Assessment and management of cardiovascular disease in the intensive care unit
David Jonathan Cook, Stephen Webb, Alastair Proudfoot
Abstract
### Learning objectives Despite a decline in mortality related to cardiovascular disease (CVD) over the last three decades, the prevalence of CVD remains high.1 Acute heart failure (AHF) is the most common emergency admission in patients above 65 years old, causing 5% of all emergency admissions with an inpatient mortality of 11%.2 One in five patients hospitalised with heart failure in the USA is admitted to an intensive care unit (ICU),3 and 31.9% of admissions for cardiogenic shock (CS) due to acute myocardial infarction were complicated by multiorgan failure.4 The contemporary ICU therefore has to have the expertise to manage acute cardiovascular care across an increasing breadth and complexity of cardiovascular conditions either as the presenting pathology or as a comorbid condition in critically unwell patients admitted for other reasons.5 This review outlines an approach to the unstable cardiovascular patient on the ICU. We will review the assessment and management of patients requiring intensive care admission with cardiovascular disease, the common aetiologies, associated investigations and the range of support modalities available on the ICU. The underlying processes of AHF and CS are based on four key physiological concepts: contractility, preload, afterload and electrical conductivity. ### Contractility Contractility or inotropy describes the heart’s inherent ability to eject blood for a given preload and afterload. A loss of contractility causes systolic dysfunction. This loss of inotropy results in a decreased stroke volume, increasing the end systolic volume. This in turn prompts a rise in preload. A compensatory increase in end diastolic volume helps to maintain stroke volume by activating the …