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Cardiovascular Critical Care I Sajni V. Patel, Pharm.D., BCCP The University of Chicago Medicine Chicago, Illinois…

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Cardiovascular Critical Care I Cardiovascular Critical Care I Sajni V. Patel, Pharm.D., BCCP The University of Chicago Medicine Chicago, Illinois…

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Learning Objectives 3 min

Cardiovascular Critical Care I Learning Objectives 1. Develop an appropriate pharmacotherapeutic regi- men based on a patient’s hemodynamic status and objective cardiac findings. 2. Design a treatm…

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Cardiovascular Critical Care I According to outlying hospital records, only 30 mL of urine was reported before time of transfer. • His chest radiography reveals evidence of diffuse patchy opacities…

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Cardiovascular Critical Care I 6. The patient returns to the ICU with a pulmonary artery catheter in place and is currently receiving dopamine at 12 mcg/kg/minute and norepinephrine at 0.08 mcg/kg…

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Exam Content Outline 1 min

Cardiovascular Critical Care I BPS Critical Care Pharmacy Examination Content Outline This chapter covers the following sections of the Critical Care Pharmacy Examination Content Outline: 1. Domain 1…

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Cardiovascular Critical Care I I.  CARDIOVASCULAR FUNDAMENTALS OVERVIEW A. Cardiac output is defined as: 1. Heart rate × stroke volume a. Stroke volume is influenced by: i. Preload: Volume of bloo…

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Cardiovascular Critical Care I Developed by Erik Abel, PharmD, BCPS Figure 1. Coronary artery circulation. D. Cardiac Anatomy in Relation to the ECG (Figure 2) 1. A single lead of an ECG tracing is…

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Cardiovascular Critical Care I Phase Electrolyte movement Conduction change Na+ influx into cell Depolarization K+ and Cl- out of cell Repolarization Ca2+ into cell and K+ out of cell Plateau K+ out o…

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Cardiovascular Critical Care I 3. However, for patients with SCAI Stages C–E cardiogenic shock, using pulmonary artery catheter- derived hemodynamic data has been associated with improved mortality (…

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Data Tables 2 min

Cardiovascular Critical Care I Based Upon Metabolic need of disease state Oxygen Consumption VO2 Afterload α1 b2 b1 b1 Hemoglobin Developed by Erik Abel, PharmD, BCPS Figure 4. Integrated model o…

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Data Tables 3 min

Cardiovascular Critical Care I Vasoactives Dopa α1 β1 β2 Other Mechanism HR CVP CO SVR PVR Vasodilators Nitroglycerin cGMP ↔ or ­↑ ↓ ↔ or ­↑ ↔ or ↓ ↔ or ↓ Nitroprusside cGMP ↔ or ­↑ ↓ ↔ or ­↑ ↓ ↓ Nit…

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Cardiovascular Critical Care I Post-operative cardiac stunning (n=41) Congestive HF (n=56) Pulmonary oedema (n=27) Cardiogenic shock (n=62) 100  - 80  - 60  - 40  - 20  - 0  - ı ı ı ı ı ı Ti…

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Cardiovascular Critical Care I Box 1. Potential Causes of Cardiogenic Shock (Critical Care Medicine 2014:xix; Cardiol Clin 2013;31:567-80, viii; Cardiol Clin 2013;31:519-31, vii-viii; Semin Respir Cr…

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Cardiovascular Critical Care I b. Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock (DOREMI) (N Engl J Med 2021;385:516-25) i. First prospective trial studying milrinone a…

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Cardiovascular Critical Care I ↓ CVP or PCWP Preload Afterload Contractility • 500 mL of crystalloid/ colloid • Blood products • Passive leg raising ↑ PAP +/- ↑ HR • Milrinone • Nitroglycerin •…

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Cardiovascular Critical Care I Patient Case (contined) 2. Given the patient’s presentation, which group of diagnostic tests would be most helpful to guide your recom- mendations to the team for J.M.’…

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Cardiovascular Critical Care I B. Presentation and Diagnosis (Circulation 2014;130:e344-426; Circulation 2013;127:e362-425) – Although other cardiac enzymes assays are available for clinical use, ca…

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Data Tables 3 min

Cardiovascular Critical Care I C. Acute Management of MI Table 2. Acute Management (Circulation 2014;130:e344-426; Circulation 2013;127:e362-425) STEMI NSTEMI/ Unstable Angina Goals of care Reperfusi…

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Cardiovascular Critical Care I Predominant interventions on presentation/onset for stabilization – Any ACS Nitrates • Can facilitate coronary vasodilation and may also be helpful in scenarios of seve…

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Cardiovascular Critical Care I D. Revascularization 1. Nonsurgical – Details of interventional cardiology procedures are too broad to be discussed in great detail in this chapter; however, the foll…

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Cardiovascular Critical Care I 2. Surgical – Details of coronary artery bypass grafting (CABG) procedures, including conduit type and use of cardiopulmonary bypass (or performing off pump), are too…

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Cardiovascular Critical Care I c. Evaluation of antiplatelet therapy can be performed with platelet function testing and/or genotyping. However, neither is currently recommended routinely in the cli…

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Cardiovascular Critical Care I Medication Aspirin Clopidogrel Prasugrel Ticagrelor Onset 30 min 2–6 hr 30 min 30 min % Platelet inhibition ~ 10–20 30–40 60–70 60–70 Recommended holding duration be…

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Data Tables 3 min

Cardiovascular Critical Care I Table 5. Parenteral Antithrombotics (Circulation 2014;130:e344-426; Circulation 2013;127:e362-425;Circulation 2015;131:1123-49; J Am Coll Cardiol 2011;58:e123-210; J Am…

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Cardiovascular Critical Care I F. Post-Intervention Complications 1. Bleeding (particularly retroperitoneal bleeding) a. Several antithrombotic agents are used during PCI to inhibit both the platel…

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Cardiovascular Critical Care I Patient Case (Continued) 4. J.M.’s ECG results reveal no acute evidence of ST segment changes. However, the resident is still consider- ing a diagnosis of ACS, given th…

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Data Tables 2 min

Cardiovascular Critical Care I 2. When evaluating ECGs in the presence of heart block, QRS complex evaluation can guide some differential diagnoses to the source of conduction problems (see Table 6)…

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Cardiovascular Critical Care I Type ECG Example Description Junctional rhythm Manifested when sinus node dysfunction allows the AV node to take over as the active cardiac pacemaker, resulting in r…

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Cardiovascular Critical Care I N Assess appropriateness for clinical condition Heart rate typically < 50 bpm if bradyarrhythmia Identify and treat underlying cause • Maintain patent airway; ass…

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Data Tables 2 min

Cardiovascular Critical Care I C. Tachyarrhythmias (beyond sinus) – Etiologies and hemodynamic consequences 1. Etiologies of tachyarrhythmias a. Usually related to enhanced automaticity, reentry, o…

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Cardiovascular Critical Care I Supraventricular Tachyarrhythmias Type Rhythm P-wave Attributes Atrial Rate (beats/min) Description Multifocal atrial tachycardias (MATs) Irregular > 3 different ty…

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Cardiovascular Critical Care I N Assess appropriateness for clinical condition Heart rate typically > 150 bpm if tachyarrhythmia Identify and treat underlying cause • M…

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Cardiovascular Critical Care I (b) Heart rhythm control (1) Antiarrhythmic therapy typically with class Ic or class III agents (see Appendix A) (2) Synchronized electrical cardioversion (3) Cathet…

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Cardiovascular Critical Care I (2) Esmolol has the shortest half-life (cleared by plasma esterases), and administration rates commonly coincide with high volumes of fluid. (3) Agents with combined…

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Data Tables 3 min

Cardiovascular Critical Care I (4) Concentration-dependent protein binding includes about 25% bound to albumin and about 50% bound to α1-acid glycoprotein (AAG). (5) As AAG increases and decreases…

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Cardiovascular Critical Care I • Eliminated renally; thus, may pose risks of digoxin toxicity in patients with acute or chronic renal failure (3) Although the volume of distribution is relatively l…

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Data Tables 2 min

Cardiovascular Critical Care I Table 9A. CHADS2 Stroke Risk Score in AF Risk Assessment Score Total Patient Score Adjusted Annual Stroke Rate, % CHADS2 Congestive heart failure 1.9 Hypertension 2.8…

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Cardiovascular Critical Care I Table 10. HAS-BLED or HEMOR2RHAGES Bleeding Risk Scores in AF Risk Factor Assessment Score Total Patient Score Bleeds/100 Patient-Yr of Warfarin HAS-BLED Hypertension…

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Cardiovascular Critical Care I i. For patients with AF/flutter taking anticoagulants who undergo cardiac stenting, the strongly recommended approach is to manage with dual therapy (anticoagulant + P…

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Cardiovascular Critical Care I VI.  HEART FAILURE A. Clinical Syndrome – Manifested because of congenital or acquired structural or functional myocardial dysfunction that impairs filling and/or empt…

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Cardiovascular Critical Care I Box 4. Non-ischemic Cardiomyopathies Non-ischemic Cardiomyopathies • Amyloidosis • Sarcoidosis • Drug induced • Alcohol • Anabolic steroids • Chemotherapy § Anthr…

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Cardiovascular Critical Care I 4. Etiologies of RV failure Box 5. Etiologies of RV Failure (Exp Clin Cardiol 2013;18:27-30; J Am Coll Cardiol 2010;56:1435-46) ARDS Arrhythmias Cardiac tamponade Conge…

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Cardiovascular Critical Care I 2. Once other causes of symptomatic congestion and/or low perfusion at rest have been ruled out and a diagnosis of decompensated HF is deemed likely, the following sho…

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Cardiovascular Critical Care I b. Dobutamine and milrinone are most often used for suspected or confirmed low cardiac output states. Milrinone may be preferred more than dobutamine in the presence o…

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Data Tables 3 min

Cardiovascular Critical Care I Table 13. Valvular Disease Characteristics and Management Considerationsa,b (Circulation 2021;143:e72–227) Valvular Disease Type Management Considerations Aortic steno…

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Cardiovascular Critical Care I Valvular Disease Type Management Considerations Tricuspid regurgitation (TR) • Likely to influence pulmonary artery catheter assessments of cardiac output by way of…

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Cardiovascular Critical Care I D. Anticoagulation 1. Three guidelines exist regarding valve anticoagulation, with varying agreement in the recommendations. 2. Prosthetic mitral valves have increase…

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Cardiovascular Critical Care I Procedure Warfarin, Target INR Range Class of Recommendation/ Level of Evidencea Antiplatelet Therapy Class of Recommendation/ Level of Evidencea Transcatheter AV…

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Cardiovascular Critical Care I E. Valve Thrombosis 1. Highest risk within the first year after replacement 2. Most predominant risk is in mechanical prosthetic valves, but can also occur with biopr…

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Cardiovascular Critical Care I ii. Can lead to severe cardiogenic shock iii. SAM is more of a dynamic obstruction in which the degree of obstruction and flow gradient is dependent on heart rate, ca…

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Cardiovascular Critical Care I VIII.  ADVANCED THERAPIES FOR HEART FAILURE AND CARDIOGENIC SHOCK A. The goals behind advanced therapies can be thought of as dynamic, depending on patient progression…

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Data Tables 3 min

Cardiovascular Critical Care I Table 16. Mechanical Interventions for Shock Short to Intermediate Term Intra-aortic balloon pump (IABP) counterpulsation • Placed by femoral arterial catheter or per…

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Cardiovascular Critical Care I Short to Intermediate Term Extracorporeal life support (ECLS) or extracorporeal membrane oxygenation (ECMO) • Similar to cardiopulmonary bypass in which large-bore…

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Cardiovascular Critical Care I (2) Mupirocin 2% (Bactroban) every 12 hours to each nostril to maintain moist nasal passages (3) Oxymetazoline 0.05% (Afrin) to each nostril every 12 hours as needed…

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Cardiovascular Critical Care I (d) Other laboratory values/considerations (1) Hypercoagulable states (i.e., heparin-induced thrombocytopenia [HIT]) (2) CBC with differential (3) Reticulocyte count…

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Cardiovascular Critical Care I ii. Antibiotic treatment (a) Antibiotic coverage should account for site of suspected infection, previous pathogens and susceptibilities, proximity to driveline site…

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Cardiovascular Critical Care I REFERENCES 2022 ACC/AHA guideline for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Hear…

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Cardiovascular Critical Care I De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362(9):779-789. https://doi. org/10.…

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Cardiovascular Critical Care I Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-e1032. https://doi.org/10.1161/ cir.0000000000001063 Hillis LD, Smith PK, Anderson JL, et al.…

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Cardiovascular Critical Care I Lopes RD, Heizer G, Aronson R, et al. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med. 2019;380(16):1509-1524. https:…

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Cardiovascular Critical Care I Circulation. 2021;143(5):e72-e227. https://doi. org/10.1161/cir.0000000000000923 Overgaard CB, Dzavík V. Inotropes and vasopressors: review of physiology and clinical…

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Cardiovascular Critical Care I N Engl J Med. 2009;361(11):1045-1057. https://doi. org/10.1056/nejmoa0904327 Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH. Antithrombotic and thrombolytic therapy…

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Answers & Explanations 4 min

Cardiovascular Critical Care I ANSWERS AND EXPLANATIONS TO PATIENT CASES 1. Answer: B Given this patient’s CAD, type 2 diabetes, dyslipidemia, gastroesophageal reflux disease, hypertension, obstruc-…

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Cardiovascular Critical Care I (i.e., supraventricular tachycardia) to terminate the arrhythmia or to help differentiate atrial from ventricu- lar arrhythmias. 7. Answer: C The physician is conside…

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Self-Assessment 4 min

Cardiovascular Critical Care I ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS 1. Answer: C A diagnosis of cardiogenic shock is most likely, given the patient’s history, presentation, ongoing…

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Cardiovascular Critical Care I APPENDIX A – OVERVIEW OF ANTI-ARRHYTHMICS Class MOA Drug (available dosage forms) ECG Effects Management Considerations and Pearls Notable Drug Interactions Defibril- la…

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Cardiovascular Critical Care I II β-Blockade Ex. Carvedilol (PO) Labetalol (PO/IV) Metoprolol (PO/IV) Esmolol (IV) N/A or ­↑ N/A N/A or ↓ Sinus bradycardia AV block Hypotension more likely with non…

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