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CHAPTER SUMMARY AND CENTRAL ILLUSTRATION

Chapter Summary

This chapter discusses the evolution of the coronary care unit (CCU) into the modern day cardiac intensive care unit (CICU). While the traditional CCU consisted mostly of patients with acute myocardial infarction (MI) and postreperfusion care, the contemporary CICU serves a more complex demographic of patients with acute and chronic cardiac disease, multiple comorbidities, and advanced age. Operationalization requires rapid triage of patients often from regional centers to hubs focused on ST-segment elevation myocardial infarction (STEMI), shock, acute aortic emergencies, pulmonary embolism, and out-of-hospital cardiac arrest. Other unique populations include patients requiring management of structural heart disease, temporary mechanical circulatory support, endocarditis, and periprocedural management. Ensuring appropriate systems of care, infrastructure, and workforce capable of caring for these patients has led to the emerging field of critical care cardiology. The CICU has truly become an intensive care unit requiring knowledge of critical care medicine with guidance largely extrapolated from the general intensive care unit literature, but with a recognized need to develop CICU-specific evidence-based patterns of care.

eFig 61-01 Chapter 61: Evolution of Cardiac Critical Care

HISTORY OF THE CORONARY CARE UNIT: 1960 TO 2000

Eugene Braunwald has described the creation of the coronary care unit (CCU) as the “single most important advancement in the treatment of (acute myocardial Infarction).” The concept of the CCU was conceived in 1961 by Dr. Desmond Julian, a young cardiologist at the Edinburgh Royal Infirmary. Aware of the significant incidence of early arrhythmia related mortality following acute myocardial infarction and influenced by the introduction of external defibrillation by Zoll1 and advances in closed chest cardiopulmonary resuscitation by Kouwenhoven,2 he proposed a central unit to cluster patients following acute myocardial infarction with ready access to electrocardiographic monitoring and trained medical staff.3,4 This organizational action led to an immediate 7% absolute increase in survival following acute myocardial infarction and was promptly adopted worldwide. Subsequently, the first unit in the United States was created in 1963 by Dr. Hughes Day at Bethany Medical Center in Kansas City who is also credited with coining the term CCU.5

Over the next three decades, the CCU became a clinical and research laboratory for the treatment and advancement of cardiac care predominantly in patients following an acute myocardial infarction (AMI). In 1967, Killip and Kimball risk stratified 250 patients with AMI admitted to the four-bed New York Hospital–Cornell Medical Center CCU and established the profound impact of acute heart failure and cardiogenic shock in this setting.6 (Table 61–1). Shortly thereafter, the design of the balloon tipped catheter by Swan and Ganz enabled continuous direct bedside hemodynamic monitoring that resulted in the recognition of the hemodynamic subsets of myocardial infarction and correlates of cardiogenic shock by Forrester and colleagues (Fig. 61–1).7...

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