James E. Calvin

Does the pulmonary capillary wedge pressure predict left ventricular preload in critically ill patients

The construction of a Frank-Starling myocardial function curve relating heart work to left ventricular preload is clinically utilized to assess therapeutic protocols in critically ill patients. The pulmonary capillary wedge pressure (PWP) is the index of left ventricular filling pressure most frequently utilized as representative of left ventricular preload.The authors assessed the relationship between left ventricular preload measured as the left ventricular end-diastolic volume (LVEDV), and the PWP, in acutely ill patients with sepsis and cardiac disease. Within each group, no relationship was found between the LVEDV and the PWP; however, when omitting the effect of PEEP, a modest correlation was noted (r = 0.302; p < 0.01). Of the left ventricular ejection fraction. LVEDV and PWP, the PWP accounted for less than 5% of the explained variance in the stroke volume index.The PWP is a poor predictor of left ventricular preload, probably because of abnormalities of left ventricular compliance in critically ill patients.

Self-management Counseling in Patients With Heart Failure: The Heart Failure Adherence and Retention Randomized Behavioral Trial

CONTEXT Motivating patients with heart failure to adhere to medical advice has not translated into clinical benefit, but past trials have had methodological limitations. OBJECTIVE To determine the value of self-management counseling plus heart failure education, compared with heart failure education alone, for the primary end point of death or heart failure hospitalization. DESIGN, SETTING, AND PATIENTS The Heart Failure Adherence and Retention Trial (HART), a single-center, multiple-hospital, partially blinded behavioral efficacy randomized controlled trial involving 902 patients with mild to moderate heart failure and reduced or preserved systolic function, randomized from the Chicago metropolitan area between October 2001 and October 2004 and undergoing follow-up for 2 to 3 subsequent years. INTERVENTIONS All patients were offered 18 contacts and 18 heart failure educational tip sheets during the course of 1 year. Patients randomized to the education group received tip sheets in the mail and telephone calls to check comprehension. Patients randomized to the self-management group received tip sheets in groups and were taught self-management skills to implement the advice. MAIN OUTCOME MEASURE Death or heart failure hospitalization during a median of 2.56 years of follow-up. RESULTS Patients were representative of typical clinical populations (mean age, 63.6 years; 47% women, 40% racial/ethnic minority, 52% with annual family income less than

The incidence of major morbidity in critically ill patients managed with pulmonary artery catheters: a meta-analysis.

30,000, and 23% with preserved systolic function). The rate of the primary end point in the self-management group was no different from that in the education group (163 [40.1%)] vs 171 [41.2%], respectively; odds ratio, 0.95 [95% confidence interval, 0.72-1.26]). There were no significant differences on any secondary end points, including death, heart failure hospitalization, all-cause hospitalization, or quality of life. CONCLUSIONS Compared with an enhanced educational intervention alone, the addition of self-management counseling did not reduce death or heart failure hospitalization in patients with mild to moderate heart failure. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00018005.

Utility of history, physical examination, electrocardiogram, and chest radiograph for differentiating normal from decreased systolic function in patients with heart failure

Introduction: The impact of pulmonary artery (PA) catheters on patient outcome has been questioned and their usage has become controversial. Meta‐analysis on mortality has shown a trend for improved survival with PA catheter‐guided therapy. We now perform a meta‐analysis on morbidity from PA catheters in the published literature. Methods: We did a search of the medical database (Medline) from 1970 through 1996, using the headings “pulmonary artery catheterization,” “Swan‐Ganz catheterization” and “right heart catheterization,” and restricting the results to “effectiveness” and “usefulness.” We also consulted with other experts regarding published randomized controlled trials (RCTs). This yielded 16 RCTs addressing the question of effectiveness of PA catheter‐guided treatment. Of these, 12 were found to include data on morbidity. Major morbidity, defined as organ failures as per the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference criteria, from these trials was entered into a formal meta‐analysis. Results: A total of 1,610 patients from the 12 trials were analyzed. Morbidity events were observed in 62.77% of the PA catheter treatment group, and in 74.34% of the control group. A relative risk ratio of 0.78074 was obtained, with a 95% confidence interval of 0.6459‐0.94374 and a corresponding p of .0168, a lower morbidity in the PA catheter treatment group. Those with PA catheter‐guided treatment had a mean protective effect of 21.9% for risk of morbidity. Other important covariates such as acuity of illness, quality score of trials, year of publication, type of PA catheter‐guided treatment used (PA catheter vs. no PA catheter, or PA catheter vs. PA catheter for supranormal hemodynamic values), and surgical or mixed patient population, all increased variability and were not statistically significant predictors for risk ratio of morbidity. Conclusions: Meta‐analysis of RCTs included in this study shows that there is a statistically significant reduction in morbidity using PA catheter‐guided strategies.

Understanding articles describing clinical prediction tools

To determine whether clinical parameters alone can differentiate normal versus decreased systolic left ventricular function in patients with heart failure. Detailed clinical data were collected prospectively from 225 consecutive patients who were hospitalized with heart failure. Findings in patients with normal (ejection fraction > or =45%) or decreased (ejection fraction <45%) left ventricular function were compared. Systolic function was normal in 104 patients (46%) and decreased in 121 patients (54%). Patients with normal function were older (mean [+/- SD] age, 59 +/- 13 years vs. 54 +/- 13 years, P = 0.007) and more likely to be female (56% vs. 35%, P = 0.001), obese (body mass index > or =30 kg/m(2), 62% vs. 48%, P = 0.04), have marked systolic (> or =160 mm Hg, 50% vs. 27%, P <0.001) and diastolic (> or =110 mm Hg, 25% vs. 13%, P = 0.02) hypertension, and use calcium antagonists (34% vs. 14%, P = 0.001). Patients with decreased function were more likely to use alcohol (37% vs. 20%, P = 0.007), angiotensin-converting enzyme (ACE) inhibitors (85% vs. 62%, P <0.001), and digoxin (57% vs. 27%, P <0.001); and more likely to have tachycardia (51% vs. 32%, P = 0.004), rales (89% vs. 80%, P = 0.05), electrocardiographic left ventricular hypertrophy (42% vs. 22%, P = 0.002), left atrial abnormality (52% vs. 22%, P <0.001), or flow cephalization on chest radiograph (91% vs. 79%, P = 0.02). Only sex, tachycardia, and use of digoxin and ACE inhibitors were associated with ventricular function in multivariable analysis. However, the sensitivity, specificity, and predictive values for all clinical variables were low. Differences in clinical parameters in heart failure patients with decreased versus normal systolic function cannot predict systolic function in these patients, supporting recommendations that heart failure patients should undergo specialized testing to measure ventricular function.

Effective obesity treatments.

ObjectivesClinical prediction rules and models are developed by applying statistical techniques to find combinations of predictors that categorize a heterogeneous group of patients into subgroups of risk. Our goal is to teach clinicians how to evaluate the validity, results, and applicability of art

Value of the american college of cardiology/american heart association stenosis morphology classification for coronary interventions in the late 1990s

To curb the epidemic of obesity in the United States, revised Medicare policy allows support for efficacious obesity treatments. This review summarizes the evidence from rigorous randomized trials (9 lifestyle trials, 5 drug trials, and 2 surgical trials) on the efficacy and risk- benefit profile of lifestyle, drug, and surgical interventions aimed at promoting sustained (= 2 years) reductions in weight. Both lifestyle and drug interventions consistently produced an approximate 7-lb (3.2-kg) weight loss that was sustained for 2 years and was associated with improvements in diabetes, blood pressure, and/or cardiovascular risk factors. Surgical interventions have a less solid empirical base but offer promise for the promotion of significant and sustained weight reduction posttreatment in the morbidly obese but with possible significant short-term side effects. In summary, there is strong and consistent support from rigorous randomized trials that lifestyle or drug interventions result in modest weight loss with minimal risks but disproportionate clinical benefit. Combinations of lifestyle, drug, and, where appropriate, surgical interventions may be the most efficacious approach to achieving sustained weight loss for the widest diversity of patients.

Unstable angina and non-Q wave myocardial infarction: does the clinical diagnosis have therapeutic implications?

The goal of this study was to reassess the accuracy of the American College of Cardiology/American Heart Association (ACC/AHA) stenosis morphology classification for predicting coronary intervention success and complications in the era of new devices. Previous studies performed in the early part of this decade for percutaneous transluminal coronary angioplasty in patients with multivessel coronary artery disease found that these criteria were predictive of success rates but not complication rates. Data for 957 consecutive coronary interventions in 1,404 lesions from June 1994 to October 1996 were prospectively classified according to ACC/AHA guidelines and entered into a database. Ninety-one and 9/10 of coronary interventions were successful, defined as <50% residual stenosis of each vessel attempted in the absence of major in-hospital complications, including Q-wave myocardial infarction, ventricular arrhythmia, need for emergency coronary artery bypass surgery, or death. Success rates did not differ between A (186 of 193, 96.3%), B1 (211 of 221, 95.5%), and B2 (676 of 711, 95.1%) lesions, but each was more successful than C (246 of 279, 88.2%) lesions (p <0.003, p < 0.004, and p = 0.0001, respectively). The class of lesion (A, B, or C) did not predict device (atherectomy, rotablator, and stent) use but specific morphologic characteristics of lesions within these classes were predictive of which device was used. Multiple regression analysis revealed that total occlusion and vessel tortuosity were predictive of procedure failure. Lesion type (A, B, or C) was not predictive of complications, but bifurcation lesions (p = 0.0045), presence of thrombus (p = 0.0001), inability to protect a major side branch (p = 0.0468), and degenerated vein graft lesions (p = 0.0283) were predictive. Thus, the ACC/AHA grading system is predictive of successful coronary intervention outcome, particularly of C-type characteristics, but not of complications or device success rate and selection. Although lesion type (A, B, or C) was not predictive of complications, specific lesion morphologies were predictive of adverse events and device use.

CRITICAL CARE IN THE UNITED STATES : Who Are We and How Did We Get Here?

OBJECTIVES The goal of this review is to reevaluate the unstable coronary syndromes in the setting of new therapies and biochemical markers. BACKGROUND Patients with acute coronary syndromes comprise a large subset of many cardiology practices. Patients with unstable angina (UA) and non-Q wave myocardial infarction (NQMI) may sustain a small amount of myocardial loss but have significant amounts of viable, yet ischemic, myocardium, placing them at high risk for future cardiac events. In the past, enzyme differentiation of NQMI from UA was considered important to assess prognosis and direct therapy. METHODS Manuscripts published in peer-reviewed journals over the past three decades were reviewed and selected for this review. Recent abstracts were also considered and cited where appropriate. RESULTS In the late 1990s, although UA and NQMI remain parts of a spectrum, it is apparent that the distinction between these two entities is no longer sufficient to identify high risk patients; rather, specific electrocardiographic changes, aspects of the clinical history, newer biochemical markers, and angiographic findings help to better distinguish higher risk individuals from a large patient population with unstable coronary syndromes and these factors usually determine therapy. CONCLUSIONS Based on these results, it is likely that newer therapies such as glycoprotein IIb/IIIa receptor antagonists, low molecular weight heparins, and coronary stents will be directed toward these high risk patients.

Insurance Coverage and Care of Patients with Non–ST-Segment Elevation Acute Coronary Syndromes

Critical care medicine has progressed significantly over the past two to three decades. We will review the history and evolution of critical care medicine and ICUs in the United States. The evolving health care delivery system and the changing and important role of the intensivist will be addressed. Finally, a discussion about what critical care physicians must do to prepare for the future is presented.