Defining the Role and Needs of the Modern Cardiac ICU

Over the past decades, cardiac intensive care units (CICUs) have become populated by sicker patients with increasingly complex needs. Caring for these patients requires the skill sets of cardiologists, interventionalists, cardiac surgeons and heart failure specialists, as well as advanced nursing and pulmonary support staff. Expertise is needed in ever-advancing cardiovascular interventions including the use of temporary mechanical circulatory support devices.

So contends the American Heart Association (AHA) in a new AHA scientific statement published in Circulation, which reviews models of modern, well-run CICUs with a focus on program structure, clinical practice, training and research. Such CICUs are associated with lower mortality rates, shorter length of stay and reduced resource consumption.

“CICUs have evolved from primarily treating acute myocardial infarction in the 1960s to now handling a plethora of acute cardiovascular problems in patients with poor cardiac function and multiple comorbidities,” says AHA scientific statement co-author Venu Menon, MD, Director of Cleveland Clinic’s Cardiac Intensive Care Unit. “Modern units require a paradigm to successfully meet the needs of these patients, encompassing acute and chronic management of advanced heart failure along with critical cardiac care.”

“The AHA statement benefits from input from more than a dozen authors, reflecting the diversity of professionals from different institutions that provide acute care for patients with advanced cardiovascular issues,” adds statement co-author Amanda Vest, MBBS, Section Head of Heart Failure and Transplantation Cardiology at Cleveland Clinic. “The result is detailed guidance that can be adapted to match an institution’s CICU resources and patient population to optimize outcomes.”

Elements of a modern CICU

To enhance CICU availability at a regional level, the AHA statement supports a three-tiered organizational system:

• Level 1 destination centers are able to provide comprehensive care for all acute cardiovascular conditions, including severe cardiogenic shock, and for patients with preexisting valvular and aortic conditions and heart failure
• Level 2 centers serve as secondary referral centers that can provide some advanced critical care
• Level 3 centers supply community access to basic critical care

Components of a level 1 CICU include the following:

• High-intensity staffing, either headed by a specialty critical care cardiologist or co-managed by a cardiologist and critical care physician; a patient’s primary care physician or general cardiologist may share in key decision-making
• Specialized interdisciplinary teams dedicated to managing cardiac arrest, cardiogenic shock and pulmonary embolism
• Availability of critical care resources for temporary mechanical circulatory support, temperature control, continuous renal replacement therapy and advanced hemodynamic monitoring
• Access to bedside procedures, including pulmonary artery catheterization, mechanical ventilation and airway management, bronchoscopy, thoracentesis, transesophageal echocardiography and pericardiocentesis

The statement also emphasizes the crucial role of specially trained critical care nurses for maintaining a compassionate and competent environment, and it suggests strategies for their recruitment and retention.

“A modern CICU is a team sport,” Dr. Vest comments. “Multiple specialists must work together to handle the complexity of problems encountered.” She adds that no single model is applicable to all institutions and that “there are many ways to achieve optimal care.”

Critical care cardiology – a subspecialty whose time has come

The AHA statement discusses preparing the next generation of CICU specialists — who need skill sets to handle the comprehensive management of life-threatening cardiovascular disease — with dual training and certification in cardiovascular diseases and critical care medicine. The five-year program at Cleveland Clinic includes a three-year general cardiology fellowship, a one-year advanced heart failure and transplant cardiology fellowship, and a one-year critical care cardiology fellowship.

“A cardiac critical care specialist is well suited to head a level 1 CICU and take the lead in multiple arenas beyond patient care,” says Dr. Menon, who directs Cleveland Clinic’s Cardiovascular Fellowship Program and pioneered one of the nation’s first programs devoted to the subspecialty of critical care cardiology. “Roles include training and fostering staff relationships, ensuring best practices, developing projects and participating in multicenter research, and creating and evaluating new models of care delivery.”

About a dozen physicians have completed the program at Cleveland Clinic, and Dr. Menon sees ever-increasing interest in this intensive pathway from cardiology fellows who want to serve as a bridge between traditionally separate fields.

He notes that the recently formed Society of Critical Care Cardiology is advancing the specialty to help fill the need for CICU directors nationwide.

Personal perspectives

The value of specialized training of this type is reflected in the experiences of two current Cleveland Clinic cardiologists, Ran Lee, MD, and Andrew Higgins, MD. Each supplemented his general cardiology fellowship with additional fellowship training in both critical care medicine and advanced heart failure and transplantation cardiology, including training at Cleveland Clinic.

Both Drs. Lee and Higgins were drawn to critical care cardiology by the clear need for specialized skills in this realm and by the challenges and rewards inherent in this care. “I enjoy integrating the interactions between organ systems in addition to providing complex cardiovascular care,” Dr. Lee says. “In some ways being a critical care cardiologist allows me to ‘de-specialize’ and view patients more holistically. It’s also rewarding to help patients and their families during their most vulnerable moments and try my best to lift them up.”

“Critical care cardiology was still in its infancy when I was a medical student, but I knew I had to work in this hybrid niche because I really enjoyed the coupling of high-acuity clinical care with careful, detail-oriented management of the patient as a whole,” Dr. Higgins says. “So I sought out training at the centers where this subspecialty was being developed, including Columbia and subsequently Cleveland Clinic.”

Both Drs. Higgins and Lee emphasize how much more complex and ill CICU patients are today compared with just 10 years ago. “Many admissions to the cardiac ICU are less primarily heart-focused but are instead driven more by concomitant comorbidities,” Dr. Lee explains. “Critical care cardiologists offer these patients rapid, efficient delivery of services such as bedside procedures or ventilator management while still providing excellent cardiology care.”

Dr. Higgins cites the example of a patient with respiratory failure concomitant with an acute valvular disorder or decompensated systolic heart failure. “Which issue to tackle first is often unclear,” he says, noting that quick intubation can facilitate the patient’s next intervention but also risks tipping the patient into cardiac arrest. “No one is better equipped to sort out these challenges and begin tackling them one by one than the critical care cardiologist.”

Data collection and research possibilities

In addition to its focus on clinical care, the new AHA statement also emphasizes that a well-run CICU provides the opportunity for collecting and reporting performance data to registries and for evaluating quality improvement projects in cardiac critical care delivery.

Potential areas of research include:

• Defining the optimal professional balance between cardiovascular subspecialties in the CICU
• Determining best uses of mechanical circulatory support devices
• Tracking and assessing intermediate metrics, such as individualized sedation and spontaneous breathing protocols and timing of removal of intravascular lines and Foley catheters

“Major gaps in knowledge remain in multiple arenas of running a modern CICU,” Dr. Menon observes. “Randomized controlled studies are particularly challenging in this setting, and novel approaches are needed to provide evidence for efficacy and safety of specific therapies.”