Page 26 - Delaware Medical Journal - February 2016

Cardiology Critical Care Crisis:
Can Working Across The Aisle Be The Salvation?
Zaher Fanari, MD; Sumaya Hammami, MD, MPH; Armin Barekatain, MD, MSc
There are many changes in the demographics of patients admitted to Cardiac Care Unit (CCU) due to the aging of
US population and coexistence of chronic illnesses, such as diabetes mellitus, hypertension, renal dysfunction, and obstructive lung disease. There is increasing evidence that intensivist staffing in the critical care settings is associated with not only improvements in both Intensive Care Unit (ICU) and in-hospital mortality, but also with better medical resource use. Evidence for decreased mortality has led to increased involvement of critical care trained physicians in multidisciplinary care teams in both medical and surgical ICUs, a trend that has not been adopted to any significant extent in CCUs. A partnership between cardiologists and critical care specialists may offer a better roadmap to deal with cardiac critical care crisis, provide better care for our patients, and prepare the next generation of cardiologists to deal with emerging challenges in the field.
Since their introduction in the early 1960s, Cardiac Care Units (CCUs) have played a crucial role in reduction of in-hospital mortality rates after myocardial infarction
(MI) from 30 to 40 percent in the 1950s to 15 to 20 percent
in the 1970s.1 Prompt detection and treatment of peri-infarct arrhythmias were the focus of these early CCUs. Consequently, by 1980, the major cause of death related to MI had shifted from arrhythmias to ventricular failure.1 Subsequently, monitoring techniques, treatment options, and interventions were developed to allow evaluation of cardiac performance and improvement
of patients’ outcomes. Despite these advances, at least one descriptive study has shown negligible subsequent improvements in the overall mortality rate in the CCU since
increases in non-cardiovascular critical illness in the
CCU patient population.2
There are many changes in the demographics of patients admitted to CCU due to the aging of US population and coexistence of chronic illnesses, such as diabetes mellitus, hypertension, renal dysfunction, and obstructive lung disease.3 Additionally there is
a substantial increase in the rate of sepsis and acute renal failure complicating acute and chronic cardiovascular conditions requiring mechanical ventilation, bronchoscopy, or renal replacement therapy during patients’ stay in the CCU. The advances in mechanical
circulatory support and advanced heart failure therapies introduced
new challenges in the acute management of these patients and any
4
potential complication related to that. As a result, the medical and
procedural issues that determine outcome in the contemporary CCU are often the ones that require substantial expertise in critical care medicine.4 This shift in the care of critically ill cardiology patients marked the evolvement of cardiac care units to cardiac intensive care units (CICU).

care settings is associated with not only improvements in both intensive care unit (ICU) and in-hospital mortality, but also with better medical resource use.5-8 Evidence for decreased mortality has led to increased involvement of critical care trained physicians in multidisciplinary care teams in both medical and surgical ICUs, a care units.9 The main reasons for such a discrepancy are under recognition of the crisis within individual institutions, the lack of absence of incentives for those who are interested in pursuing it.
In a response to this crisis, the American Heart Association issued a statement suggesting three different models to meet the intensivists demand in the CICU.4 CICU patients with surgical or medical ICU patients, producing a
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Del Med J | February 2016 | Vol. 88 | No. 2
Abstract