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Intensive Diuresis and Ultrafiltration

Fluid overload has been recognized as a serious complication of cardiac disease. It is associated with an increased risk of respiratory failure, prolonged need for mechanical ventilation, the development of acute kidney injury (AKI), a longer stay in the hospital, and increased mortality rate. Patients with chronic kidney disease (CKD) and heart disease are particularly at risk. Congestive heart failure (CHF) is a common reason for…

Inotropic and Vasoactive Agents

Inotropic and vasoactive agents often play an important role in the management of hemodynamic instabilty in the intensive care setting. This chapter discusses the relevant pharmacology and clinical indications for the parenteral inotropic, vasodilator, and vasoconstrictor agents most frequently used in the cardiac intensive care unit (CICU). These agents are used to correct or stabilize hemodynamic function; therefore in many cases their proper selection and dosing…

Antiplatelet Therapy

Over the last 3 decades, clinical management and outcomes of patients presenting with acute coronary syndromes (ACSs) have improved dramatically. Better understanding of the role of the platelet in the pathophysiology of the ACS has been the fundamental pillar for that progress. The development and availability of effective pharmacologic agents and the advance of coronary revascularization procedures have been the tools by which scientific advances were…

Anticoagulation: Antithrombin Therapy

Antithrombotic therapies are a mainstay of contemporary cardiovascular medicine; it is essential for providers in the cardiac intensive care unit (CICU) to have a thorough understanding of these pharmacologic agents. Patients with acute coronary syndromes (ACSs) and those undergoing percutaneous coronary intervention (PCI) account for a substantial proportion of CICU admissions; the thoughtful use of antithrombotic therapies in these settings is required to safely balance the…

Overdose of Cardiotoxic Drugs

Cardiac arrhythmias, myocardial depression, and vasodilation are the major cardiovascular effects observed in poisonings. A large number of therapeutic and nontherapeutic agents can cause toxicity directed toward the cardiovascular system, whether in the setting of an actual overdose or merely a therapeutic misadventure. This chapter addresses some of the most significant and most common cardiovascular toxins. These toxicants are briefly described, including a review of relevant…

Hemodynamically Unstable Presentations of Congenital Heart Disease in Adults

Recent decades have seen great growth in the number of adults with congenital heart disease (ACHD). Between 1985 and 2000, the number of adults with congenital heart disease has doubled, resulting in approximately 1 million adult survivors in the United States who are increasingly having late complications. This is accompanied by a similar increase in hospitalizations as more adult patients develop late complications of disease. As…

Pulmonary Hypertension

Over the past 2 decades, significant advances have been made in the understanding of the pathophysiology of pulmonary hypertension. In addition, dramatic improvements have occurred in the diagnostic and therapeutic approach of patients afflicted with this disease. The resulting development of new interventions for disease management has fundamentally transformed its natural history and has improved the perception of its various phenotypes. This has enabled a more…

Massive Acute Pulmonary Embolism

Acute pulmonary embolism (PE) represents the sudden obstruction of part or all of the pulmonary arterial vasculature, usually caused by embolization of thrombus from the deep veins within the lower limbs and pelvis. It may also be caused by embolism of air, fat, or amniotic fluid. PE is the third most common cause of cardiovascular death (after coronary artery disease and stroke); more than 600,000 cases…

Acute Respiratory Failure

Respiratory failure is defined as the inability to maintain either the normal delivery of oxygen to tissues or the normal removal of carbon dioxide from the tissues. From a physiologic perspective, respiratory failure can be caused by diffuse pulmonary dysfunction (ventilation/perfusion [V̇/Q̇] mismatch or pulmonary shunt), neurologic dysfunction (depression of the respiratory drive), cardiac dysfunction (low cardiac output or pulmonary edema), or a lack of hemoglobin…

Acute Pericardial Disease

Pericardial disease is encountered less frequently than myocardial disease in the cardiac intensive care unit (CICU). However, its ability to mimic ischemic heart disease and congestive heart failure can make the diagnosis of pericardial disease challenging at times. While many patients with pericardial disease have a subacute or chronic presentation, the astute clinician must always consider pericardial disease in patients who present with hemodynamic embarrassment and…

Acute Aortic Syndromes: Diagnosis and Management

Introduction Acute thoracic aortic syndromes comprise a spectrum of medical and surgical emergencies, including acute aortic dissection, penetrating aortic ulcer, and aortic intramural hematoma. All of these conditions are potentially life threatening and warrant prompt diagnosis and emergent management. The clinical presentation of acute aortic syndromes is highly variable, ranging from occult disease to classic clinical presentations. Numerous etiologic factors, acting singly and in combination, have…

Hypertensive Emergencies

Definition Hypertensive emergencies are characterized by severe elevations in blood pressure (BP) (>180/120 mm Hg) complicated by impending or progressive target organ dysfunction. Targeted organs typically include the aorta, brain, eyes, heart, and kidneys. Immediate (minutes to hours) BP reduction is essential to prevent further morbidity. This contrasts with hypertensive urgencies , in which severe elevations in BP are not accompanied by target organ dysfunction. In these…

Acute Presentations of Valvular Heart Disease

Acute deterioration in valvular function represents a tremendous challenge to the practicing clinician. The presentation of valvular emergencies is usually dramatic; a thorough knowledge of predisposing etiologies, hemodynamic abnormalities, and therapeutic modalities is essential to making appropriate management decisions. Despite an increasing population of patients with prosthetic valves, a resurgence of rheumatic fever, and the continued rise in intravenous drug use–associated infective endocarditis, the overall incidence…

Diagnosis and Treatment of Unstable Supraventricular Tachycardia

Introduction Supraventricular tachycardias (SVTs) occur frequently in critically ill patients and are associated with increased morbidity and mortality. Immediate exact diagnosis is not necessary and initial management should focus on ensuring hemodynamic stability. Tachycardias should be characterized by QRS complex width, rate, regularity, and rapidity of onset, as initial treatment can be guided by these characteristics rather than a precise diagnosis. Hemodynamically stable regular tachycardias should…

Electrical Storm and Incessant Ventricular Tachycardia

Ventricular tachycardia (VT) accounts for 5% to 10% of admissions to cardiac intensive care units (CICUs). With the successes of modern reperfusion therapy to reduce mortality in ST elevation myocardial infarction (STEMI), of pharmacotherapy and implantable cardioverter defibrillators (ICDs) to prolong survival in heart failure, and of implantable left ventricular assist devices (LVADs) to sustain life in end-stage cardiomyopathy, the number of patients with the substrate…

Sudden Cardiac Death

Cardiovascular disease is one of the most common causes of death, accounting for approximately 1 of every 2.9 deaths in the United States and approximately 17 million deaths worldwide each year. Of deaths due to a cardiovascular cause, more than 50% occur suddenly, making sudden cardiac death (SCD) one of the most common causes of death in the United States. Despite advances in the understanding of…

Cardiorenal Syndrome Type 1

Various organ systems within the body are intimately connected to each other and communicate via organ crosstalk, the complex biologic communication and feedback between organ systems mediated by soluble and cellular messengers. In the normal state, this crosstalk helps to maintain homeostasis and optimal function of the body and all its component systems. However, during disease, this crosstalk can transfer signals from the diseased organ that…

Distributive Shock

The range of care covered by cardiac intensive care units (CICUs) has expanded drastically since they were originally developed as coronary care units (CCUs) for the management of acute myocardial infarction (MI) in the early 1960s. In addition to the rising complexity of cardiovascular diseases seen in the CICUs, other critical conditions such as respiratory failure, renal failure, and sepsis have become increasingly more prevalent as…

Stress (Takotsubo) Cardiomyopathy

Stress cardiomyopathy (SCM) is a generally reversible acute cardiac syndrome that was originally described in the Japanese population over 30 years ago. Hence, the Japanese term takotsubo (an octopus trap with a narrow neck and round bottom, Fig. 20.1 ) cardiomyopathy/syndrome has gained favor, as it describes the appearance of the left ventricle during systole. SCM is also known as apical ballooning syndrome (ABS), broken heart…

Acute Fulminant Myocarditis

Definition and Epidemiology Myocarditis is defined as inflammation of the myocardium generally following an injury such as infection, ischemia, or trauma. Approximately 2.5 million cases of myocarditis and cardiomyopathy were diagnosed globally in 2015. Most cases of acute myocarditis present with chest pain or mild left ventricular (LV) dysfunction. Fulminant myocarditis refers to a specific clinicopathologic form of recent-onset myocarditis requiring inotropic or mechanical circulatory support…