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Review

Evolution of the concept of coronary care and the emergent role of critical care

Mokhtar, Sherif

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The Egyptian Journal of Critical Care Medicine: April 2018 - Volume 6 - Issue 1 - p 1-3
doi: 10.1016/j.ejccm.2018.04.001
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Abstract

1. Introduction

With the discovery of the potential benefits of closed cardiac massage and defibrillation in the management of acute MI, the consequent development of the Coronary Care Unit (CCU) to allow monitoring and rapid treatment of potentially lethal arrhythmias in acute MI has been regarded by many as one of the greatest innovations in Cardiology [1].

The first description of the CCU was presented by Julian to the British Thoracic Society in 1961. Soon after, the first CCU was established in the U.S. by H. Day in 1961 in Cansas City. This was followed shortly by a landmark study from Killip and Kimball (1967) confirming the importance of the CCU as a beneficial tool in the management of patients with acute myocardial infarction (MI) [1].

The landscape of the CCU today, however, has changed vastly from that of the 1960s. No longer is it simply an observation unit for patients with acute MI, but rather it has become a dynamic and diverse arena of patient care. Dedicated CCU's that were developed in the 1960's have been transformed into combined units such as CCU and cardiology ward, CCU and ICU, high dependency units with very few dedicated CCUs remaining [2]. The most common of CCUs (25%) was a combination of CCU/cardiology ward, 17% were a combined CCU/ICU, and 12.5% of CCU were a dedicated unit.

The history of the CCU had previously been described in Four Stages, primarily related to management of patients with coronary artery disease [3]. Shown in Table 1.

Table 1
Table 1:
Stages in The History of CCU.

Increasing numbers and changing needs of critically ill pts with the exploding indications for interventional cardiology created the problem of the changing role of CCU. CCUs are not only dealing with CAD pts as the name implies, but broadly cover a wide spectrum of critically ill cardiac pts whose survival is threatened by life-threatening arrhythmias, acute pulmonary edema, cardiogenic shock, etc…

Since its foundation, the demographics of patients admitted to the CCU have changed significantly, with a reduction in the incidence of ST elevation MI, an increased incidence of non-ST elevation MI, and larger numbers of patients presenting with haemodynamic instability related to other cardiovascular conditions. Further, the patient population is increasingly elderly and with greater comorbidities [4,5].

Today's prototypical CCU patients include those with complicated and uncomplicated MI, decompensated heart failure and frank cardiogenic shock, severe valvular heart disease, high-grade conduction disturbances, incessant ventricular arrhythmias, complications of percutaneous procedures, and sequelae of intravascular device infections.

The exploding techniques of interventional process raised the issue of the need for specialized physicians who can handle such emergency procedures as endotracheal intubation, CVP cannulation, basic and advanced life support (BLS – ACLS)…etc.

As a result, now more than ever before, the distinctions between our CCUS and traditional medical ICUs have become increasingly blurred. The cardiologist is being called on to care, at the onset, for patients with multiple critical care issues. A typical example is the pt admitted with acute MI who shortly sustained cardiac arrest, needed CPR and assisted ventilation but developed cardiogenic shock, passed into renal shutdown, etc… Furthermore, patients in the CCU are subject to the same nosocomial complications seen in other intensive care settings including sepsis, septic shock etc… Prolonged life expectancy and increasing comorbidities have increased the challenges of managing this patient population.

Thus, an additional phase in the CCU has been proposed – the Critical Care Phase – and the CCU has been renamed the Cardiac Care Unit [4,6].

Table
Table

The increasingly overlapping knowledge base required by the cardiologist responsible for the CCU, and the intensivist responsible for the medical intensive care unit, together with the pathology seen on admission can lead to confusion when defining and describing the CCU. Whilst the majority of Intensive Care Units are led by clinicians trained in critical care medicine, and who are in a position therefore to deliver high-quality evidence-based critical care to their patients, this is not the case in the CCU.

Many cardiologists erroneously believe that their general cardiology training addresses adequately the competencies required to manage critically ill cardiovascular patients (ESC Curriculum for The General Cardiologist, Esc Curriculum for Acute Cardiac Care). If cardiologists are to continue to optimally manage the CCU there is clearly a need for training in intensive care for these specialists [7–9].

Meanwhile to ensure an optimal door to needle time for primary PCI the need arose for the ready availability of an acute Cath. Lab. equipped for handling such pts with acute MI with corresponding teams of doctors trained for intervention. The latter could be cardiologists or critical care physicians who are obviously already available at the scene and well trained in BLS, vascular access, ET intubation, and a unique Egyptian experience have readily available cath lab.

Figure
Figure

The extended skill set required to manage the modern CCU has led to the development of the Subspecialty Of Acute Cardiac Care, together with a relevant syllabus and curriculum (The ESC Core Curriculum for Acute Cardiac Care).

The Acute Cardiac Care Curriculum is therefore far beyond the scope of the core/general cardiology curriculum, recognizing the developments in both intensive care medicine and acute cardiology that have occurred over recent years and the requirement for a multi-system approach to the critically ill patient.

Figure
Figure

Diagnostic Indications

  1. Hemodynamic Evaluation of Critically Ill pts.
  2. Electrophysiologic evaluation of Symptomatic Bradycardia
  3. Electrophysiologic evaluation of Supraventricular and Ventricular Tachycardias
  4. Diagnostic Coronary Arteriography “Acute Coronary Syndromes”

Therapeutic Indications:

  1. Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction
  2. Haemodynamic Support “IABC”
  3. Termination of Supraventricular and Ventricular Arrhythmias
  4. Temporary pacing in Symptomatic Bradycardia & overdrive pacing in VT.
  5. Permanent Pacemaker Implantation in Bradyarrhythmias
  6. Multisite PM implantation in Refractory HF
  7. ICD implantation in refractory VT and Survivors of Cardiac Arrest
  8. Radiofrequency Ablation of incessant SVT & AF, and life threatening V. tachycardia

Examples presented and clear indications listed leave no double about the importance and positive impact of catheter lab. availability in the ICU, at least in tertiary care hospitals & academic centres.

The CCU has changed dramatically since its initial inception, and with it has changed the required skill set of the CCU cardiologist. It is no longer acceptable to assume that all cardiologists are trained in acute cardiac care and can also manage the critically ill cardiac patient. Similarly critical care medicine extended its scope to handle critically ill multi organ failure patients including emergency interventions.

Given the breadth of critical care diseases and the remarkable patient diversity now seen in our CCUs, we should anticipate an imminent challenge to the general cardiologists that currently staff these units and a call for dedicated intensivists to assume care for these complex patients.

The marriage between cardiology and critical care would have lasting effects not just in direct patient care but also in the arena of medical research. Accumulating evidence has indicated that outcomes are better when critical care is provided by specially trained providers in a dedicated intensive care unit. Provision of optimal care in the contemporary cardiac ICU (CICU) presents a different set of challenges and requires an expanded set of skills compared with 10 years ago [7–10].

In addition to obtaining the key cardiological skills, cardiologists are also required to develop the relevant competencies required for intensive care medicine as outlined by The European Society of Intensive Care Medicine collaboration [11], and competency Based Training programme for Intensive Care Medicine for Europe and other world regions (ESICM, CoBaTrICE). Similarly, the American Board of Internal Medicine proposed requirements for Advanced Critical Care Certification for those with cardiology training in order to address this need [12,13].

Therefore CCU cardiologists must now be trained in the management of acute lung injury, prolonged ventilation and ventilator weaning, delirium, renal replacement therapy, venous thrombosis, gastrointestinal hemorrhage, ICU polyneuropathy, and septic shock, etc… which skills are mastered by ICU specialists.

Availability of appropriately trained cardiologists in the field of CCU Medicine should lead to increased and improved dialogue between all the relevant specialties, extend the availability and visibility of the relevant skills of the cardiologist, and would permit the critical care specialist to handle emergency procedures like primary PCI, RF ablation of arrhythmia, PM placement and cardiac resynchronization therapy in HF, thus improving management of this critically ill patient population.

2. Conclusions

The CCU has changed dramatically since its initial inception, and with it has changed the required skill set of the CCU cardiologist.

Given the breadth of critical care diseases and the remarkable patient diversity now seen in our CCUs, we should anticipate an imminent challenge to the general cardiologists that currently staff these units and a call for dedicated intensivists to assume care for these complex patients.

It has been predicted that the workload of the CCU in the next decade will increase, highlighting the need to ensure also a qualified critical care nursing workforce. International guidelines recommend that at least 75% of the nursing workforce in CCU should have a postgraduate critical care qualification [6,14].

Accumulating evidence has indicated that outcomes are better when critical care is provided by specially trained providers in a dedicated intensive care unit. Provision of optimal care in the contemporary cardiac ICU (CICU) presents a different set of challenges and requires an expanded set of skills compared with 10 years ago and a need for mutual training [7–10].

References

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