What are the key components and management strategies of the cardiac system, including coronary artery disease (CAD), in the Cardiovascular Intensive Care Unit (CVICU)?

Comprehensive Management of Coronary Artery Disease (CAD) in CVICU

Coronary Artery Disease (CAD) in the Cardiovascular Intensive Care Unit (CVICU) requires aggressive, multidisciplinary management focused on early identification, appropriate intervention, and comprehensive post-procedure care to optimize patient outcomes and reduce mortality.

Anatomy and Physiology of the Cardiac System

• The cardiovascular system consists of the heart as the central pump and the vascular network that distributes blood throughout the body 1
• Coronary arteries supply oxygen and nutrients to the myocardium, with any blockage potentially leading to ischemia and infarction 1
• Atherosclerosis, the primary cause of CAD, involves lipid disturbances, inflammation, thrombosis, vascular smooth muscle cell activation, endothelial dysfunction, and oxidative stress 2
• Compensatory arterial remodeling occurs in early atherosclerosis, allowing plaque accumulation without significant luminal narrowing until advanced disease stages 3

CAD Pathophysiology and Clinical Presentation

• CAD is characterized by atherosclerotic plaque formation in coronary arteries, leading to impaired myocardial blood flow 2
• Clinical manifestations range from stable ischemic heart disease to acute coronary syndromes (unstable angina, NSTEMI, STEMI) and cardiogenic shock 4
• Stable ischemic heart disease includes patients with nonobstructive CAD to those with complex 3-vessel disease 4
• Acute coronary syndromes can present with both obstructive and nonobstructive CAD patterns 4
• Typical angina presents as chest pain or discomfort that:
  • Is exertional or stress-related
  • Lasts for minutes with gradual exacerbation
  • Is relieved by rest or nitroglycerin within minutes 2

Key Components of Cardiac Assessment in CVICU

• Comprehensive medical history review including current and previous cardiovascular diagnoses, procedures, and left ventricular function assessment 5
• Documentation of relevant comorbidities including peripheral arterial disease, cerebrovascular disease, pulmonary disease, kidney disease, and diabetes mellitus 5
• Thorough physical examination focusing on vital signs, cardiopulmonary assessment, peripheral circulation, and post-procedure wound sites 5
• Laboratory testing including cardiac biomarkers (Troponin I/T, BNP/NT-proBNP), complete blood count, electrolytes, and renal function assessment 5
• 12-lead ECG to identify arrhythmias, conduction abnormalities, and ischemic changes 5
• Imaging studies including transthoracic echocardiography to assess ventricular function, valvular structure/function, and pericardial effusion 5
• Hemodynamic assessment for signs of hypovolemia, right ventricular failure, and cardiac tamponade 5

CAD Management in CVICU

Acute Coronary Syndrome Management

• Obtain pre-hospital 12-lead ECG for patients with possible ACS as early as possible 4
• Provide early notification to receiving hospitals for activation of intervention teams for STEMI patients 4
• For STEMI patients, implement immediate reperfusion strategies:
  • Primary percutaneous coronary intervention (PCI) is preferred when available within appropriate timeframes 4
  • Consider fibrinolytic therapy when timely PCI is not available 4
• For NSTEMI/unstable angina, risk stratification guides the timing of invasive strategy 4
• Implement invasive hemodynamic monitoring for patients with cardiogenic shock 4
• Consider mechanical circulatory support for refractory cardiogenic shock based on cardiac power output (CPO) and pulmonary arterial pulsatility index (PAPi) measurements 4

Post-Cardiac Arrest Care

• Implement a comprehensive, structured, multidisciplinary system of care for post-cardiac arrest patients 4
• Optimize cardiopulmonary function and vital organ perfusion after return of spontaneous circulation (ROSC) 4
• Transport patients to appropriate facilities with comprehensive post-cardiac arrest treatment capabilities 4
• Identify and intervene for acute coronary syndromes 4
• Implement temperature control to optimize neurologic recovery 4
• Anticipate, treat, and prevent multiple organ dysfunction 4

Chronic Coronary Disease Management

• Implement guideline-directed medical therapy (GDMT) including:
  • Antithrombotic agents
  • Beta-blockers
  • Statins
  • Angiotensin system antagonists 4
• For obstructive CAD, consider the indications, risks, benefits, and alternatives to PCI, coronary artery bypass grafting (CABG), and medical management 4
• Engage in evidence-based shared decision-making with a multidisciplinary team for revascularization decisions 4
• Avoid routine periodic testing with coronary CTA or stress testing in stable patients without clinical status changes 4
• Avoid routine periodic invasive coronary angiography in stable patients 4

Post-Cardiac Surgery Assessment and Management

• Perform comprehensive assessment including vital signs, cardiopulmonary examination, and evaluation of post-procedure wound sites 5
• Monitor for signs of cardiac tamponade including jugular venous distention, muffled heart sounds, and hypotension 5
• Evaluate for common post-operative complications:
  • Left ventricular dysfunction
  • Cardiogenic shock
  • Structural complications
  • Arrhythmias
  • Recurrent ischemia
  • Pericardial effusion/tamponade 2
• Implement cardiac rehabilitation programs that include:
  • Individualized diet plans following heart-healthy patterns
  • Weight management and body composition assessment
  • Physical activity recommendations
  • Risk factor modification 4

Management of Abnormal Cardiac Findings in CVICU

Cardiogenic Shock

• Implement early invasive hemodynamic monitoring with pulmonary artery catheterization 4
• Identify shock phenotype based on hemodynamic parameters:
  • Left ventricular dominant shock: CPO <0.6W, PAPi >1.0
  • Right ventricular dominant shock: CPO <0.6W, PAPi <1.0
  • Biventricular shock: CPO <0.6W, PAPi <1.0, elevated right atrial and pulmonary capillary wedge pressures 4
• Consider mechanical circulatory support for refractory shock based on hemodynamic parameters and clinical presentation 4
• Address the underlying cause (e.g., revascularization for ischemic etiology) 4

Cardiac Arrest

• Provide high-quality CPR with proper chest compression depth (5 cm) and rate (100-120/min) 6
• Minimize interruptions in compressions and switch compressors every 2 minutes 6
• Perform early defibrillation for shockable rhythms 6
• Implement post-cardiac arrest care including:
  • Optimizing cardiopulmonary function
  • Targeted temperature management
  • Coronary angiography when indicated 6
• Address reversible causes including hypovolemia, hypoxia, acidosis, electrolyte abnormalities, hypothermia, tension pneumothorax, cardiac tamponade, toxins, pulmonary embolism, and coronary thrombosis 6

CVICU Tips for CAD Management

• Use intracoronary imaging (IVUS, OCT) and physiological testing (FFR, nonhyperemic pressure ratios) to guide interventional decision-making 4
• Understand the interpretation of invasive diagnostic tests, including recognition of plaque characteristics, vessel measurements, and optimal stent deployment 4
• Recognize that plaque disruption in non-critically stenotic lesions can cause many acute coronary syndromes 3
• Consider CAD as a systemic inflammatory disorder rather than just a localized stenotic disease 3
• Monitor for signs of recurrent ischemia and implement preventive strategies beyond mechanical revascularization 3
• Recognize that modern medical therapy has significantly improved prognosis, with mortality rates in stable CAD patients approaching that of the general population 7