April 2024 Highlights
Nutritional support during ICU stay - a stepwise approach towards better outcomes
Nutritional support plays an important role in management of critically ill patients, especially patients with acute heart failure, acute coronary syndrome, post-cardiac-arrest patients and patients with cardiogenic shock.
Nutritional support in acute heart failure
The nutritional risk and prevalence of malnutrition is high in patients with acute heart failure (up to 40%) due to bowel ischemia, microcirculatory failure, and malabsorption. Although adequate nutrition might play an important role in improving outcomes, studies on this matter are still lacking.
Nutritional support for these patients is based on general principles- early nutritional assessment, form of administration and assessment of nutritional risk. It is recommended to start enteral feeding in the first 48h upon CICU admission. In the acute phase (<72h) it is best to implement hypocaloric nutrition with adequate substitution of micronutrients.
Parenteral feeding can be associated with higher risk of infection, and it is recommended as first line in case of severe gastrointestinal dysfunction.
However, early parenteral feeding is recommended in severely malnourished patients.
Nutritional support in acute coronary syndrome
Malnutrition is these patients may be associated with worsening outcomes. The same principles apply as for critically ill patients.
Nutritional support after cardiac arrest
Patients after suffering cardiac arrest may require close monitoring, especially if receiving ECLS for refractory cardiac arrest. In those patients’ enteral nutrition should be introduced with caution, as rates of intestinal ischemia are higher. Delayed feeding is associated with better outcomes. Studies on this field are needed to create uniform protocols of management of these patients.
Nutritional support in cardiogenic shock
As we all know, cardiogenic shock is a low cardiac output state secondary to cardiac dysfunction, leading to end-organ hypoperfusion and tissue hypoxia. During this condition mesenteric arteriolar vasoconstriction plays a major role in trying to maintain systemic blood pressure. Together with venous congestion it leads to decrease in local perfusion and increased risk of bowel ischemia.
If enteral feeding is started in this highly vulnerable hemodynamic state, there is a risk of mesenteric ischemia. Starting early enteral feeding is still controversial. It may be beneficial to do a permissive underfeeding in the first few days, especially in patients who require use of vasopressors. The incidence of proven bowel ischemia using those protocols was <1%.
Having in mind the incidence and severity of cardiovascular diseases requiring CICU admission, comprehensive multidisciplinary approach to nutritional support is needed to optimize care of critically ill patients. Further research is needed to try to obtain uniform and individualized protocols that could improve patient survival, duration of ICU stay and quality of life after CICU admission.
Figure from Maria Bergami - visual is created by Biorender
March 2024 Highlights
The light in the end of the tunnel – unrevealing mechanisms of ventricular fibrillation during the first ST elevation myocardial infarction by the use of proteonomics.
Stampe et al. conducted a study using proteonomics that unrevealed that 26 proteins are associated with ventricular fibrillation. Pending further analysis two of the proteins were strongly associated with VF (ACTBL2, F13A1). The findings of this study represent a groundbreaking moment that points the light towards further investigation of early VF in ST elevation myocardial infarction.
Embrace the challenge – the role of ventricular assist device in management of fulminant myocarditis
The study by Takahito Nasu et al. represent a pioneering large-scale registry study using data from Japanese Registry for Percutaneous Ventricular Assist Devices. Use of Impella device showed better success rate in comparison with ECPELLA. Having in mind the high percentage of adverse events further investigation is needed to optimize patient selection and treatment in this matter.
Deep dive into pulmonary embolism – identifying early predictors affects the outcome?
Zuin et al. deal with “Early predictors of clinical deterioration in intermediate-high risk pulmonary embolism” Their educational paper is complemented by a clinical consensus statement from the Association for Acute Cardiovascular Care that outlines the diagnostic and treatment pathways for acute right ventricular failure secondary to acutely increased right ventricular afterload.
Triglyceride deposit cardiomyovasculopathy (TGCV) – rare or just undiagnosed condition?
Nakano et al. introduce us to TGCV by conducting a study on 400 patients with ACS and 148 patients with diabetes and ACS. The study reports 4.3-5.4% prevalence emphasizing the need for further investigation and risk stratification of these patients, having in mind that they may present with diffuse coronary artery stenosis.
Figure from Maria Bergami
February 2024 Highlights
Cardiogenic shock patients on VA-ECMO – individual approach as the solution in prediction and reduction of complications?
VA-ECMO is a well-established method of treating patients with cardiogenic shock. But the risk of complications is still very high. Benedict N. Beer et al. conducted a retrospective multicenter cohort study with the aim to accurately describe the risk of complications and mortality events and to evaluate possible predictors of such events in those patients.
The study showed that the majority of 30-day survival patients treated with VA-ECMO had favorable neurological outcome (CPC 1/2). The presence of AEs, which are more common in women, are strongly associated with worsened neurological outcome and 30-day survival.
Further studies are needed to identify patients that could benefit from this strategy, having in mind the high risk of complications, whose prediction is still challeging and in need for RCTs. One possible solution might be the use of ECMELLA strategy that may reduce typical VA-ECMO complications but the strong evidence is still lacking. Patient selection might be improved by forming the multidisciplinary cardiogenic shock teams worldwide.
Figure from Maria Bergami
January 2024 Highlights
Sex-specific 99th percentile high-sensitivity cardiac troponin assays – are we there yet?
Dr. Maria Rubini Gimenez discusses the diagnostic and prognostic value of sex-specific 99th percentiles in high sensitivity cardiac troponin assays for AMI.
The study by Lehmacher et al. reveals comparable diagnostic accuracy between uniform and sex-specific cutoffs, suggesting no clear advantage for the latter.
The results extend this message to uniform cutoffs for hs-cTnI, but the diagnostic accuracy’s reliance on hs-cTnT concentrations is acknowledged as a limitation which requires futher studies before recommending sex-specific cutoffs in clinical practice.
Figure from Maria Bergami
Climate change as a global health problem – are we too late to prevent the consequences?
The EHJ-ACVC joins over 200 heart journals and urges the United Nations, political leaders, and health professionals to address climate change and biodiversity loss together as an indivisible global health emergency.
Recognising the interconnectedness of climate and nature crisis, they emphasise the severe impact on health, from infectious diseases to mental health issues. The call urges the WHO to declare this crisis a global health emergency to be able to restore biodiversity and combat climate change.
Figures from Maria Bergami
Our mission: To reduce the burden of cardiovascular disease.