for travel to more distant transplant centers. Such DT centers operate in conjunction with a VAD/transplant partner in the care of patients awaiting transplantation. Because LVAD implant centers are frequently remotely located from the patients that they serve, a model of shared-care has developed, whereby the continued care of …

Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.

Therapeutic hypothermia (TH) and targeted temperature management improve neurologic recovery, and survival for patients resuscitated from witnessed out-of-hospital ventricular tachycardia (VT) and ventricular fibrillation (VF) cardiac arrest. The American Heart Association recently gave a class IIb recommendation for the use of TH for non-VT/VF and unwitnessed arrests. We explored changes in baseline characteristics, resource use, and outcomes after expanding indications for TH at our institution based on these guidelines. Fifty-six consecutive patients treated with TH for out-of-hospital cardiac arrest were retrospectively evaluated based on whether they received treatment before (protocol 1) or after (protocol 2) broadening inclusion criteria. In protocol 1, TH was indicated after a witnessed VT/VF arrest. In protocol 2, TH was indicated for unwitnessed arrests, pulseless electrical activity, or asystole. Both populations undergoing TH had similarly extensive medical comorbidities and consumed considerable hospital resources. Overall, 64% of the patients from both protocols died in the hospital, although nominally lower mortality was seen in patients treated under protocol 1 compared with protocol 2 (59% vs. 67%, P = 0.57). Lower mortality was observed after VT/VF than after pulseless electrical activity or asystole (47% vs. 93% vs. 56%, P = 0.017). No patient survived following an unwitnessed arrest, and age (odds ratio per 10 years = 2.59; 95% confidence interval, 1.34-4.81) was independently associated with increased mortality. In an evolving field where best practice is still poorly defined, these data, along with future prospective studies in larger populations, should help to enhance care delivery and optimize cost-effectiveness strategies.

Background— Little is known about the association of kidney dysfunction and outcome in acute severe hypertension. This study aimed to measure the association between baseline chronic kidney disease (estimated glomerular filtration rate), acute kidney injury (AKI, decrease in estimated glomerular filtration rate ≥25% from baseline) and outcome in patients hospitalized with acute severe hypertension. Methods and Results— The Studying the Treatment of Acute Hypertension (STAT) registry enrolled patients with acute severe hypertension, defined as ≥1 blood pressure measurement >180 mm Hg systolic and/or >110 mm Hg diastolic and treated with intravenous antihypertensive therapy. Data were compared across groups categorized by admission estimated glomerular filtration rate and AKI during admission. On admission, 79% of the cohort (n=1566) had at least mild chronic kidney disease (estimated glomerular filtration rate P P =0.003), and AKI ( P P ≤0.0001 for both). Subjects with AKI experienced higher mortality at 90 days ( P =0.003). Any acute loss of estimated glomerular filtration rate during hospitalization was independently associated with an increased risk of death (odds ratio, 1.05; P =0.03 per 10-mL/min decline). Other independent predictors of mortality included increasing age ( P P =0.016), white versus black race ( P =0.003), and worse baseline kidney function ( P =0.003). Conclusions— Chronic kidney disease is a common comorbidity among patients admitted with acute severe hypertension, and AKI is a frequent form of acute target organ dysfunction, particularly in those with baseline chronic kidney disease. Any degree of AKI is associated with a greater risk of morbidity and mortality.

Background: Clinical practice guidelines recommend admitting patients with stable non-ST segment elevation acute coronary syndrome (NSTE ACS) to telemetry units, yet up to two thirds of patients are admitted to critical care units (CCU). The outcomes of patients with stable NSTE ACS initially admitted to a CCU versus a cardiology ward with telemetry have not yet been described. Methods: We used a population-based dataset of 7,869 patients hospitalized with NSTE ACS admitted to hospitals in Alberta, Canada between April 1, 2007 and Mar 31, 2013 and excluded patients (n=589) who received CCU procedures or therapies on the day of admission. We compared outcomes among patients initially admitted to a CCU (n=5141) with those admitted to cardiology telemetry wards (n=2728). Results: Patients admitted to cardiology telemetry wards were older (median 69 vs 65 years, p Conclusions: No differences in clinically important outcomes were observed between patients with NSTE ACS initially admitted to wards or CCUs. These findings suggest that stable NSTE ACS can be managed appropriately in telemetry wards and present an opportunity to reduce hospital costs and critical care capacity strain.

Background: Delirium is common in the medical and surgical intensive care unit (ICU), and its association with morbidity and mortality is well described. Despite emerging data which has highlighted a growing critical care burden in the contemporary cardiac ICU (CICU), much less is known about delirium in this specialized setting. Methods and Results: Records for consecutive CICU patients >18 years who were admitted to our academic, tertiary-care institution from December 2012 through March 2014 for a primary cardiovascular diagnosis were reviewed. Only those with a documented Confusion Assessment Method for ICU (CAM-ICU) score were included in the final analysis. Baseline characteristics, resource use, and outcomes were collected. Disease severity was assessed using the modified Acute Physiology and Chronic Health Evaluation II (APACHE II) Score and the Simplified Acute Physiology Score II (SAPS II). Multivariable logistic and linear regression models were constructed to evaluate the association between CICU delirium, length of stay (LOS), and death. Among 590 patients included, the prevalence of CICU delirium was 20.3%. Delirious patients were older, had greater disease-severity, required longer ICU stays (5 vs. 2 days, p Conclusions: In those with cardiac critical illness, delirium is common and associated with worse survival and greater resource consumption. Future study is needed to validate these findings and to develop effective strategies for the early identification and treatment of the delirious CICU patient.

Introduction: A recent AHA scientific statement highlighted the evolving complexity of critical care delivery for cardiac patients, and the emerging need for novel staffing models. In this document, a “closed” unit structure - in which a dedicated intensive care team treats all admitted patients - was specifically advocated. However, in light of escalating critical care costs within US hospitals, there is a pressing need to better understand the financial impact of different care platforms. Methods: In July 2013, our academic cardiac intensive care unit (CICU) was transitioned from an “open” to a “closed” model of care. In a before-and-after study design, consecutive admission records were reviewed from Aug 2012-Dec 2012 (“open” unit) and from Aug 2013-Dec 2013 (“closed” unit). Routinely collected financial and demographic data were examined, and the impact of case-mix index (CMI) on cost was evaluated. Results: In the “open” and “closed” models, there were 333 patient-visits accounting for 1,891 patient-days and 397 visits accounting for 2,558 patient-days, respectively. While demographics, payor mix, and fixed vs. variable cost distribution were unchanged (Table), the total cost-per-patient and cost-per-patient-day were lower within the “closed” CICU ($8,676 vs. $10,118 and $1,346 vs. $1,782, respectively) despite a greater average CMI (4.6 vs. 3.6). Total and 30d CICU readmission rates were also lower in the “closed” unit (Table). Readmissions in the "closed" unit resulted in greater cost-per-patient-day than new admits ($1,576 vs. $1,339). Conclusions: A “closed” CICU staffing model is associated with lower health care costs. This may be partly explained by lower CICU recidivism, but likely is multifactorial. Additional study will focus on the influence of resource use, critical care delivery to key sub-populations, and the development of effective strategies for further cost containment.

Background: Unlike in classic heart failure populations where natriuretic peptides (NPs) are well-validated biomarkers for diagnosis and prognosis, the utility of NPs in patients with mechanical circulatory support is unknown. No prior study has systematically evaluated the predictive value of changes in NP levels on outcomes among contemporary patients after LVAD implantation. Methods: We reviewed records for all consecutive patients implanted with a continuous-flow LVAD at our institution from 2008-2012. Trends in NT-proBNP during LVAD support were measured, and the association of pre-implant NT-proBNP, as well as relative change in NT-proBNP, with mortality and hospitalization were analyzed. Results: Ninety-eight patients were included - 79 as bridge to transplantation (BTT), 19 as destination therapy (DT). Median follow-up was 256d, during which 24 patients died, 31 received a heart transplant, and 43 remained on LVAD support. Median NT-proBNP (pre-implant = 5540 pg/mL) decreased exponentially following device implant and stabilized at 60d (1950 pg/mL; Fig 1). In a Cox-proportional hazards model, neither pre-implant nor 60d NT-proBNP levels were associated with survival or readmission. However, a greater relative decrease in NT-proBNP from pre-implant to 60d was significantly associated with freedom from hospitalization (HR 1.77, p=0.04; Fig 2). Conclusions: NT-proBNP decreased exponentially and reliably, before reaching a steady state at 60d following device implantation. Our study is the first to show that serial changes in NPs may be useful in predicting LVAD outcomes. Future study should focus on whether NT-proBNP changes are influenced by baseline variables, and if NPs can be used to guide clinical management.

We thank Dr Lin and colleagues for their questions regarding the analysis from the Studying the Treatment of Acute Hypertension Registry (STAT) registry exploring the relationship between both acute and chronic kidney disease in patients with acute hypertension.1 There are two different aspects of their questions that can be addressed. First, on the mathematical or statistical level, Lin et al suggest different ways in which the data can be analyzed. The inclusion of various parameters of blood pressure (including mean arterial pressure) as well as the analysis of change in kidney function using different methods were conducted within STAT. The results and conclusions were not significantly different from those presented in the published article, so they were not included owing to space constraints. More importantly, though, Lin et al emphasize that these data are counterintuitive to what would be expected based on studies that have been conducted in …

Abstract 503 Jason N Katz, Duke Univ Medical Ctr & Duke Clinical Res Inst, Durham, NC; Amanda L Stebbins, Duke Clinical Res Inst, Durham, NC; John H Alexander, Duke Univ Medical Ctr & Duke Clinical Res Inst, Durham, NC; Harmony R Reynolds, New York Univ, New York, NY; Karen S Pieper, Duke Clinical Res Inst, Durham, NC; Witold Ruzyllo, Natl Inst of Cardiology, Warsaw, Poland; Karl Werdan, Martin-Luther-Univ Halle-Wittenberg, Halle-Wittenberg, Germany; Alexander Geppert, Wilhelminen hospital Vienna, Vienna, Austria; Vladimir Dzavik, Univ of Toronto, Toronto, ON, Canada; Frans Van de Werf, Univ Hosp of Gasthuisberg, Leuven, Belgium; Judith S Hochman, New York Univ, New York, NY; TRIUMPH Investigators Jason Katz, 2008 Finalist and Presenting Author