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Exercise stress testing

1 What is the purpose of exercise stress testing, and how can a patient exercise during stress testing? Exercise stress testing (EST) using electrocardiography (ECG) is routinely performed to diagnose myocardial ischemia, estimate prognosis, evaluate the outcome of therapy, and assess cardiopulmonary reserve. Exercise is used as a physiological stress to detect cardiac abnormalities that are not present at rest. They are accomplished with a treadmill,…

Chest x-ray

1 Describe a systematic approach to interpreting a chest radiograph (chest x-ray). Common recommendations are to: 1. Begin with general characteristics such as the age, gender, size, and position of the patient. 2. Next examine the periphery of the film, including the bones, soft tissue, and pleura. Look for rib fractures, rib notching, bony metastases, shoulder dislocation, soft tissue masses, and pleural thickening. 3. Then evaluate…

Electrocardiography

1 What are the most commonly used voltage criteria to diagnose left ventricular hypertrophy? Numerous criteria have been established for the electrocardiographic (ECG) diagnosis of left ventricular hypertrophy (LVH). Below are the three that are used most frequently: R wave in V5-V6 plus S wave in V1-V2 >35 mm (Sokolow criterion). R wave in lead I plus S wave in lead III >25 mm. R wave…

Heart murmurs and sounds

1 What are the auscultatory areas of murmurs? Auscultation typically starts in the aortic area, continuing in clockwise fashion: first over the pulmonic, then the mitral (or apical), and finally the tricuspid areas ( Fig. 2.1 ). Because murmurs may radiate widely, they often become audible in areas outside those historically assigned to them. Hence, “inching” the stethoscope (i.e., slowly dragging it from site to site)…

Cardiovascular physical examination

Editor’s Note to Readers: For an excellent and more detailed discussion of the cardiovascular physical examination, read Physical Diagnosis Secrets, 2nd edition, by Salvatore Mangione. 1 What is the meaning of a slow rate of rise of the carotid arterial pulse? A carotid arterial pulse that is reduced ( parvus ) and delayed ( tardus ) suggests the presence of aortic valvular stenosis . Occasionally, this…

US and European Cardiology Society Guidelines

Atrial Fibrillation 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64:e1–e76. Congenital Heart Disease ACC/AHA 2008 Guidelines for the Management of…

Palliative Care in the Cardiac Intensive Care Unit

Burden of Heart Failure The burden of heart failure (HF) includes frequent deteriorations often requiring hospitalization, high mortality, and significant symptoms, reducing the quality of life. HF contributes to more than 10% of deaths in the United States. Despite advances in therapy, the number of deaths attributable to HF today is similar to the numbers in 1995. Patients who survive a hospitalization for HF have age-adjusted…

Cardiopulmonary Resuscitation and Critical Care After Cardiac Arrest

This chapter reviews the clinical care of a patient with cardiac arrest. Cardiac arrest consists of complete or nearly complete cessation of blood flow and is fatal unless reversed in seconds or minutes. The cardiac intensivist may manage initial resuscitation of a patient to reverse cardiac arrest. In addition, post–cardiac arrest patients are critically ill; the intensivist must care for the aftermath of this event. Understanding…

Mechanical Ventilation and Advanced Respiratory Support in the Cardiac Intensive Care Unit

Compared to initial coronary care units dedicated to the monitoring of and rapid intervention in life-threatening ventricular arrhythmias in the setting of acute myocardial infarction (MI), cardiac intensive care units (CICUs) have evolved into models providing care for a broader spectrum of acute cardiovascular conditions along with increasing prevalence of noncardiac comorbidities. Recent data suggested a further expansion in the role of CICUs to care for…

Emergency Airway Management

Respiratory distress is a common complication of acute illness. It may result from a primary pulmonary disorder, such as acute respiratory distress syndrome, or be a sequela of another disease, such as volume overload owing to acute renal insufficiency or sepsis. Respiratory distress may necessitate support with control of the airway and positive pressure ventilation. Failure to maintain adequate oxygenation and ventilation can lead to brain…

Heart Transplantation for Advanced Heart Failure

Heart failure (HF) continues to be a leading cause of morbidity and mortality in the United States. Approximately 5.7 million Americans are currently living with HF; that number is expected to increase to more than 8 million by 2030. For the 915,000 new cases of HF diagnosed each year, 5-year mortality remains at approximately 50%. The gross annual cost for managing HF is approximately $30.7 billion…

Ventricular Assist Device Therapy in Advanced Heart Failure

The development of reliable left ventricular assist devices (LVADs) has revolutionized heart failure (HF) management. In the cardiac intensive care unit (CICU) context, LVADs are encountered in three situations: first, selection of the appropriate heart failure patients for mechanical circulatory support (MCS) and preoperative evaluation; second, management of these patients perioperatively; and third, treatment of complications and prevention of adverse events. This chapter addresses these issues.…

Temporary Mechanical Circulatory Support Devices

Clinicians practicing in the cardiac intensive care unit (CICU) are challenged with increasingly complex patients who often require hemodynamic support to improve end-organ perfusion and reduce mortality. The high mortality associated with cardiogenic shock has been the stimulus for technological advances that provide life-sustaining hemodynamic support when maximum pharmacologic therapy is ineffective. Numerous devices to augment cardiac output (CO) have been developed that can be placed…

Invasive Hemodynamic Monitoring

Hemodynamics is derived hydrodynamics, the physics of the motion and action of water. The dimensions of hemodynamics include flow, pressure, static resistance, dynamic impedance, reflectance and compliance, branching effects, viscosity, fluid friction, turbulence, and other physical characteristics. The goals of hemodynamic assessment and manipulation in the critically ill patient are to ensure adequate organ blood flow, oxygen supply, and ultimately to improve survival. Noninvasive parameters to…

Pericardiocentesis

Pericardiocentesis was first described in 1840 and has since became the primary method for diagnosing the etiology of a pericardial effusion and treating pericardial tamponade. Initially, the procedure was performed blindly through a subxiphoid approach. Later, fluoroscopy and electrocardiography (ECG) were used to guide the procedure. Since 1979, echocardiography has been used for direct visualization of cardiac structures and adjacent vital organs during the procedure. The…

Temporary Cardiac Pacing

Temporary cardiac pacing delivers electrical cardiac stimulation to treat a cardiac bradyarrhythmia until the underlying problem resolves or a permanent pacing solution is provided. Temporary cardiac pacing is most commonly used for symptomatic bradycardia and is occasionally used to determine whether a patient requires permanent pacing. The important factors that determine whether a patient requires a temporary or permanent pacemaker include the patient's rhythm, hemodynamic tolerance…

Central Venous Access Procedures

Peripheral Intravenous Cannulation Patients in the cardiac intensive care unit (CICU) require reliable intravenous access. Dependable peripheral vein cannulation technique is an essential tool to establish intravenous access in critically ill patients. Equipment Equipment for peripheral venous access includes the following: (1) 16-, 18-, and 20-gauge intravenous (IV) catheter over needle units with backup supplies, (2) alcohol swabs, (3) tourniquet, (4) TB or 3-mL syringe with…

Pharmacologic Interactions

Concomitant administration of several drugs is common in the treatment of cardiovascular diseases. Often, combinations of drugs are necessary and result in improved outcomes. With a large number of medications, however, there is also an increased concern about drug interactions. Although the number of potential interactions is great, many are inconsequential. Conversely, drug interactions can have significant adverse effects or even be lethal. Many drug interactions…

Analgesics, Tranquilizers, and Sedatives

Analgesics, tranquilizers, and sedatives are among the most commonly prescribed medications in the intensive care unit (ICU) and are frequently used for the management of pain, agitation, and delirium. These medications are not benign; as the patient population becomes older with more comorbidities, the management of these drugs can profoundly impact patient outcomes in the cardiac ICU (CICU). Thus it is important for the cardiac intensivist…

Antidysrhythmic Electrophysiology and Pharmacotherapy

The management of critically ill patients is often complicated by cardiac arrhythmias. Patients with acute cardiac ischemia, heart failure, respiratory failure, or renal failure are at risk for different arrhythmias, including atrial fibrillation, supraventricular tachycardia, ventricular tachycardia, and ventricular fibrillation. This includes patients both with and without a history of cardiac arrhythmias. Over the last several decades, procedural methods of managing cardiac arrhythmias have provided patients…