Author + information
- Valentin Fuster, MD, PhD, MACC∗ ()
- ↵∗Address for correspondence:
Dr. Valentin Fuster, Editor-in-Chief, Journal of the American College of Cardiology, American College of Cardiology, 2400 N. Street NW, Washington, DC 20037.
“Revolutions are not push button affairs; rather, they evolve only if there exists a reservoir of hope and grievance that can be galvanized into popular action.”
—Michael Parenti (1)
As many of you know, I carefully scrutinize what are touted as the newest technological breakthroughs in medicine. However, one area of clinical care about which I feel quite excited is a more formal cardiovascular intensive care unit (CICU), because the newest units are ultimately better for the patient and better for the education of the cardiovascular clinician. The demand for cardiovascular critical care is increasing globally due to the aging population and is also reflected by the usage trends of critical care settings in general (2,3). Between 2000 and 2005, although the total number of hospital beds in the United States decreased, the number of critical care beds increased by 6.5%, and the annual costs attributed to critical care increased by 44%, representing 13.4% of all hospital costs (4). To meet the growing needs of the present and future patient populations, the critical care setting has undergone 4 stages of evolution to revolutionize care for the critically ill cardiovascular patient.
The coronary care unit (CCU) emerged in the mid-20th century as a major advance in cardiology practice (5,6) (Stage I). Julian (7) first described treating 5 cardiac arrest cases in acute myocardial ischemia and infarction patients at the Royal Infirmary in Edinburgh in 1961. Led by cardiologists, the CCU was developed when it became clear that close monitoring by trained specialty staff, cardiopulmonary resuscitation, and medical interventions could reduce mortality resulting from cardiovascular disease complications, such as myocardial infarction and fatal arrhythmias.
As ST-segment elevation myocardial infarction (STEMI) care became protocol-based and standardized, this CCU setting began to focus on more diverse patient populations, including non-STEMI, even though it is still led by cardiologists. In this Stage II of the CCU, the cardiologist was responsible for patients with multiple critical care issues, often because their cardiac problems were perceived to be paramount at initial triage (8). Also, CCU cardiologists had become more adept in the management of acute lung injury, prolonged ventilation and ventilator weaning, delirium, renal replacement therapy, venous thrombosis, gastrointestinal hemorrhage, intensive care unit (ICU) polyneuropathy, and septic shock. These patients with cardiovascular disease were susceptible to the same nosocomial complications seen in other intensive care settings (8).
Accordingly, the CCU evolved into a more formal CICU (Stage III) in the late 2000s, the training for those clinicians also began to evolve. In the CICU, cardiac problems may or may not be predominant, and general intensive problems might take priority. These patients are treated for both cardiac and noncardiac entities. As a result, this environment led to the emergence of the cardiac intensivist, who should be trained in acute care medicine, emergency, as well as internal medicine and cardiology. In fact, in a recent Editorial Comment in JACC, Dudzinski and Januzzi (9) wrote that the CICU will benefit from not only the medical knowledge input from an intensivist perspective, but also the culture of quality improvement and the focus on prevention of iatrogenic harms (e.g., ventilator-associated pneumonia, catheter-related bloodstream infection) is central to management in a modern medical CICU setting.
Today, the revolution has been fully realized in Stage IV, which is a cardiac surgical-medical intensive care unit. Most of the cases that present to this setting are cardiovascular, but cardiologists and cardiovascular surgeons need to work together on pre- and post-operative patients. Thus, to understand the types of care provided to those patients who present to a Stage IV-type CICU, I will present a few recent cases who were admitted to Cardiac Surgical-Medical Intensive Care Unit at Mt. Sinai Health System in New York:
• A 54-year-old man with difficult-to-control hypertension presented with tearing back pain and was found to have an acute type A aortic dissection. Cardiothoracic surgeons performed emergent repair of the ascending aorta and hemiarch. Vascular surgeons evaluated residual thoracoabdominal dissection for endovascular therapy options. Cardiologists guided intensive medical management of hypertension and transition to an oral regimen.
• A 47-year-old woman with nonischemic cardiomyopathy and severe left ventricular systolic dysfunction presented with implantable cardioverter-defibrillator shocks and was found to be in acutely decompensated heart failure after appropriate therapies for ventricular tachycardia. Advanced heart failure cardiologists continued to follow their patient into the ICU, guided pharmacological hemodynamic support and volume management, and provided counsel regarding options for advanced therapies. Cardiac electrophysiologists guided antiarrhythmic drug therapy, optimizing the patient's cardiac resynchronization therapy defibrillator programming, and provided counsel regarding options for catheter ablation. Interventional cardiologists inserted an intra-aortic balloon pump to support intensive medical management and bridge the patient to a decision about advanced therapies. Cardiothoracic surgeons evaluated the patient as a candidate for left ventricular assist device implantation as a bridge to transplantation.
• A 61-year-old man presented with crushing chest pain and was found to have an anterior wall STEMI and cardiogenic shock. Interventional cardiologists performed emergent primary percutaneous coronary intervention of the proximal left anterior descending artery and implanted a percutaneous left ventricular assist device and pulmonary artery catheter. Advanced heart failure cardiologists assessed the patient early in his course to guide optimization of vasoactive drug therapies using invasive hemodynamic measures. When acute hypoxemic respiratory failure developed on ICU day 3, a cardiologist who had been following the patient daily auscultated a new systolic murmur and echocardiography disclosed acute ischemic mitral regurgitation. Cardiothoracic surgeons emergently cannulated for venoarterial extracorporeal membrane oxygenation to stabilize the patient in preparation for surgical management, for which both mitral valve surgery and left ventricular assist device implantation were considered.
Traditionally, the clinical services, rather than the patient, have been the center of care. Historically, the care of each of these patients has been primarily housed in 1 specialty silo, with other specialists functioning as consultants, or has necessitated multiple transfers of the patient among different care settings. The new cardiac surgical-medical model makes the patient the center of care, with continuous management by a core team of acute cardiovascular physicians, providers, and nurses—all in collaboration with cardiologists and cardiovascular surgeons. Strategic planning of a patient’s diagnosis and management over the course of a hospitalization is grounded in multidisciplinary discussion, giving patients the benefit of not only the full spectrum of a hospital's resources (an additive benefit) but also the wisdom of multidisciplinary deliberation (a multiplicative benefit greater than the sum of its parts).
In conclusion, this new cardiac surgical-medical intensive care unit, which I have deemed as Stage IV in this revolution of intensive care, is best for the patient, because the complex disease states are assessed and treated by experts from various cardiovascular specialists. In a complementary fashion, this setting is also best for education, so that nurses, fellows, specialists, and the whole assembly of the cardiovascular personnel holistically treat the patient in a team-based environment.
Dr. Fuster would like to thank Matthew Toomey, MD, for his assistance with some information in this Editor’s Page.
- 2018 American College of Cardiology Foundation
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- for the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS)
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