Top 5 Cardiac Studies - Alastair Proudfoot
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Alastair Proudfoot is a general and cardiac intensivist at Barts Heart Centre. He has a clinical and research interest in the management of cardiogenic shock and both short term and durable mechanical circulatory support.
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Top 5 Cardiac Studies - Alastair Proudfoot
- 1. Cardiac ICU
- 3. Design • Prospective, double-blind, RCT • CS after successful PPCI for AMI • noradrenaline vs adrenaline for 24h – Drugs then open-label • Outcomes: – Cardiac index evolution up to 72 hours – Refractory CS
- 7. 1 2 3 Pathobiology unclear The take home.. Cardiogenic shock trials are hard! Optimal inotrope?
- 9. • 8014 OHCA – Epinephrine 1mg q3-5min vs Saline • 1o outcome 30d survival • 2o outcomes: – Survival until hospital admission – Hospital & ICU – Neurologic outcomes at discharge & 3/12
- 10. • 💉 21 mins • 🚑 <7 mins • ⚡️ 19% • ♻️ 36% 🚀 vs 11% 🍬 • 💓 224/8014 (2.8% 🙀) 🍬=94 (2.4% 🙀 ) 🚀=130 (3.2% 🙀) OR for survival 1.47 p=0.02 NNT =112
- 11. 31% 18% 🚀 🍬
- 12. Survival at a cost1 2 3 4 Relevance to IHCA? Bespoke adrenaline? Focus on post ROSC care The take home..
- 15. Endpoint • 1o endpoint - composite of: – survival at 2 years free of disabling stroke • mRS>3; – survival free of reoperation to replace or remove a malfunctioning device
- 16. Figure S3. Actuarial All Cause Survival (Per Protocol Population)
- 18. • Fewer total hospitalizations per patient-year • 2.1 vs 2.7 • 8.3 fewer hospital days per patient-year • 17 days versus 26 days • Post-discharge costs: $37,685 vs $76,599
- 19. Promising data1 2 3 Cost implications The take home.. Longer term complication data
- 20. In patients undergoing cardiac surgery, who have a moderate- to-high risk of death, does a restrictive transfusion strategy compared with a liberal strategy impact on a composite outcome of death, myocardial infarction, stroke and acute kidney injury requiring dialysis?
- 21. • PRBCC if Hb< 7.5g/dL intra-operatively or post-operatively vs • PRBCC if <9.5g/dL intra-operatively or post-operatively or <8.5g/dL on ward
- 23. In patients with AMI CS and evidence of multi-vessel disease, does immediate multi-vessel PCI vs culprit PCI (with staged revascularisation) improve outcome?
- 24. Intervention • Culprit-lesion only PCI – Further staged revascularisation • Multi-vessel PCI – Culprit + all other with >70% stenosis • Both groups – Standard PCI with DES – Max dose of contrast material = 300 mls • MCS & RRT at discretion of clinical team • Structured follow up 6 & 12 months
- 25. Outcomes • No difference in composite of 30d mortality & RRT • No diff mortality • No diff RRT • In culprit only – Increased rehospitalisations – Increased revascularisation
- 26. No benefit multi vessel PCI1 2 3 When & why late revasc? Readmissions The take home..
Editor's Notes
- VT #13
- no differences in most of the secondary hemodynamic endpoints (ie, MAP, SVRI, cardiac power index, PA systolic pressure, wedge pressure, LVEF, biomarkers, or incidence of arrhythmias). At 60 days, mortality was 52% in the epinephrine group and 37% in the norepinephrine group (P = 0.25).
- PPCI for AMI, systolic arterial pressure <90 mm Hg or mean arterial pressure (MAP) <65 mm Hg without a vasopressor agent or need for vasopressor therapy to correct hypotension; 3) cardiac index <2.2 l/min/m2 in the absence of vasopressor or inotrope therapy; 4) pulmonary artery occlusion pressure >15 mm Hg or echocardiographic evidence of high pressure; 5) echocardiographic ejection fraction <40% without inotrope support (this criterion was not taken into account in instances of treatment with dopamine, norepinephrine, epinephrine, dobutamine, or milri- none); 6) at least one evidence of tissue hypo- perfusion (e.g., skin mottling, oliguria, elevated lactate level, altered consciousness); and 7) an inser- ted pulmonary artery catheter.
- 36 more people alive in adrenaline group at 30d Need to terat 112 people to have 1 survivor irrespective of neuro Survival rates at various time points were significantly better in the Epinephrine group Length of stay in ICU and hospital did not differ Epinephrine increased 30-day survival in patients with nonshockable rhythms (adjusted odds ratio, 2.15; 95% CI, 1.13 to 4.09) but had unclear benefit in those with shockable rhythms (adjusted odds ratio, 1.33; 95% CI, 0.95 to 1.86). NNT CPR 15 and NNT defibrillation where indicated 5
- One major limitation of the trial is that the protocol neither controlled nor measured in-hospital treatments. The most common cause of in-hospital death is iatrogenic limitation of life support, which may result in the death of potentially viable patients
- IHCA epi given after median of 3 mins
- Inclusion: Patients with advanced heart failure requiring LVAD Patients requiring bridge or destination therapy Exclusion: Planned biventricular support Irreversible end-organ dysfunction Active infection 60% ineligible for transplantation Randomized, parallel N=366 centrifugal-flow pump (n = 190) axial-flow pump (n = 176) not powered to show a difference in survival Adaptive design additional 72 patients randomized after the initially reported 294 from the short-term cohort Aspirin & warfarin
- Marked reduction in overall incidence of stroke 10% (vs 19% for the HM II pump), the lowest such rate attained in any LVAS trial - seen with both ischemic and hemorrhagic strokes. HM3 more hemocompatible
- These differences were driven by patients hospitalized for suspected pump thrombosis (HM3: 0.6% versus HMII: 12.5%; P<0.001) and stroke (HM3: 2.8% versus HMII: 11.3%; P=0.002).
- TRICS-III was published in Nov 2017. At 28 days, a restrictive transfusion strategy was found to be non-inferior to a liberal transfusion strategy in cardiac surgery patients with a moderate-to-high risk of death with regards to a composite outcome of death and major disability
- Randomised controlled trial 1:1 ratio of restrictive vs liberal strategy 5243 randomised; 5092 of these patients were included in the modified intention-to-treat analysis, and 4860 (2430 in each treatment group) were included in the primary per-protocol analysis No difference in secondary endpoints including death, MI, stroke, AKI with RRT, readmissions
- Further revasc on basis of clinical status & presence of residual ischaemia on object testing 700 randomised
- Composite outcome Sub-analysis showed that this was primarily due to mortality rather than renal replacement therapy requirements
- Or detriment of culprit only