Cardiology clinics
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This article presents an overview of the evolution of cardiac critical care in the past half century. It tracks the rapid advances in the management of cardiovascular disease and how the intensive care area has kept pace, improving outcomes and incorporating successive innovations. The current multidisciplinary, evidence based unit is vastly different from the early days and is expected to evolve further in keeping with the concept of 'hybrid' care areas where care is delivered by the 'heart team'.
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Cardiogenic shock (CS) is a condition in which a marked reduction in cardiac output and inadequate end-organ perfusion results from an array of cardiac insults, the most common of which is acute myocardial infarction. CS is a systemic disease involving a vicious cycle of inflammation, ischemia, and progressive myocardial dysfunction, which often results in death. This life-threatening emergency requires intensive monitoring accompanied by aggressive hemodynamic support; other therapies are tailored to the specific pathophysiology. The development of novel therapeutic strategies is urgently required to reduce the unacceptably high mortality rates currently associated with CS.
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Mild therapeutic hypothermia (MTH) results in a significant decrease in mortality and improvement of neurologic outcomes in cardiac arrest (CA) survivors. Cardiologists and intensivists must be acquainted with the indications and technique because MTH is the only proven neuroprotective therapy for CA survivors. CA involves reinstituting meaningful cardiac activity and minimizing secondary neurologic injuries. This article focuses on MTH as the main strategy for post-CA care.
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Medical advances over the past 50 years have helped countless patients with advanced cardiac disease or who are critically ill in the intensive care unit (ICU), but have added to the ethical complexity of the care provided by clinicians, particularly at the end of life. Palliative care has the primary aim of improving symptom burden, quality of life, and the congruence of the medical plan with a patient's goals of care. This article explores ethical issues encountered in the cardiac ICU, discusses key analyses of these issues, and addresses how palliative care might assist medical teams in approaching these challenges.
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Massive pulmonary embolism (PE) is a potentially lethal condition, with death usually caused by right ventricular (RV) failure and cardiogenic shock. Systemic thrombolysis (unless contraindicated) is recommended as the first-line treatment of massive PE to decrease the thromboembolic burden on the RV and increase pulmonary perfusion. ⋯ Critical care management predominantly involves supporting the RV, by optimizing preload, RV contractility, and coronary perfusion pressure and minimizing afterload. Despite these interventions, mortality remains high.