Essential reading for Cardiovascular Intensive Care

The "Cardiovascular Intensive Care" section is a series of annotations and footnotes to Section 2.1.4, by the same name, from the CICM Second Part General Exam Syllabus (First Edition).  This syllabus item combines material from vaguely cardiological topics, with some stuff mixed in which could more properly be described as vascular surgery, cardiac arrest resuscitation, or even recurrent branches of the First Part syllabus (such as haemodynamic monitoring). As the result of assimilating all this mass, "Cardiovascular Intensive care" ended up ballooning considerably, and now appears at the top of the list of CICM Part II topics (mostly because the number of "cardiovascular" SAQs is inflated by all the ECG questions, each of which is really just a third or a quarter of a "full" SAQ).

What follows is an index of helpful review articles that will have an impact in the early stages of preparing for the CICM Part II. The syllabus has an extensive list of what the candidate should be able to do ("for each of the above conditions expected knowledge will include" etc), and these resources should hopefully be able to answer some of these requirements.  Where the syllabus expects "relevant guidelines and evidence", the trials and guidelines are kept separate, to limit the size of this page but also because the ability to quote guidelines and debate trial evidence comes in at a different stage of exam preparation. Moreover it felt useful to separate trials and guidelines in cardiac arrest and resuscitation from the trials and guidelines in critical care cardiology because they cover somewhat different cognitive domains (and historically those were separate SAQ sections in the old classification used by Deranged Physiology, which pre-dated the Second Part Syllabus).

L1 conditions in "Cardiovascular Intensive Care"

The expectations from the syllabus document are:

...expected knowledge will include:

  • Epidemiology
  • Aetiology
  • Pathophysiology and clinical course
  • Assessment encompassing history, clinical examination, and relevant investigations
  • Management encompassing resuscitation, definitive treatment, initial and ongoing monitoring with supportive treatment
  • Complications and known sequelae
  • Relevant guidelines and evidence

Candidates should be able to:

  • Apply knowledge to intensive care clinical scenarios
  • Perform an appropriate clinical assessment
  • Analyse and synthesise information from a clinical assessment and investigations
  • Develop an evidence-based management plan tailored to patient needs"

Shock is listed as a syllabus item here, as well as in the Trauma Intensive Care section, as well as in Sepsis and Infections where it is more clearly distinct as "septic shock". This could mean that this "shock" section must be mostly about cardiogenic shock, but realistically one would probably benefit from a more generous interpretation, where "shock" is also treated as "all shock" or "undifferentiated shock".  Thus:

Shock in the broader sense

Shock which is undifferentiated

Reviews on all the different types of shock

Cardiac arrest

Ischaemic heart disease here is a separate syllabus item from acute coronary syndromes, which cleverly specifies that this section is intended for stable ischaemic heart disease, as everything else falls into the ACS definition. 

Acute coronary syndromes

Heart failure

Pulmonary hypertension: 

Hypertensive Crisis also appears in the renal section, where presumably it refers to specific renal-related causes of hypertensive emergencies (eg.  renal artery stenosis and scleroderma renal crisis) or to specific renal complications of hypertensive emergencies (i.e. renal failure due to the hypertension). Which leaves this section here to deal with all the other variants:

Valvular heart disease could be a huge topic (do you want granular detail for aetiology, epidemiology, / pathophysiology for each valve? Each leaflet?) Some kind of compromise needed be made. It ended up looking like this:

Aortic aneurysm and dissection are obviously somewhat different entities, so:

Cardiac arrythmias would be too big a topic if it were treated properly here, so it is only offered as a series of narrative reviews. Realistically the meat of the topic is in the causes and management guidelines. 

Thrombotic disease here is presumably something separate from the "arterio-venous thrombotic disease, e.g., DVT, thrombophilic disorders, HITTS, TTP-HUS" that occupies a prominent L1 position in the haematology and oncology section. Nor is this stroke (that's in neuro), nor is this PE ("clot, fat and other" went into the respiratory section). What thrombotic disease are we left with, that could be cardiovascular in theme, but unrelated to PE or DVT, and that is not an acute coronary syndrome (which has its own syllabus entry)? Reader, if an SAQ on this topic is ever encountered, we will complete this section, but for now it will be filled with a space-occupying rant.


L1 Topics in "Cardiovascular Intensive Care"

Haemodynamic monitoring is well integrated into the First Part annotated syllabus, so much so that it would be a huge pain to uproot and transplant it. Moreover it would serve neither the First Part candidates, who need to know it for the occasional written question, nor the Second Part candidates, who do not need that level of detail. Thus, "relevant anatomy, principles and practice, interpretation" is deprioritised here. "Relevant guidelines and evidence" and "controversies and risks" seem like more important topics for the almost-Fellow. Thus:

Interpretation of the electrocardiogram seems like something most candidates at this stage in their training will require no additional support for, other than the exposure to regular opportunities to practice their systematic approach. If they still don't have one of those, here's a couple of good examples.  The LITFL ECG resources, and specifically 150 of their "top 100 ECGs" are the best free pre-exam self-testing resource, and (historically) have also acted as the source of some the exam ECGs, back when they did not let you take the paper home. 

Mechanical supports: ECMO / IABP is a huge topic. 

Cardiopulmonary resuscitation  is again a massive topic, but fortunately overlaps with "cardiac arrest" which is already thoroughly flogged as an L1 condition, and moreover being the subject of numerous  past SAQs, assessment has driven learning to the point where everyone is generally capable of answering basic questions on this subject. Still:

L2 conditions in "Cardiovascular Intensive Care"

These are somewhat deprioritised, as the college does not expect aetiology/epidemiology or guidelines from the candidates:

"...expected knowledge will include:

  • Assessment encompassing history, clinical examination, and relevant investigations
  • Management encompassing resuscitation, definitive treatment, initial and ongoing monitoring with supportive treatment
  • Complications and known sequelae

Candidates should be able to:

  • Apply knowledge to intensive care clinical scenarios
  • Perform an appropriate clinical assessment
  • Analyse and synthesise information from a clinical assessment and investigations
  • Develop a management plan tailored to patient needs"

Congenital heart disease, presumably meaning "adult congenital heart disease in the ICU for reasons other than the repair of their congenital heart disease, otherwise this would be in the perioperative section":

Myocarditis: Lampejo et al (2021) or Basso (2022)

Pericarditis: Lazarou et al (2022)

Vena cava obstruction syndromes

L2 topics in "Cardiovascular Intensive Care"

Mechanical supports: VAD/Impella: 

Echocardiography in intensive care

  • ...

For each of these,  "expected knowledge will include" only  "principles and practice" and "controversies and risks", which means the echocardiography item is difficult to reconcile with other elements of the training program. Consider that CICM trainees are expected to do basically a semester of study on TTE before transitioning to independent practice. The implications of this knowledge are that either a) the college expects to test echo skills separately and this subject is not really a part of the Second Part Exam syllabus except on a very superficial level, or b) the expectations of the Second Part Exam overlap with the rest of the program, in which case the real syllabus for "Echocardiography in intensive care" is actually this appendix of the T-35 document, and when they say "principles and practice", they actually mean "functionally identify types of shock, monitor significant physiological abnormalities and guide individual therapy... identifying normal versus grossly abnormal anatomical structures and identifying significant functional abnormalities ... limited to the use of
2D and M-mode modalities with a clear understanding of the associated limitations of these techniques"
(Nanjayya et al, 2019).

To defend against the possibility of such expectations, the well-resourced exam candidate should aim to complete their echo competency before their Second Part Exam, as this will do no harm, and could potentially bring good. Those who haven't had the opportunity will benefit from reading the notes and watching the lectures from the RNSH FCUS course, which are of course not as good as attending the course.
 

References

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Buonpane, Angela, et al. "Mechanical cardiopulmonary resuscitation devices: evidence synthesis with an umbrella review." Current Problems in Cardiology (2024): 102485.

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Babu-Narayan, Sonya V., et al. "Imaging of congenital heart disease in adults." European heart journal 37.15 (2016): 1182-1195.

Tompkins, Rose, and Anitra Romfh. "General principles of heart failure management in adult congenital heart disease." Heart failure reviews 25.4 (2020): 555-567.

Verheugt, Carianne L., et al. "Mortality in adult congenital heart disease." European heart journal 31.10 (2010): 1220-1229.

Niwa, Koichiro, Harald Kaemmerer, and Yskert von Kodolitsch. "Current diagnosis and management of late complications in adult congenital heart disease." Cardiovascular Diagnosis and Therapy 11.2 (2021): 478.

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Lampejo, Temi, et al. "Acute myocarditis: aetiology, diagnosis and management." Clinical Medicine 21.5 (2021): e505.

Basso, Cristina. "Myocarditis." New England Journal of Medicine 387.16 (2022): 1488-1500.

Lazarou, Emilia, et al. "Acute pericarditis: update." Current Cardiology Reports 24.8 (2022): 905-913.

Azizi, Abdul Hussain, et al. "Superior vena cava syndrome." Cardiovascular Interventions 13.24 (2020): 2896-2910.

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