The most exciting advances in intensive and acute cardiac care

Things move fast at the acute end of medicine — and nowhere is this more apparent than in the field of intensive and acute cardiovascular care. This important field (some say the development of the coronary care unit was one of the most important advances in cardiology) has been somewhat neglected at the expense of super-subspecialisation in cardiology. But times are changing. The increasing complexity of patients requiring acute cardiac care has demanded that we no longer ignore cardiac intensive care, including developing training and education programmes, transforming structural and organisational norms and focusing our attention on more research in these most challenging and high stakes areas. The argument that any cardiologist can assess and manage critically ill cardiac patients has long been lost, as the technical and clinical advances in intensive care have moved in parallel with, but separate from, those in cardiology. The coronary care unit (once a place to monitor and treat patients with ST elevation myocardial infarction) has largely been renamed the cardiac (intensive) care unit, reflecting the breadth and complexity of cardiovascular and associated diseases now presenting to the acute cardiac care cardiologist.

In areas that have remained seemingly static for years, we now have the potential to transform outcomes for our patients. The swine flu pandemic has led to a global resurgence of interest in extracorporeal membrane oxygenation (ECMO) in adults, with emerging indications in cardiomyopathy, cardiogenic shock, and even as a salvage following cardiac arrest. Systematic application of research to the development of novel pharmacological vasoactive agents — so often disappointing in the past — provides us with opportunities to support circulation whilst minimising harm to other organs. But the greatest areas of potential development are surely where cutting edge cardiology meets the critically ill, thanks to true multidisciplinary collaboration. Examples include the potential for our electrophysiological colleagues to optimise the management of arrhythmia in the critically ill, and for our interventional colleagues and surgeons to develop smaller and safer percutaneous mechanical support, intervening in increasingly minimal access ways.

This is best exemplified by the development of transcatheter valve interventions, which represent a true paradigm shift in the management of patients with severe valve disease. Patients previously deemed inoperable may now be offered life changing/saving therapies, and increasingly neglected techniques such as balloon aortic valvuloplasty are now being revisited in the most critically ill, with potential for definitive later intervention. At the other end of the technology spectrum, the appropriate and timely collaboration with teams providing comfort and support to critically ill patients and their loved ones is vital to delivering high quality intensive care. The demands provided by this are different from, but equally important to, those where we develop and implement novel therapies and techniques designed to save life. The intensive care cardiologist should always be mindful that high technology care must be mixed with compassion. The realities of doing so sometimes require great skill, and the importance of such a holistic approach, even in this most challenging of areas, is increasingly and explicitly recognised by specialists in the field.

Arguably the greatest collaboration, however, comes with the use of echocardiography in intensive care — with its potential to direct and change the management of the majority of patients. This technique was previously the sole domain of the cardiologist, but is now used throughout the patient pathway in acute cardiac care — with emerging evidence of its positive impact on assessment and management of critically ill patients, ranging from pre-hospital medicine, to the most complex and high-technology cardiac intensive care unit patient. This powerful bedside diagnostic and physiological monitoring technique has transformed cardiac intensive care, is increasingly recommended as standard of care in the acute setting, and is an example of effective multidisciplinary collaboration to improve care in the most critically ill.

This is truly an exciting time in the field of intensive and acute cardiac care. As a junior doctor training in cardiology, and then intensive care, I was always told this subspecialty was not important, and urged to focus my training elsewhere. I am glad I did not.

Featured image: Heartbeat by PublicDomainPictures. CC0 via Pixabay.