MATTERS OF THE HEART
I am an intensive care trainee wanting to get a better understanding of the literature in intensive care medicine.
This 6 part series is intended to identify and summarise landmark papers in various aspects of management in ICU.
It is in no way intended to be comprehensive or exhaustive. Its is also intended to promote discussion – please let me know if you think I have excluded anything!
This week – matters of the heart. Included are the HACA and Bernard papers that heavily influenced guidelines for OOHCA but are now being questioned. Keep an eye out for the upcoming TTM trial which may shed more light on hypothermia and OOHCA, or check out Podcast number 67 with Niklas Nielsen here.
IABP-SHOCK II 2012
Intra-aortic balloon support for myocardial infarction with cardiogenic shock
N Engl J Med. 2012; 367(14): 1287-96
The Lowdown
- 598 patients with acute coronary syndrome (70% STEMI) and cardiogenic shock, and where early revascularisation was planned
- Exclusions: other causes of cardiogenic shock, massive pulmonary embolus, severe aortic regurgitation
- Randomised to IABP or no IABP plus usual cares
- Primary endpoint: 30 day all-cause mortality was not different between IABP and control (39.7% and 41.3%, respectively; P=0.69)
Take Home Message
Intra-aortic balloon pump did not improve 30 day mortality in patients with ACS and cardiogenic shock
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ESCAPE 2005
Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial
JAMA. 2005; 294(13): 1625-33
The Lowdown
- 433 patients with severe symptomatic heart failure
- Exclusions: Creatinine 3.5g/dL, prior use of dopamine/ dobutamine/ milrinone this admission
- Randomised to therapy guided by clinical assessment only, or by clinical assessment and pulmonary artery catheter
- Primary endpoint, 6-month days alive and out of hospital – not different between groups
- PAC group superior symptomatic improvement at 1 month, but not by 6 months
- PAC group had a higher incidence of adverse events associated with catheter placement (21.9 vs 11.5%, P = 0.04)
Take Home Message
In patients with severe heart failure, the use of pulmonary artery catheters to guide therapy did not affect mortality at 6 months compared with clinical judgement alone.
PACs were associated with a higher rate of complications
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COMMIT 2005
Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial
Lancet. 2005 Nov 5;366(9497):1622-32
The Lowdown
- 45,852 patients with acute MI
- Exclusions – SBP <100, HR< 50, heart block, primary PCI
- Randomised to placebo or IV metoprolol up to 15mg then 200mg daily until discharge or for 28 days
- Primary outcomes: death/ reinfarction/ cardiac arrest. No difference between metoprolol and placebo
- Metoprolol resulted in less reinfarction (2% vs 2.5%, p = 0.001) and less VF (2.5% vs 3%, p = 0.001) but increased cardiogenic shock (5% vs 3.9%, p<0.00001) compared with placebo
Take Home Message
In patients with acute MI, the use of early, aggressive metoprolol decreased arrhythmias and reinfarction, but increased cardiogenic shock
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HACA 2002
Mild therapeutic hypothermia to improve the neurologic outcome in cardiac arrest
N Eng J Med. 2002; 346(8): 549-56
The Lowdown
- 275 patients with witnessed out of hospital cardiac arrest
- Randomised to normothermia or hypothermia (32-34 degrees) for 24 hours, then rewarmed over 8 hours
- Exclusions: pre-existing coagulopathy
- Hypothermia had lower 6 month mortality (55% vs 41%) and favourable neurological outcome (55% vs 39%)
- Hypothermia associated with non-significant increase in complications – bleeding, pneumonia and sepsis
Take Home Message
Hypothermia after VF/ VT arrest improved mortality and neurological outcome
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Bernard 2002
Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia
N Engl J Med. 2002 Feb 21;346(8):557-63
The Lowdown
- 77 patients with out of hospital VF cardiac arrest
- Exclusions: age <18 years for men or 50 for women, cardiogenic shock, other possible causes of coma
- Randomised to hypothermia (T = 33 degrees) for 12 hours or normothermia
- Primary outcome – neurological function able to be discharged home or to a rehabilitation facility. Better for hypothermia patients (49 vs 26%, p= 0.046)
- Non-significant trend towards improved mortality in hypothermia group
Take Home Message
Hypothermia after out of hospital arrest improved neurological outcome
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SHOCK 1999
Early revascularization in acute myocardial infarction complicated by cardiogenic shock
N Eng J Med. 1999; 341(9): 625-34
The Lowdown
- 302 patients with acute myocardial infarction and shock randomly assigned to early revascularization or medical management
- Exclusions: severe systemic illness, other cause of shock, severe valvular disease, dilated cardiomyopathy, and unsuitability for revascularization
- Trend to mortality benefit at 30 days and a significant mortality benefit at 6 months in the early revascularisation group (50 vs 63% mortality)
Take Home Message
In patients with cardiogenic shock following AMI, emergency revascularization did not significantly reduce overall mortality at 30 days.
However, after six months there was a significant survival benefit
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