Abstract Body (Do not enter title and authors here): Background: ARDS affects 200,000 patients annually with 35-60% mortality. Cardiac dysfunction occurs in 60-78% of patients, yet systematic monitoring exists in <30% of ICUs despite point-of-care echo availability in 85% of facilities. This represents a critical quality gap with immediate improvement opportunity using existing technologies.

Objective: Systematically evaluate cardiac monitoring evidence in ARDS and develop practical implementation framework for immediate deployment across diverse ICU settings using currently available technologies.

Methods: Systematic search of MEDLINE, EMBASE, Cochrane through November 2024 for studies evaluating cardiac monitoring in ARDS using standard ICU equipment. Included RCTs and observational studies (≥20 patients) assessing cardiovascular effects of ventilation strategies. Evidence quality assessed using GRADE methodology. Surveyed technology availability and developed tiered protocols based on resource capabilities.

Results: Seven studies (892 patients, low-moderate evidence quality) demonstrated cardiac dysfunction associated with increased mortality (OR 2.3, 95% CI: 1.6-3.2) but significant implementation gaps. Point-of-care echo available in 85% of ICUs, cardiac biomarkers in 98% of hospitals, yet protocols exist in <30%. Developed three-tier framework: Tier 1 (basic assessment, >95% ICUs, 6-12 months, <$50,000), Tier 2 (enhanced monitoring, 60-70% ICUs), Tier 3 (advanced centers). Barriers were organizational rather than technological.

Conclusions: Despite limited evidence, immediate systematic cardiac monitoring implementation is feasible using existing technologies. Three-tier framework addresses resource limitations through scalable protocols. Pilot implementation in motivated centers could demonstrate feasibility while generating real-world evidence, transforming evidence limitations into quality improvement opportunities.

Impact: Could improve recognition in 140,000 ARDS patients annually, potentially reducing mortality and ICU length of stay while establishing infrastructure for future research.