Analysis of Indications for Electrotherapy Using Classification Trees

Electrotherapy is a dynamically developing method of treatment of sinus node dysfunction and atrioventricular conduction disturbances. It is an extremely important method used in the treatment of heart failure. The aim of this paper was to use classification trees for the differentiation between patients implanted with one of the three electrotherapy devices, i.e. SC-VVI/AAI, DC-DDD, ICD/CRT. The analysed data concerned 2071 patients who underwent implantation or device replacement procedures in the years 2010–2018, hospitalized in a coronary care unit. CART-type classification trees with 5-fold cross-validation were used for the analysis. The decision concerning the choice of a particular electrotherapy device is always made based on the latest guidelines and the patient’s clinical condition. The used classification trees may enable verification of the state of implementation of guidelines in real-life therapeutic decisions.

D-dimer as a prognostic factor in patients admitted to a tertiary care intensive coronary care unit

Introduction D-dimer is a small protein fragment and is a product of fibrinolysis. A high levels of D-dimer have been suggested as a prognostic factor in cancerous and other critically ill patients. We aimed to evaluate D-dimer levels and outcomes of critically ill patients admitted to a tertiary care intensive coronary care unit (ICCU). Material and method All patients admitted to the ICCU at our Medical Center between January 1, 2020 and December 31, 2020 were included in the study. Patients were divided into 2 groups according to their D-dimer level on admission. Low D-dimer level <500 ng/ml, and high D-dimer level ≥500 ng/ml. Survival, in-hospital interventions and complications were compared. Results and discussion Overall 1,082 consecutive patients were included, mean age was 67 (±16), 70% were males. Of them 296 (27.4%) had low D-dimer level and 663 (61.3%) had high D-dimer level. Patients with high D-dimer level were older as compared to patients with low D-dimer level (mean age 70.4±15 and 59±13 years respectively, p=0.004), had significantly higher rate of female gender (35.9% vs 15.9% respectively, p<0.0001) and significantly higher rate of any prior cardiac interventions prior to their admission (26.7% vs 4.4% respectively, p<0.0001). Interestingly, patients with high D-dimer level had significantly lower rate of any acute coronary syndrome (ACS) as compared with the low D-dimer group (25.7 vs 66.4% respectively, p<0.0001) and lower rate of smokers (22.5 vs 45.6% respectively, p<0.0001). All 11 post-COVID-19 patients had high D-dimer level on admission. A multivariate Cox proportional hazards analysis for mortality, adjusted for age, gender, risk factors for cardiovascular disease, ejection fraction<40 found that high D-dimer level was independently associated with higher mortality rates (HR=5.8; 95% CI; 1.7–19.1; p=0.004) as shown in Figure 1. Conclusion Elevated D-dimer levels on admission in ICCU patients is a poor prognostic factor of in-hospital morbidity and mortality in the first year following hospitalization. FUNDunding Acknowledgement Type of funding sources: None. Cumulative survival according to d-Dimer

Risk Stratification Model for Predicting Coronary Care Unit Readmission

Background: Use of statistical models for assessing the clinical risk of readmission to medical and surgical intensive care units is well established. However, models for predicting risk of coronary care unit (CCU) readmission are rarely reported. Therefore, this study investigated the characteristics and outcomes of patients readmitted to CCU to identify risk factors for CCU readmission and to establish a scoring system for identifying patients at high risk for CCU readmission. Methods: Medical data were collected for 40,187 patients with a history of readmission to the CCU of a single multi‐center healthcare provider in Taiwan during 2010-2019. Characteristics and outcomes were compared between a readmission group and a non-readmission group. Data were segmented at a 9:1 ratio for model building and validation.Results: The number of patients with a CCU readmission history after transfer to a standard care ward was 2397 (5.9%). The twelve factors that had the strongest associations with CCU readmission were used to develop and validate a CCU readmission risk scoring and prediction model. When the model was used to predict CCU readmission, the receiver-operating curve characteristic was 0.7217 for risk score model group and 0.7316 for the validation group. A CCU readmission risk score was assigned to each patient. The patients were then stratified by risk score into low risk (-20-5), moderate risk (6-26) and high risk (27-33) cohorts check scores, which showed that CCU readmission risk significantly differed among the three groups.Conclusions: This study developed a model for estimating CCU readmission risk. By using the proposed model, clinicians can improve CCU patient outcomes and medical care quality.

Neutrophil Percentage to Albumin Ratio Was Associated with Clinical Outcomes in Coronary Care Unit Patients

Background: Neutrophil percentage to albumin ratio (NPAR) was proved to be correlated with the prognosis of a variety of diseases. The purpose of this study was to explore the effect of NPAR on the prognosis of coronary care unit (CCU) dpatients.Method: All data of this study was extracted from Medical Information Mart for Intensive Care III (MIMIC-III, version1.4) database. All patients were divided into four groups according to NPAR quartiles. Primary outcome was in-hospital mortality and secondary outcomes were 30-day mortality, 365-day mortality, length of CCU stay, length of hospital stay, acute kidney injury, renal replacement therapy. Multivariable binary logistic regression analysis was performed to confirm the independent effect of NPAR. Subgroup analysis was used to determine the effect of NPAR on in-hospital mortality in different subgroups. Receiver-operating characteristic (ROC) curves were applied to evaluate the ability of NPAR to predict in-hospital mortality. Kaplan–Meier curves were built to compare cumulative survival of different groups.Result: 2364 CCU patients were enrolled in this study. In-hospital mortality rate increased significantly as NPAR quartiles increased (P < 0.001). In multivariable logistic regression, NPAR was proved to be independently associated with in-hospital mortality (Quartile 4 vs Quartile 1: OR, 95% CI: 1.80, 1.19-2.72, P=0.005, P for trend = 0.001). Moderate ability of NPAR to predict in-hospital mortality was demonstrated through ROC curves, the AUC of NPAR was 0.653 (P<0.001), which is better than PLR (P<0.001), neutrophil (P<0.001) but lower than SOFA(P=0.046) and SAPS II (P<0.001). Subgroup analysis did not find obvious interaction in most subgroups. Moreover, Kaplan-Meier curves showed that as NPAR quartiles increased, 30-day (Log rank, P<0.001) and 365-day (Log rank, P<0.001) cumulative survival decreased significantly. NPAR was also proved to be independently associated with acute kidney injury (Quartile 4 vs Quartile 1: OR, 95% CI: 1.57, 1.19-2.07, P=0.002, P for trend = 0.001). Length of CCU and hospital stay were prolonged significantly in higher NPAR quartiles.Conclusion: NPAR was an independent risk factor of in-hospital mortality in CCU patients and had a moderate ability to predict in-hospital mortality.

Management of temporary epicardial pacing wires in the cardiac surgical patient

Temporary epicardial pacing wires are used after cardiothoracic surgery to maintain a stable cardiac rhythm. They must be distinguished from the more commonly encountered transvenous temporary pacing wires, which are often used in coronary care units for the same purpose. Patients with temporary epicardial pacing wires may be transferred to hospital wards where these wires are not usually encountered, such as COVID wards, the general intensive care unit, the coronary care unit or general surgical wards if a laparotomy was required in the early period following cardiac surgery. Serious complications may arise in managing patients with temporary epicardial pacing wires, which are well known in the cardiothoracic unit but not so well known elsewhere in the hospital. This article discusses the dangers associated with the management of temporary epicardial pacing wires in adult patients, some of which are common to temporary transvenous pacing wires and others are unique to temporary epicardial pacing wires.

Risk factors for acute myocardial infarction evidenced in hospitalized patients in the coronary care unit / Fatores de risco para infarto agudo do miocárdio evidenciados em pacientes hospitalizados em unidade coronariana

Objetivo: DESCREVER OS FATORES DE RISCO IDENTIFICADOS EM PACIENTES COM INFARTO AGUDO DO MIOCÁRDIO (IAM) HOSPITALIZADOS EM UNIDADE CORONARIANA. Método: ESTUDO DESCRITIVO, TRANSVERSAL COM ABORDAGEM QUANTITATIVA, REALIZADO COM 125 INDIVÍDUOS COM DIAGNÓSTICO DE INFARTO AGUDO DO MIOCÁRDIO. A AMOSTRA FOI COLETADA POR CONVENIÊNCIA DE FORMA CONSECUTIVA. OS DADOS FORAM ANALISADOS COM AUXÍLIO DO PROGRAMA ESTATÍSTICO STATISTICAL PACKAGE FOR THE SOCIAL SCIENCES (SPSS) (VERSÃO 21) E APROVADO SOB PARECER 457.504. Resultados: PREDOMINOU INDIVÍDUOS DO SEXO MASCULINO DE ETNIA BRANCA E COM UMA MÉDIA DE 62 ANOS. OS FATORES DE RISCO MAIS PREVALENTES NA AMOSTRA FORAM: SEDENTARISMO, HIPERTENSÃO ARTERIAL, HISTÓRICO FAMILIAR, TABAGISMO, INGESTA ALCOÓLICA E DIABETES MELLITUS. Conclusão: A PESQUISA TRAZ DADOS RELEVANTES PARA O CONTROLE DOS FATORES DE RISCO IDENTIFICADOS, MOSTRA ONDE DIRECIONAR AS AÇÕES PREVENTIVAS, A FIM DE DIMINUIR A INCIDÊNCIA DO INFARTO AGUDO DO MIOCÁRDIO, SUAS SEQUELAS E A MORTALIDADE.

Association between early intensive care or coronary care unit admission and post-discharge performance of activities of daily living in patients with acute decompensated heart failure

The management of acute decompensated heart failure often requires intensive care. However, the effects of early intensive care unit/coronary care unit admission on activities of daily living (ADL) in acute decompensated heart failure patients have not been precisely evaluated. Thus, we retrospectively assessed the association between early intensive care unit admission and post-discharge ADL performance in these patients. Acute decompensated heart failure patients (New York Heart Association I–III) admitted on emergency between April 1, 2014, and December 31, 2018, were selected from the Diagnosis Procedure Combination database and divided into intensive care unit/coronary care unit (ICU) and general ward (GW) groups according to the hospitalization type on admission day 1. The propensity score was calculated to create matched cohorts where admission style (intensive care unit/coronary care unit admission) was independent of measured baseline confounding factors, including ADL at admission. The primary outcome was ADL performance level at discharge (post-ADL) defined according to the Barthel index. Secondary outcomes included length of stay and total hospitalization cost (expense). Overall, 12231 patients were eligible, and propensity score matching created 2985 pairs. After matching, post-ADL was significantly higher in the ICU group than in the GW group [mean (standard deviation), GW vs. ICU: 71.5 (35.3) vs. 78.2 (31.2) points, P<0.001; mean difference: 6.7 (95% confidence interval, 5.1–8.4) points]. After matching, length of stay was significantly shorter and expenses were significantly higher in the ICU group than in the GW group. Stratified analysis showed that the patients with low ADL at admission (Barthel index score <60) were the most benefited from early intensive care unit/coronary care unit admission. Thus, early intensive care unit/coronary care unit admission was associated with improved post-ADL in patients with emergency acute decompensated heart failure admission.

Polyarteritis Nodosa Presenting as Hypertensive Crisis

Hypertensive crisis is a deadly complication that should be avoided at all costs, let alone when it is associated with a rare disease, such as Polyarteritis Nodosa (PAN). We present a case of an adult female who initially came to Bangladesh Medical College Hospital (BMCH) with a prolonged high-grade fever responding to antipyretics. Upon follow up, the patient went into a hypertensive crisis, which led to the admission to Coronary Care Unit (CCU). The hypertension was difficult to control until the culprit was revealed. Polyarteritis Nodosa was then diagnosed by angiography, which showed tight stenosis of the left renal artery. Prompt treatment was initiated, and the patient's blood pressure normalized. Our case highlights the importance of detecting such diseases, since it may be easily missed as it usually presents with nonspecific symptoms. Newly detected Hypertension in patients of any age should not be taken lightly and should be investigated promptly. We hope our case report sheds enough light on this issue for other clinicians and researches to identify and prevent later on. Bangladesh Crit Care J March 2021; 9(1): 52-55