Evolution of the coronary care unit: Clinical characteristics and temporal trends in healthcare delivery and outcomes*
TL;DR: Substantial changes have occurred over time in patient characteristics, diagnoses, and procedures within the coronary care unit of a large, academic medical center, in particular, there have been significant increases in noncardiovascular critical illness.
Abstract: Objective:To describe long-term temporal trends in patient characteristics, processes of care, and in-hospital outcomes among unselected admissions within the contemporary coronary care unit.Design:Hospital administrative database that records both payment and operation data.Setting:Coronary care un
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TL;DR: Cardiovascular medicine has lagged behind other medical disciplines that have met the “critical care crisis” with ICU-focused innovations in organization, training, and quality improvement, according to the American Heart Association Council on Cardiopulmonary, Critical Care, and Intensive Care Unit (CICU).
Abstract: Critical care, defined as the diagnosis and management of life-threatening conditions that require close or constant attention by a group of specially trained health professionals, is inherent to the practice of cardiovascular medicine. The demand for cardiovascular critical care is increasing with the aging of the population and is reflected by trends in the use of critical care in general.1 Between 2000 and 2005, although the total number of hospital beds in the United States declined by 4.2%, 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 hospital costs.2 Projections for the next 15 years suggest that the need for critical care will increase markedly in the United States and globally.1,3–5 For example, in Canada, a 57% increase in the need for critical care beds is anticipated during that period.5
Concurrent with increases in demand, the medical demographics of general and cardiac critical care have evolved toward a patient population with an increasing number of comorbid medical conditions who require more prolonged and more technologically sophisticated invasive support. As a result, the delivery of critical care is advancing substantially in its complexity. Moreover, accumulating evidence has indicated that outcomes are better when critical care is provided by specially trained providers in a dedicated intensive care unit (ICU).6–9 In the context of this evolution, 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. Cardiovascular medicine has lagged behind other medical disciplines that have met the “critical care crisis”4 with ICU-focused innovations in organization, training, and quality improvement. Therefore, the American Heart Association Council on Cardiopulmonary, Critical …
240 citations
TL;DR: The concept of the so-called ‘vulnerable plaque’ has proved highly useful to guide research and thinking regarding the pathophysiology of the acute coronary syndromes (ACS), but the time may have come to reconsider this construct, as knowledge has accumulated, the risk profile of the populace has shifted, and the current therapies have reshaped the disease.
Abstract: The concept of the so-called ‘vulnerable plaque’ has proved highly useful to guide research and thinking regarding the pathophysiology of the acute coronary syndromes (ACS). Yet, the time may have come to reconsider this construct, as knowledge has accumulated, the risk profile of the populace has shifted, and our current therapies have reshaped the disease. Over the last several decades, the quest to identify and treat the ‘vulnerable plaque’ has generated much interest.1 Loaded with lipid, macrophage rich, covered by a thin fibrous cap, and considered perilously poised to rupture, the thin-capped fibroatheroma (TCFA) has become a target for imaging, possible intervention, model attempts in animals, and much discussion.2 Many equate type 1 myocardial infarction with ‘plaque rupture’. Yet, the ‘vulnerable plaque’ concept, as useful as it has proved heuristically, may not represent the contemporary challenge, an unmet clinical need, or a fertile field for future research.
The notion of the ‘vulnerable plaque’ arose from autopsy studies that disclosed some two-thirds to three-fourths of fatal acute myocardial infarctions resulted from a fracture of the plaque's fibrous cap that engendered thrombosis ( Table 1 ; Figure 1 ). The elegant post-mortem studies of pathologist pioneers redirected the cardiology community from confusion about the causality of thrombosis in ACS and a focus on vasospasm towards plaque rupture.3,4 However compelling, the number of ruptured plaques resulting in luminal occlusion in these autopsy studies lacked a ‘denominator’. While such studies could interrogate the culprit of a fatal myocardial infarction, they did not determine how many plaques with morphologic characteristics associated with vulnerability did not cause a fatal rupture.
View this table:
Table 1
Challenges to the ‘vulnerable plaque’ concept
Figure 1
Contrasts between …
239 citations
Cites background from "Evolution of the coronary care unit..."
...We also now find ourselves the midst of a transition in the presentation of ACS, with STEMI on the wane and non-ST segment elevation myocardial infarction (NSTEMI) rising.(11) While much of the increase in NSTEMI might result from the introduction of ever more sensitive troponin assays, shifting ACS previously classified as ‘unstable angina’ to NSTEMI, the decline in STEMI, and rise in NSTEMI began before the use of such assays....
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TL;DR: In this article, the prevalence and risk factors for delirium among patients in a mixed cardiology and cardiac surgery intensive care unit (CVICU) were investigated. But, the authors did not identify any specific risk factors.
Abstract: Objective
Delirium, an acute organ dysfunction, is common among critically ill patients leading to significant morbidity and mortality; its epidemiology in a mixed cardiology and cardiac surgery intensive care unit (CVICU) is not well established. We sought to determine the prevalence and risk factors for delirium among CVICU patients.
200 citations
TL;DR: Patients readmitted to ICUs have increased hospital mortality and lengths of stay and the use of readmission as a quality measure should only be implemented if patient case-mix is taken into account.
Abstract: Objective:To examine the association between ICU readmission rates and case-mix–adjusted outcomes.Design:Retrospective cohort study of ICU admissions from 2002 to 2010.Setting:One hundred five ICUs at 46 United States hospitals.Patients:Of 369,129 admissions, 263,082 were first admissions that were
132 citations
Cites background from "Evolution of the coronary care unit..."
...7% readmission rate for cardiac (coronary) ICUs may reflect the recently reported increase in complexity and severity of illness among these patients (34, 35)....
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Brigham and Women's Hospital1, University of North Carolina at Chapel Hill2, University of Alberta3, University of Florida4, MedStar Washington Hospital Center5, Mayo Clinic6, Lehigh Valley Hospital7, Cleveland Clinic8, Cooper University Hospital9, University of California, San Diego10, University of Louisville11, Duke University12, New York University13, Virginia Commonwealth University14, Toronto General Hospital15, Johns Hopkins University16, Rush University Medical Center17, National Institutes of Health18
TL;DR: In a contemporary network of tertiary care CICUs, respiratory failure and shock predominated indications for admission and carried a poor prognosis, while patterns of practice varied considerably between centers, a substantial, low-risk population was identified.
Abstract: Importance Single-center and claims-based studies have described substantial changes in the landscape of care in the cardiac intensive care unit (CICU). Professional societies have recommended research to guide evidence-based CICU redesigns. Objective To characterize patients admitted to contemporary, advanced CICUs. Design, Setting, and Participants This study established the Critical Care Cardiology Trials Network (CCCTN), an investigator-initiated multicenter network of 16 advanced, tertiary CICUs in the United States and Canada. For 2 months in each CICU, data for consecutive admissions were submitted to the central data coordinating center (TIMI Study Group). The data were collected and analyzed between September 2017 and 2018. Main Outcomes and Measures Demographics, diagnoses, management, and outcomes. Results Of 3049 participants, 1132 (37.1%) were women, 797 (31.4%) were individuals of color, and the median age was 65 years (25th and 75th percentiles, 55-75 years). Between September 2017 and September 2018, 3310 admissions were included, among which 2557 (77.3%) were for primary cardiac problems, 337 (10.2%) for postprocedural care, 253 (7.7%) for mixed general and cardiac problems, and 163 (4.9%) for overflow from general medical ICUs. When restricted to the initial 2 months of medical CICU admissions for each site, the primary analysis population included 3049 admissions with a high burden of noncardiovascular comorbidities. The top 2 CICU admission diagnoses were acute coronary syndrome (969 [31.8%]) and heart failure (567 [18.6%]); however, the proportion of acute coronary syndrome was highly variable across centers (15%-57%). The primary indications for CICU care included respiratory insufficiency (814 [26.7%]), shock (643 [21.1%]), unstable arrhythmia (521 [17.1%]), and cardiac arrest (265 [8.7%]). Advanced CICU therapies or monitoring were required for 1776 patients (58.2%), including intravenous vasoactive medications (1105 [36.2%]), invasive hemodynamic monitoring (938 [30.8%]), and mechanical ventilation (652 [21.4%]). The overall CICU mortality rate was 8.3% (95% CI, 7.3%-9.3%). The CICU indications that were associated with the highest mortality rates were cardiac arrest (101 [38.1%]), cardiogenic shock (140 [30.6%]), and the need for renal replacement therapy (51 [34.5%]). Notably, patients admitted solely for postprocedural observation or frequent monitoring had a mortality rate of 0.2% to 0.4%. Conclusions and Relevance In a contemporary network of tertiary care CICUs, respiratory failure and shock predominated indications for admission and carried a poor prognosis. While patterns of practice varied considerably between centers, a substantial, low-risk population was identified. Multicenter collaborative networks, such as the CCCTN, could be used to help redesign cardiac critical care and to test new therapeutic strategies.
126 citations
Cites background or methods from "Evolution of the coronary care unit..."
...Our findings provide new evidence in 3 areas that affect the evolution of cardiac critical care: (1) the shift in CICU demographics toward a greater diversity of clinical conditions, (2) the potential for further refinement of triage to the CICU in light of favorable outcomes among a substantial subcohort of patients admitted for observation or monitoring, and (3) the complexity of advanced CICU care required for most patients admitted to contemporary CICUs....
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...Therefore, we established an investigator-initiated, multicenter network focused on cardiac critical care to (1) quantitatively characterize cardiac critical care in contemporary advanced CICUs and (2) develop an infrastructure for nested, pragmatic, clinical trials in critical care cardiology....
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References
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TL;DR: The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death fromComorbid disease for use in longitudinal studies and further work in larger populations is still required to refine the approach.
39,961 citations
"Evolution of the coronary care unit..." refers methods in this paper
...To examine changes in admission severity of illness and to better clarify case-mix during the study period, the Charlson comorbidity index was calculated for all CCU admissions by a method previously described (16, 17)....
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TL;DR: There was an excess of deathsDue to arrhythmia and deaths due to shock after acute recurrent myocardial infarction in patients treated with encainide or flecainide.
Abstract: Background and Methods. In the Cardiac Arrhythmia Suppression Trial, designed to test the hypothesis that suppression of ventricular ectopy after a myocardial infarction reduces the incidence of sudden death, patients in whom ventricular ectopy could be suppressed with encainide, flecainide, or moricizine were randomly assigned to receive either active drug or placebo. The use of encainide and flecainide was discontinued because of excess mortality. We examined the mortality and morbidity after randomization to encainide or flecainide or their respective placebo. Results. Of 1498 patients, 857 were assigned to receive encainide or its placebo (432 to active drug and 425 to placebo) and 641 were assigned to receive flecainide or its placebo (323 to active drug and 318 to placebo). After a mean follow-up of 10 months, 89 patients had died: 59 of arrhythmia (43 receiving drug vs. 16 receiving placebo; P = 0.0004), 22 of nonarrhythmic cardiac causes (17 receiving drug vs. 5 receiving placebo; P = 0.0...
2,896 citations
TL;DR: Anyone, anywhere, can now initiate cardiac resuscitative procedures to give not only mouth-to-nose artificial respiration but also adequate cardiac massage without thoracotomy.
Abstract: Cardiac resuscitation after cardiac arrest or ventricular fibrillation has been limited by the need for open thoracotomy and direct cardiac massage. As a result of exhaustive animal experimentation a method of external transthoracic cardiac massage has been developed. Immediate resuscitative measures can now be initiated to give not only mouth-to-nose artificial respiration but also adequate cardiac massage without thoracotomy. The use of this technique on 20 patients has given an over-all permanent survival rate of 70%. Anyone, anywhere, can now initiate cardiac resuscitative procedures. All that is needed are two hands.
1,942 citations
TL;DR: The results of treatment of 250 patients with established acute myocardial infarction in a coronary care unit in a university hospital are described in this article, where a classification of functional severity based on clinical evidence of heart failure or shock is presented.
Abstract: The results of treatment of 250 patients with established acute myocardial infarction in a coronary care unit in a university hospital are described. The criteria for diagnosis have been carefully defined. In 62 per cent of patients admitted with a tentative diagnosis of acute infarction, the initial impression was confirmed. Fifteen per cent of patients admitted to the unit were classified as having possible infarction; in this group, the mortality rate was 3 per cent. A classification of functional severity based on clinical evidence of heart failure or shock is presented. Morbidity and mortality in acute myocardial infarction are related to the functional severity of the illness. Although arrhythmia is common, the overriding importance of five life-threatening arrhythmias is emphasized. Mortality of patients in the coronary care unit was not improved in comparison to those treated under regular care until strong central direction of therapeutic programs, immediate treatment of arrhythmia in cardiac arrest, and delegation of some medical authority to trained nurses was accomplished. The change in concept of the purposes and practices of special coronary care from resuscitation to prevention of arrhythmia is emphasized. The mortality in myocardial infarction complicated by shock remains high. In the absence of shock, aggressive medical treatment in the coronary care unit reduced mortality from 26 to 7 per cent. The implications of these data in the management of patients admitted to a hospital with a diagnosis of acute myocardial infarction are discussed.
1,903 citations
TL;DR: High-intensity vs low-intensity ICU physician staffing is associated with reduced hospital andICU mortality and hospital and ICU LOS and no study found increased LOS with high-intensity staffing after case-mix adjustment.
Abstract: ContextIntensive care unit (ICU) physician staffing varies widely, and its
association with patient outcomes remains unclear.ObjectiveTo evaluate the association between ICU physician staffing and patient
outcomes.Data SourcesWe searched MEDLINE (January 1, 1965, through September 30, 2001) for
the following medical subject heading (MeSH) terms: intensive
care units, ICU, health resources/utilization, hospitalization, medical staff,
hospital organization and administration, personnel staffing and scheduling,
length of stay, and LOS. We also used the
following text words: staffing, intensivist, critical, care, and specialist. To identify observational
studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non–English-language
citations, we reviewed only English-language articles. We also searched EMBASE,
HealthStar (Health Services, Technology, Administration, and Research), and
HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful
Med and The Cochrane Library and hand searched abstract proceedings from intensive
care national scientific meetings (January 1, 1994, through December 31, 2001).Study SelectionWe selected randomized and observational controlled trials of critically
ill adults or children. Studies examined ICU attending physician staffing
strategies and the outcomes of hospital and ICU mortality and length of stay
(LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590
abstracts and identified 26 relevant observational studies (of which 1 included
2 comparisons), resulting in 27 comparisons of alternative staffing strategies.
Twenty studies focused on a single ICU.Data SynthesisWe grouped ICU physician staffing into low-intensity (no intensivist
or elective intensivist consultation) or high-intensity (mandatory intensivist
consultation or closed ICU [all care directed by intensivist]) groups. High-intensity
staffing was associated with lower hospital mortality in 16 of 17 studies
(94%) and with a pooled estimate of the relative risk for hospital mortality
of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing
was associated with a lower ICU mortality in 14 of 15 studies (93%) and with
a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI,
0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies
and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity
staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU
LOS in both studies that adjusted for case mix. No study found increased LOS
with high-intensity staffing after case-mix adjustment.ConclusionsHigh-intensity vs low-intensity ICU physician staffing is associated
with reduced hospital and ICU mortality and hospital and ICU LOS.
1,335 citations
"Evolution of the coronary care unit..." refers background in this paper
...With a growing body of evidence extolling the benefits of critical care-trained providers in traditional intensive care unit settings (29, 30), and with influential advocate groups promoting such strategies (31), necessary qualifications for CCU clinicians must be addressed....
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