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- Cardiac care facilities
- coronary care units
- atrial fibrillation
- coronary artery disease
- coronary angiography
- oxydative stress
- coronary haemodynamics
- coronary angioplasty (pci)
- coronary physiology
- intravascular ultrasound
- coronary stenting
- coronary intervention
- anthracycline cardiotoxicity
- echocardiography (transoesophageal)
- mitral valve
- aortic valve disease
The development of primary angioplasty (PPCI) programmes for acute ST elevation myocardial infarction (STEMI) following Roger Boyle's report ‘Mending hearts and brains’ in 20061 has led to a marked shift in the role of the coronary care unit (CCU) in the UK. Some units no longer admit STEMI patients, while in PPCI centres the concentrated influx of patients previously treated across a network of hospitals has placed CCU beds and staff under considerable pressure.
However, there are other factors changing and increasing the workload of acute cardiology, and the development of PPCI cannot be considered in isolation. In particular, the changing demographics of the population has led to an increasing proportion of elderly patients presenting to hospital with non-ST elevation myocardial infarction (NSTEMI), heart failure, atrial fibrillation (AF) and valvular disease, often with significant co-morbidities. The net result is that CCUs remain busy, but the nature of the workload is changing with admission of older, sicker and more complex patients.
Coronary care units first developed in the 1960s when it became clear that electrocardiographic monitoring by staff trained in cardiopulmonary resuscitation, combined with other medical interventions, could reduce the mortality from complications of myocardial infarction.2 Eugene Braunwald later described the development of the CCU as the single most important advance in the treatment of acute myocardial infarction,3 although few cardiologists felt this at the time as their main focus was on the treatment of congenital and rheumatic heart disease. Desmond Julian introduced the concept to the UK in 1964 when he developed the first European CCU in Edinburgh, on his return from Sydney.2 With the advent of thrombolysis, the role of CCU in the treatment of STEMI and management of complications became well established in all acute hospitals.
Today, approximately 30% of the acute medical take consists of patients with a primary cardiac problem.4 The majority of these acute cardiac patients are admitted to district general hospitals, often under the initial care of acute or general physicians. The advent of PPCI centres has had little impact on this as STEMI patients comprise a limited and decreasing proportion of the acute cardiac take and therefore the overall acute medical workload.5
While it has long been accepted that patients presenting with STEMI should be admitted to a CCU, the situation for patients with other acute coronary syndromes has been less clear. However, aggregated data from the MINAP audits from 2008 and 20096 provide compelling evidence to support the routine use of a dedicated acute cardiac care unit (ACCU) for all NSTEMI admissions. NSTEMI patients admitted to a dedicated cardiac facility (CCU or cardiac ward) under the direct care of a cardiologist are more likely to be prescribed appropriate secondary preventive medications and to undergo inpatient coronary angiography (J Birkhead, personal communication).
In hospitals where NSTEMI patients are more frequently managed on a CCU, patients have a significantly shorter length of stay (upper quartile performance median length of stay 5.6 days, compared with 7.5 days for lower quartile hospitals based on 85 000 NSTEMI admissions).6 Most importantly, 30-day mortality for NSTEMI in hospitals where patients were most likely to be managed in CCUs was significantly reduced (mortality in hospitals with upper quartile performance for CCU admission 5.6% vs lowest quartile 7.9%). After adjustment for confounding variables including age, gender, risk factors and admission medication, RR of 30-day death in patients admitted to a CCU was 0.88 (0.82–0.94; p<0.001) compared with those admitted to a general medical bed.6 Hence, an argument for specialist cardiac care for NSTEMI patients can be made on the grounds of economy, better access to care and most importantly, outcome.
There is also accumulating evidence that patients with a range of other acute cardiac presentations have better outcomes if managed under the care of specialist cardiology teams, even if they fall outside the traditional remit of a CCU. A case in point is the management of atrial fibrillation. Because it is predominantly a disease of the elderly, and there are such large numbers of admissions with AF, most patients in acute hospitals are cared for by general physicians and may not be admitted to an ACCU, or indeed to any cardiology ward, even if there is haemodynamic compromise. And yet patients presenting with uncontrolled AF are also best managed by specialists,7 with resulting greater adherence to guideline based therapy. This is not surprising as the diagnostic and therapeutic services required to manage these patients are more readily accessed through admission to an acute cardiac unit, where patients come under the care of a cardiology team. Arrhythmia specialist nurses can provide an efficient link to cardiology services, directing patients who can benefit from specialist input from acute assessment units or accident and emergency departments to cardiac wards.
The evidence for heart failure is even more powerful. Management of heart failure with a multi-professional approach improves outcomes for patients, and has been adopted into the latest NICE guidance and quality standards.8 The essential role of specialist heart failure nurses in the management of chronic heart failure has been emphasised,9 but it is also the case that the inpatient management of patients with acute heart failure by cardiology teams leads to lower mortality rates. Data from the 2009–2010 heart failure audit in England and Wales confirm that admission under a general medical team was associated with a 30% higher 1-year mortality, even after adjusting for known confounding variables.10 Access to in-patient cardiology care was associated with an in-hospital absolute mortality rate of 6% compared with 12% for non-cardiology care, with cardiology care being an independent predictor of a better outcome after adjusting for age and known confounders. The improved outcomes persisted in this group to 1 year of follow-up—16.2% versus 32% mortality for general medical care. Patients admitted under cardiology had more disease modifying treatment prescribed and were more likely to have heart failure specialist nursing follow-up.10 An accompanying editorial concluded that an ongoing lottery of care was unacceptable and that all patients admitted to hospital with heart failure should be treated with the same urgency associated with acute ischaemic events.11
Patients with complex adult congenital heart disease are a growing group who are prone to cardiac events, particularly arrhythmias, throughout their lives and who may present acutely to non-specialist hospitals.12 The acute cardiac unit has a key role to play in the rapid and appropriate management of the unstable patient with congenital heart disease and all units need to be able to provide correct emergency treatment.
To deal effectively with acutely unstable patients, cardiology services must be well organised, appropriately resourced and efficient with excellent links to acute and general medicine; this presents a significant challenge in the current difficult financial climate. The provision of seamless 24-h acute cardiac care will mean changes in the working practices for most hospitals. There is no uniform pathway for the transition from CCU to ACCU, but there are likely to be a number of common elements: prompt and efficient triage of patients is a prerequisite and the evolution of nurse specialists in cardiology has been an important step in this regard. Equally important is the capacity for prompt transfer of stabilised patients to other services for management of non-cardiac conditions. Adequate staffing—medical, nursing and technical—is essential, as is the continuous availability of support from a consultant cardiologist and the provision of diagnostic and therapeutic procedures such as echocardiography, pericardiocentesis and temporary pacing. Hospitals unable to provide such services alone may need to link with neighbouring units to provide network cover. Provision of sufficient cardiac bed capacity might be achieved by reorganisation of existing bed stock, but in some instances will require additional investment.
In response to widespread concerns about the future role of the CCU, a working group of the British Cardiovascular Society has been considering the organisation and provision of care for acute cardiac conditions. The final recommendations of the working group are now available.13 Key conclusions are that all hospitals admitting unselected acute medical patients should have an appropriately sized, staffed and equipped ACCU, where high-risk patients with a primary cardiac diagnosis should be managed by a specialist cardiology team with round the clock support from a consultant cardiologist. The ACCU should be open to all high risk cardiac patients who may benefit from specialist care and should not be restricted to patients with ACS.13 The challenges for hospitals and clinical teams in moving from CCU to ACCU should not be underestimated but the benefits for patients are clear.
We are grateful to John Birkhead for providing data from MINAP.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
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