Howard A. Cooper

Background: Little is known regarding gender- or race-based differences in critical care. We investigated whether gender or race was associated with pulmonary artery catheter (PAC) utilization or with in-hospital death among patients with a PAC. A particular focus was patients with cardiogenic shock (CS), in whom guidelines recommend PAC use. Methods: This was a retrospective cohort analysis from the coronary care unit of a large tertiary-care hospital staffed with full-time cardiac intensivists. Results: We analyzed 8845 consecutive adult patients, of whom 42.1% were women and 40.8% were black. PAC use rates were 11.3% in women and 11.5% in men (P = 0.79), and 11.3% in blacks and 11.5% in whites (P = 0.76). In CS patients, PAC use rates in women and men were 50.3% and 49.1% (P = 0.85) and in blacks and whites were 43.7% and 53.3% (P = 0.05). There was no independent association between gender or race and PAC use overall or in those with CS. Neither gender nor race was a predictor of in-hospital death in patients undergoing PAC. Conclusions: PAC use and in-hospital death were determined not by gender or race but by disease severity. Full-time intensivist staffing and the presence of definitive guidelines may reduce gender- and race-based treatment disparities.

Objectives Red blood cell (RBC) transfusions are common among patients with acute coronary syndromes (ACS). We sought to determine their impact on mortality according to indication. Methods We conducted a case–control analysis of ACS patients admitted to a single coronary care unit. Transfused patients were matched to nontransfused patients for age, estimated glomerular filtration rate, and nadir hematocrit. Conditional logistic regression analysis was used to determine the independent relationship between RBC transfusion and inhospital mortality. Results were stratified according to the indication for transfusion. Results Of the 3190 patients admitted with ACS, 206 (6.4%) received at least one RBC transfusion. Of these, 103 patients were matched to 185 nontransfused patients. The most common indications for transfusion were nonspecific anemia (48%) and overt blood loss (42%). Transfused patients had a significantly lower ejection fraction and were more likely to present in Killip class IV, undergo pulmonary artery catheterization, and require an intra-aortic balloon pump. On univariate analysis, RBC transfusion was associated with a doubling of the risk of inhospital mortality [odds ratio: 2.0; 95% confidence interval: 1.0–3.9; P=0.046]. However, after adjustment for confounders, transfusion was no longer significantly associated with higher inhospital mortality (odds ratio: 1.8; 95% confidence interval: 0.6–5.1; P=0.3). On stratified analysis, RBC transfusion was not significantly associated with inhospital mortality among patients transfused for either nonspecific anemia or overt blood loss. Conclusions Among coronary care unit patients with ACS, RBC transfusion does not seem to have a significant impact on inhospital mortality irrespective of the indication for transfusion.

Background: Thrombocytopenia Hypothesis: intra‐aortic balloon pump (IABP)‐associated thrombocytopenia is not associated with an increased risk of major bleeding or in‐hospital death. Thrombocytopenia is a common adverse effect of the IABP. However, the clinical implications of IABP‐associated thrombocytopenia are unknown.Methods: We assessed the incidence and predictors of thrombocytopenia, and the association between thrombocytopenia and relevant clinical end points, using prospectively collected data on 252 consecutive patients undergoing IABP in a single coronary care unit (CCU).Results: Anticoagulation with intravenous heparin was administered to 182 patients (72%). Baseline platelet counts were 232 000 ± 96 000 mL, decreased to 154 000 ± 74 000 mL at day 3, and recovered to baseline by day 8. Thrombocytopenia (nadir < 150 000 mL or > 50% reduction from baseline) occurred in 109 patients (43%), with a similar incidence among patients who received heparin and those who did not (45% vs 40%, P = 0.5). Independent predictors of thrombocytopenia were lower body weight, cardiogenic shock, and duration of IABP support. The incidence of both major bleeding and in‐hospital death were higher among patients who developed thrombocytopenia than among those who did not (13.8% vs 4.2%, P = 0.01 and 28% vs 16%, P = 0.02, respectively). However, after controlling for confounding variables, thrombocytopenia was not an independent predictor of either major bleeding (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 0.8–6.4, P = 0.1) or in‐hospital death (OR: 1.5, 95% CI: 0.8–2.9, P = 0.3).Conclusions: Among patients undergoing IABP in the CCU, thrombocytopenia is generally mild, appears to be unrelated to concomitant heparin use, and is not associated with an increased risk of major bleeding or in‐hospital death. Copyright

Background— Acute brain embolization (ABE) in left-sided infective endocarditis has significant implications for clinical decision making. The true incidence of ABE, including subclinical brain embolization, is unknown. Methods and Results— We prospectively studied 56 patients with definite left-sided infective endocarditis. Patients were examined by a study neurologist, and those without contraindication had magnetic resonance imaging of the brain. Patients without clinical evidence of acute stroke but with magnetic resonance imaging evidence of ABE were considered to have subclinical brain embolization. Clinical stroke was present in 14 of 56 patients (25%). Among 40 patients undergoing magnetic resonance imaging, the incidence rates of subclinical brain embolization and any ABE were 48% and 80%, respectively. ABE was present in 18 of 19 patients (95%) with Staphylococcus aureus infection. At 3 months, mortality was similar among patients with clinical stroke and subclinical brain embolization (62% versus 53%; P =NS) and was higher among patients with any ABE than among those without ABE (56% versus 12%; P =0.046). Valvular surgery was performed in 25 patients (45%), including 16 with ABE, at a median of 4 days. No patient suffered a postoperative neurological complication. Surgery was independently associated with a lower risk of mortality at 3 months (odds ratio, 0.1; 95% confidence interval, 0.03 to 0.6; P =0.008). Conclusions— Magnetic resonance imaging detected subclinical brain embolization in a substantial number of patients with left-sided infective endocarditis, suggesting that the incidence of ABE may be significantly higher than reports based on clinical and computed tomography findings have indicated. Brain magnetic resonance imaging may play a role in the complex decision about surgical intervention in infective endocarditis.

Cardiovascular disease has a tremendous impact on patients with end-stage renal disease (ESRD). We sought to describe the outcomes of patients with ESRD and acute myocardial infarction (AMI). We analyzed consecutive AMI patients admitted to a single coronary care unit, according to the presence or absence of ESRD. Multivariate modeling was used to determine the independent relationship between ESRD and in-hospital mortality. Data were available for 2025 AMI patients. ESRD was present in 82 patients (4%). Coronary angiography and revascularization were used aggressively in patients with ESRD, although less than among patients without ESRD (78 vs. 91%, P<0.001; and 60 vs. 79%, P<0.001, respectively). Length of stay was longer among patients with ESRD (9.5 vs. 5.0 days, P<0.001). In-hospital death occurred in 23.2% of the patients with ESRD compared with 9.0% of patients without ESRD (P<0.001). On multivariate analysis, the presence of ESRD was independently associated with the risk of in-hospital death (odds ratio 2.6, 95% confidence intervals, 1.3-4.9, P=0.005), even after controlling for the use of revascularization. Patients with ESRD and AMI are at tremendous risk for short-term mortality despite the aggressive use of coronary revascularization and modern coronary intensive care.