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The article presents a case report of a 55-year-old man who experienced cardiac arrest, cardiogenic shock, and hypoxemia. Topics include the patient's presentation after out-of-hospital cardiac arrest, initial management including defibrillation and intravenous medications, and subsequent complications such as acute respiratory failure and the need for mechanical ventilation and percutaneous left ventricular assist device (LVAD) support.

Even though this roadmap for health equity research centers around ECMO disparities, it can be used as an exemplar for health equity research throughout critical care and medicine ( B b ). Keywords: disparities; extracorporeal membrane oxygenation; intensive care unit; race; structural inequalities; systemic review EN disparities extracorporeal membrane oxygenation intensive care unit race structural inequalities systemic review 964 966 3 06/19/23 20230701 NES 230701 In this issue of I Critical Care Medicine i , Moynihan et al ([1]) report the results of a scoping review investigating neonatal, pediatric, and adult extracorporeal membrane oxygenation (ECMO) use and associated outcomes across social determinants of health (SDoH). [Extracted from the article]

This Viewpoint discusses the ABIM's continuing efforts to innovate and streamline maintenance of certification, including the recently launched Longitudinal Knowledge Assessment (LKA), to better accommodate physicians' schedules and desires for flexibility. [ABSTRACT FROM AUTHOR]

Evaluation of knowledge among internal medicine residents is subjective and can be biased. This study assesses how knowledge ratings changed after adoption of the 2014 milestone ratings system compared with standardized knowledge ratings among different racial and ethnic groups. Background: The 2014 adoption of the Milestone ratings system may have affected evaluation bias against minoritized groups. Objective: To assess bias in internal medicine (IM) residency knowledge ratings against Black or Latino residents—who are underrepresented in medicine (URiM)—and Asian residents before versus after Milestone adoption in 2014. Design: Cross-sectional and interrupted time-series comparisons. Setting: U.S. IM residencies. Participants: 59 835 IM residents completing residencies during 2008 to 2013 and 2015 to 2020. Intervention: Adoption of the Milestone ratings system. Measurements: Pre-Milestone (2008 to 2013) and post-Milestone (2015 to 2020) bias was estimated as differences in standardized knowledge ratings between U.S.-born and non–U.S.-born minoritized groups versus non-Latino U.S.-born White (NLW) residents, with adjustment for performance on the American Board of Internal Medicine IM certification examination and other physician characteristics. Interrupted time-series analysis measured deviations from pre-Milestone linear bias trends. Results: During the pre-Milestone period, ratings biases against minoritized groups were large (−0.40 SDs [95% CI, −0.48 to −0.31 SDs; P < 0.001] for URiM residents, −0.24 SDs [CI, −0.30 to −0.18 SDs; P < 0.001] for U.S.-born Asian residents, and −0.36 SDs [CI, −0.45 to −0.27 SDs; P < 0.001] for non–U.S.-born Asian residents). These estimates decreased to less than −0.15 SDs after adoption of Milestone ratings for all groups except U.S.-born Black residents, among whom substantial (though lower) bias persisted (−0.26 SDs [CI, −0.36 to −0.17 SDs; P < 0.001]). Substantial deviations from pre-Milestone linear bias trends coincident with adoption of Milestone ratings were also observed. Limitations: Unobserved variables correlated with ratings bias and Milestone ratings adoption, changes in identification of race/ethnicity, and generalizability to Milestones 2.0. Conclusion: Knowledge ratings bias against URiM and Asian residents was ameliorated with the adoption of the Milestone ratings system. However, substantial ratings bias against U.S.-born Black residents persisted. Primary Funding Source: None. [ABSTRACT FROM AUTHOR]

Abstract: Background: A reduction in right ventricular function commonly occurs in the early postoperative period after coronary artery bypass graft surgery (CABG). We sought to determine the longer-term effect of CABG on right ventricular function. Methods: Cardiac magnetic resonance imaging was performed before and approximately 3 months after surgery in 28 patients undergoing elective CABG. Right ventricular (RV) ejection fraction was assessed by planimetry of electrocardiographically gated cine images. Results: There was a statistically significant increase in left ventricular ejection fraction from 50% to 58% (P=.003) after CABG. RV ejection fraction also increased from 54% to 60% (P=.002). In patients with lower baseline RV ejection fraction (below the median, < 53%), this parameter improved from 47% to 57% (P<.001). Both on-pump (47% vs. 62%, P=.003) as well as off-pump CABG (47% vs. 55%, P=.009) lead to an improvement in RV function in patients in the initial low RV ejection fraction group. Conclusion: Long-term right ventricular function was not adversely affected by CABG. An improvement in RV function occurred after surgery in patients with low baseline RV ejection fraction and was similar in patients who underwent surgery with or without cardiopulmonary bypass. [Copyright &y& Elsevier]

There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery. [Display omitted] • Despite their higher cardiovascular disease burden, underrepresented racial and ethnic groups have less access to cardiovascular and cardiac surgical care, and worse postoperative outcomes. • Various factors, including racism and social determinants of health, contribute to perioperative health care disparities. • Applying a health equity lens to multipronged interventions may reduce disparities and improve cardiovascular outcomes among patients undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]

Over the last several decades, the cardiac intensive care unit (CICU) has seen a substantial evolution in the patient population, comorbidities, and diagnoses. However, the generation of high-quality evidence to manage these complex and critically ill patients has been slow. Given the scarcity of clinical trials focused on critical care cardiology (CCC), CICU clinicians are often left to extrapolate from studies that either exclude or poorly represent the patient population admitted to CICUs. The lack of high-quality evidence and limited guidance from society guidelines has led to significant variation in practice patterns for many of the most common CICU diagnoses. Several barriers, both common to critical care research and unique to CCC, have impeded progress. In this multinational perspective, we describe key areas of priority for CCC research, current challenges for investigation in the CICU, and essential elements of a path forward for the field. [Display omitted] • Evidence generation in the modern CICU has not matched the evolution of the patient population. • Beyond difficulties of studying critically ill patients, there are unique barriers to research in CCC. • Overcoming these barriers will require novel research designs and collaboration among multiple stakeholders. [ABSTRACT FROM AUTHOR]

Black women are disproportionately affected by cardiovascular disease with an excess burden of cardiovascular morbidity and mortality. In addition, the racialized structure of the United States shapes cardiovascular disease research and health care delivery for Black women. Given the indisputable evidence of the disparities in health care delivery, research, and cardiovascular outcomes, there is an urgent need to develop and implement effective and sustainable solutions to advance cardiovascular health equity for Black women while considering their ethnic diversity, regions of origin, and acculturation. Innovative and culturally tailored strategies that consider the differential impact of social determinants of health and the unique challenges that shape their health-seeking behaviors should be implemented. A patient-centered framework that involves collaboration among clinicians, health care systems, professional societies, and government agencies is required to improve cardiovascular outcomes for Black women. The time is "now" to achieve health equity for all Black women. [ABSTRACT FROM AUTHOR]

Objective: To evaluate racial and ethnic differences in mortality among patients hospitalized with coronavirus disease 2019 (COVID-19) after adjusting for baseline characteristics and comorbidities. Methods: This retrospective cohort study at 13 acute care facilities in the New York City metropolitan area included sequentially hospitalized patients between March 1, 2020, and April 27, 2020. Last day of follow up was July 31, 2020. Patient demographic information, including race/ethnicity and comorbidities, were collected. The primary outcome was in-hospital mortality. Results: A total of 10 869 patients were included in the study (median age, 65 years [interquartile range (IQR) 54–77; range, 18–107 years]; 40.5% female). In adjusted time-to-event analysis, increased age, male sex, insurance type (Medicare and Self-Pay), unknown smoking status, and a higher score on the Charlson Comorbidity Index were significantly associated with higher in-hospital mortality. Adjusted risk of hospital mortality for Black, Asian, Hispanic, multiracial/other, and unknown race/ethnicity patients were similar to risk for White patients. Conclusions: In a large diverse cohort of patients hospitalized with COVID-19, patients from racial/ethnic minorities experienced similar mortality risk as White patients. [ABSTRACT FROM AUTHOR]

Computed tomographic angiography (CTA) is considered to have limited accuracy for quantifying exact percent diameter stenosis in coronary arteries. However, most studies evaluating CTA use quantitative coronary angiography (QCA) as the gold standard, a technique with its own limitations. We sought to determine whether CTA measurements of stenosis severity correlate better with intravascular ultrasound (IVUS) than with QCA. Luminal dimensions of 67 de novo coronary lesions were measured by CTA, IVUS, and QCA. IVUS was performed when lesion severity by angiography was equivocal. Mean percent diameter stenosis by QCA was 51 ± 9.8% and mean IVUS minimal luminal area was 3.8 ± 1.8 mm2. There was a moderate correlation between CTA minimal luminal area and IVUS minimal luminal area (r2 = 0.41, p <0.001), but no relation between CTA and QCA measurements of minimal luminal diameter (r2 = 0.01, p = 0.57) or diameter stenosis (r2 = 0.02, p = 0.31). There was also no relation between IVUS minimal luminal area and QCA diameter stenosis (r2 = 0.01, p = 0.50). When lesions with moderate or severe calcification were excluded, the correlation between CTA minimal luminal area and IVUS minimal luminal area was good (r2 = 0.68, p <0.001). In conclusion, in this cohort of patients with intermediate-grade lesions on cardiac catheterization, absolute measurements of stenosis severity on CTA correlated with IVUS but not with QCA. Our findings suggest that limitations of quantitative coronary angiography as a gold standard need to be considered in studies evaluating the accuracy of coronary CTA. [Copyright &y& Elsevier]

Background In the SHOCK trial, an invasive strategy of early revascularization was associated with a significant mortality benefit at 6 months when compared with initial stabilization in patients with cardiogenic shock complicating acute myocardial infarction. Our objectives were to evaluate the data on real-world practice and outcomes of invasive vs conservative management in patients with cardiogenic shock. Methods We analyzed data from the Nationwide Inpatient Sample from 2002 to 2011 with primary discharge diagnosis of acute myocardial infarction and secondary diagnosis of cardiogenic shock. Propensity score matching was used to assemble a cohort of patients managed invasively (with cardiac catheterization, percutaneous coronary intervention, or coronary artery bypass graft surgery) vs conservatively with similar baseline characteristics. The primary outcome was in-hospital mortality. Results We identified 60,833 patients with cardiogenic shock, of which 20,644 patients (10,322 in each group) with similar propensity scores, including 11,004 elderly patients (≥75 years), were in the final analysis. Patients who underwent invasive management had 59% lower odds of in-hospital mortality (37.7% vs 59.7%; odds ratio [OR] 0.41; 95% confidence interval [CI], 0.39-0.43; P < .0001) when compared with those managed conservatively. This lower mortality was consistently seen across all tested subgroups; specifically in the elderly (≥75 years) (44.0% vs 63.6%; OR 0.45; 95% CI, 0.42-0.49; P < .0001) and those younger than 75 years (30.6% vs 55.1%; OR 0.36; 95% CI, 0.33-0.39; P < .0001), although the magnitude of risk reduction differed ( P interaction < .0001). Conclusions In this largest cohort of patients with cardiogenic shock complicating acute myocardial infarction, patients managed invasively had significantly lower mortality when compared with those managed conservatively, even in the elderly. Our results emphasize the need for aggressive management in this high-risk subgroup. [ABSTRACT FROM AUTHOR]