The Changing Role of the Coronary Care Cardiologist & The Emerging Role of Cardiac Intensive Care Specialists lecture presented by Dr Sherif Mokhtar, President ECCCP at the Egyptian Spanish Critical care Symposium held at Cairo, Egypt on 11 May 2023

1. The Changing Role of the Coronary
Care Cardiologist
&
The Emerging Role of Cardiac
Intensive Care Specialists
Sherif Mokhtar, MD
Professor of Cardiology
Professor of Critical Care Medicine
Cairo University, President ECCCP

2. From a CardiologyWard to Coronary
Care Unit
Towards the beginning of the last century, the main
role of the cardiologist was in the art of diagnosis
and treatment of valvular and congenital heart
disease and heart failure.
Zoll PM, 1956; Lown B, 1962, H. Day, 1960 & Julian DG. 1987

3. Evolution of the CCU
With the discovery of the potential benefits of closed
cardiac massage and defibrillation in the management
of acute MI.
The consequent development of a special unit to allow
monitoring and rapid treatment of potentially lethal
arrhythmias in acute MI has been regarded by many as:
One of the greatest innovations in cardiology.

4. Evolution of the CCU
In 1961, Desmond Julian at that
time a senior medical registrar of
the Royal Infirmary of Edinburgh,
presented his novel conception of
the CCU to the BritishThoracic
Society

5. Evolution of the CCU
In the same year 1961, Dr H. Day
started his CCU in Kansas City,
USA.

6. CCU & Hospital Mortality after MI
The Advent of CCUs was temporally
associated with and often credited for a
substantial decrease in the in-hospital
mortality rate after MI from 30%–40% in
the 1950s to 15%–20% in the 1970s.

7. FromaCardiologyWard
to
CoronaryCareUnit

8. From a CardiologyWard to
Coronary Care Unit
Exciting technological advances in the invasive
treatment of CAD and the changing demographics of
the patients profile, had shifted the focus of
cardiologists from being primarily on valvular and
congenital HD
To
Revascularization & Comprehensive Critical Care.

9. Coronary Care Unit
In an analysis of trends over 2 decades of
academic CCU care
A marked increase in the prevalence of sepsis
and acute renal failure complicating acute and
chronic cardiovascular conditions
A dramatically changing demographic profile
of the patient population in the contemporary
CCU.
Evolving Demographics
(Katz et al., 2010)

10. Emergence of the Contemporary CCU
Chronic illnesses, including:
• Diabetes mellitus
• Hypertension
• Renal dysfunction
• Obstructive lung disease
Now commonly coexist with cardiovascular illness
in today’s CCU, which leads to greater case-mix
and escalating illness severity.
Cardiovascular Illness & Co-Morbidities
(Quinn et al., 2005)

11. Emergence of the Contemporary CCU
Emerging technologies and improved therapeutics
have altered the natural history of critical illness in some
groups of pts previously considered unsalvageable,
thereby increasing
• The length of stay
• Risk of iatrogenic complications, and
• Resource consumption.
Effect of ModernTechnologies & New
Therapeutics
(Quinn et al., 2005)

12. Changing Admission Diagnoses

14. Admission Diagnosis

15. Stages inThe History of CC
Years Phase I Comments
1912 Clinical observation ▪ Herrick’s classic description
of AMI published
▪ Infarcted heart considered
a wounded organ
▪ Main treatment rest
▪ In-hospital mortality 30%

16. Stages inThe History of CC
Years Phase II Comments
1961 Coronary care unit ▪ Julian’s first description of the
coronary care unit
▪ Dedicated areas with
continuous ECG monitoring,
defibrillators and resuscitation-
trained staff
▪ Halved in-hospital mortality

17. Stages inThe History of CC
Years Phase III Comments
1970s -80s Technology ▪ Pulmonary artery
catheterization
▪ Coronary angiography
▪ Beta blockade
▪ Thrombolysis
▪ Primary PCI

18. Stages inThe History of CC
Years Phase IV Comments
1980s-90s Evidence-based ▪ Randomized trials as basis for
treatment
▪ Guidelines from
national/international societies.

19. From Coronary Care to Critical Care
Over recent years, there has been increased
admissions of highly complex patients:
With an increase in the use of
• Bronchoscopy,
• Renal replacement therapy
• Increasing progression of patients requiring prolonged
ventilation… etc.
Thus, an additional phase in the CCU has been proposed -
THE CRITICAL CARE PHASE - and the CCU was Renamed.
The Cardiac IntensiveCare Unit-CICU

20. Stages inThe History of CC
Years PhaseV Comments
2003 Critical Care ▪ Formation of ESC WG ACC
▪ Recognition of requirement for
validated intensive care
knowledge, skills and behaviors
for cardiologists (CoBaTrICE)
▪ Sub-specialization in acute
cardiac care
CoBaTrICE, Competency BasedTraining program forTraining in Intensive Care
Medicine for Europe and other world regions.
ESCWG ACC, European Society of CardiologyWorking Group onAcute Cardiac
Care

21. CCU Leadership
Whilst the majority of ICUs are led by clinicians trained in
critical care medicine, and who are in a position therefore to
deliver high-quality evidence-based critical care to their
patients
THIS IS NOTTHE CASE IN CCU
Many Cardiologists Erroneously BelieveThatTheir
GeneralCardiologyTrainingAddresses Adequately the
Competencies Required to manageCritically Ill
Cardiovascular Patients ESC Curriculum for the general cardiologist)
(ESC Curriculum for acute cardiac care)

22. Defining a Modern CCU
The increasingly overlapping knowledge base required
by:
▪ The cardiologist responsible for the CCU,
and
▪ The intensivist responsible for the medical care of
cardiac pts in the intensive care unit,
Can lead to confusion when defining and describing
A modern CCU

23. Evolution of a Modern CICU
Effect of AdvancedTechnologies and Special Populations :
Physicians in a modern CICU must be experienced in
managing the use and complications of Advanced Medical
Technologies, including:
▪ Noninvasive and invasive hemodynamic monitoring
▪ Complex modes of mechanical ventilation,
▪ Renal replacement therapies,
▪ Imaging guidance for bedside vascular procedures,
▪ Methods for induction of therapeutic hypothermia, and
▪ Mechanical circulatory support.

24. TheCriticalCareCenter
ofCairoUniversity
ComprehensiveMedical&
CardiacCriticalCare

25. CCM in Egypt
The term Critical Care Medicine is now a popular
term in Egypt and increasing numbers of doctors are
being attracted to this subspecialty, I would say an
Independent Specialty.
It is no longer a mere ICU or recovery ward, but
rather a distinct entity of Critical Care Medicine since
1992.
Broadened Concept

26. TheEgyptianEditionofCCM
ImplementingtheConceptof
CardiacIntensiveCare

27. Critical Care Medicine in Egypt
From Coronary Care to Cardiac
intensive Care
Besides handling all medico surgical crises, our practice
of Critical Care Medicine extended to new horizons.
The Egyptian edition of Critical Care Medicine now
comprises diagnostic and interventional activities in
critically ill cardiac patients

28. Critical Care Medicine in Egypt
Cardiac Intensive Care
Overlap with Cardiology
Advanced diagnostic tools and skills for life-threatening cardiac
situations were essentially recruited and mastered and included:
▪ Coronary angiography
▪ Myocardial perfusion studies
▪ Diagnostic cardiac electrophysiology
▪ Ultrasonography
▪ Molecular Biology
▪ ECMO
▪ Past cardiac arrest patients care & therapeutic hypotension

29. Cardiac Catheterization & Interventional
Procedures
A modern monoplane Philips
system is in active use with an
average of 7-10 cases of coronary
angiographic studies &
interventions daily 5-6 days/ week
besides night calls and weekend
emergencies

30. Cardiac Electrophysiology, Cardiac Pacing,
RF ablation and ICD Implantation
Electrophysiology lab. activities
comprise the diagnosis and
radiofrequency ablation of
supraventricular and ventricular
tachycardias, as well as temporary
and permanent pacemaker
implantations

31. Ultrasound Imaging & US guided procedures
Ultrasound Imaging is now an
integral part of the diagnostic
workup in the critically ill. Dr.
Ashraf Wadie directs the ultrasound
lab containing Accuson and &
Sequoia Echographs in the first unit
and a Hewlett-Packard Machine in
the outpatient clinic

32. Cardiac Nuclear Lab
An internationally-recognized
diagnostic nuclear lab. for acute
imaging in ischemic heart disease
using a 3-head Siemens Gamma
Camera, is located in a special
research unit annexed to the critical
care center.

33. Advanced Mechanical Circulatory
Support
The number of heart failure admissions has been escalating,
And patients with acute heart failure syndromes and end-stage heart
failure can now be stabilized emergently with the use of mechanical
circulatory support devices:
▪ Intra-aortic balloon counter pulsation,
▪ Percutaneous and surgically implanted ventricular assist devices
▪ Extracorporeal membrane oxygenation
have become a major focus of the CICU and requires a well
co-ordinated multidisciplinary approach.

35. Implementing the Concept of Cardiac
Intensive Care
There has been a need for training Cardiologists In Intensive Care
Medicine.

36. From CCU to CICU
Need for CardiologyTraining of
Intensivists
There is, of course, a parallel requirement to ensure
that intensivists should be adequately trained in cardiac
crises diagnosis & therapy in particular given the rapid
recent advances in the treatment of:
▪ Heart Failure, and
▪ Percutaneous interventions.
▪ Cardiac Electrophysiology.
▪ Device implantation

37. From CCU to CICU
Need for CardiologyTraining of
Intensivists
Intensivists are more likely to implement newer care technologies
that may improve outcome through:
▪ Common practice
▪ Provision of urgent therapy
▪ Familiarity with acute conditions usually seen only with critical
care setting
▪ Facilitation of multidisciplinary care

38. AccordingThe European Society of Intensive Care Medicine in
collaboration with ESC.
The extended skill set required to manage the modern CCU has led
to the development of the subspecialty of Acute Cardiac Care.
In addition to obtaining the key cardiological skills, cardiologists are
also required to develop the relevant competencies required for
intensive care medicine.
(The ESC Core Curriculum for Acute Cardiac Care)

39. Acute Cardiac Care Association Meeting

40. The Acute Cardiac Care Curriculum :
▪ Far beyond the scope of the core/general cardiology
curriculum,
▪ Needs recognizing the developments in both intensive care
medicine and Acute Cardiology that have occurred over
recent years and
▪ The requirement for a multi-system approach to the
critically ill patient.

41. The Emerging Concept of CICU
Need for DualTraining of Cardiologists
This clearly requires :
▪ Additional training within the general and cardiovascular
intensive care unit setting, and
▪ Mandates close COLLABORATION BETWEEN
CARDIOLOGISTSAND INTENSIVISTS

42. The Emerging Role of CICU
Need for DualTraining of Cardiologists
Advanced Critical Care Certification for those with Cardiology
training has been proposed byThe American Board of Internal
Medicine, with a growing recognition by both cardiological
and intensive care societies that cardiology training is indeed
an appropriate base for intensive care training

43. A modern Cardiac Intensive Care Unit
Requirements
I. Should be capable of managing all cardiovascular
conditions and major non cardiovascular comorbid
conditions.
II. May admit advanced heart failure patients dependent on
percutaneous ventricular assist devices and
III. Handle those who have undergone surgical ventricular
assist device placement or cardiac transplantation

44. A modern Cardiac Intensive Care Unit
Requirements
Should have
IV- All forms of invasive and noninvasive monitoring
capabilities,
V- Advanced technologies that will allow the CiCU to support
the cardiovascular system and
VI- Manage patients with refractory shock or resuscitated
cardiac arrest.

45. The Emerging Role of Cardiac Intensive
Care Units
Impact on Cardiology Practice
I. It is no longer acceptable to assume that all cardiologists are
trained in Acute Cardiac Care and can manage the critically ill
cardiac patient.
SimilarlyCritical Care Medicine extended its scope to handle
critically ill cardiac patients including emergency
interventions.

46. From CCU to ICU
Impact on Cardiology Practice
II. Cardiologists must now be trained in the management of
▪ Acute lung injury
▪ Prolonged ventilation and ventilator weaning, delirium,
▪ Renal replacement therapy, venous thrombosis,
▪ ICU polyneuropathy
▪ Septic shock, etc… which skills are mastered by ICU
specialists.

47. Changing Role of the Coronary Care
Cardiologists
III. DedicatedCardiac Intensivists is an alternative approach.
The increasingly challenging and extensive medical comorbid
disease of patients cared for in the CICU has created a need
for clinical cardiologists skilled in general critical care
medicine.
The cardiac intensivist must have well-developed expertise in
both general critical care and cardiovascular medicine.

48. Changing Role of the Coronary Care
Cardiologists
IV. A collaborative model with a primary cardiovascular
specialist with close, daily consultative care by a dedicated
intensivist may be most appropriate in some health systems.

49. Changing Role of the Coronary Care
Cardiologists
V. Shared ResponsibilityWith Consulting Intensivists
The most flexible organizational paradigm is a semi-open unit
in which a cardiologist and a general intensivist comanage
each patient or selected patients in the CICU.

50. Changing Role of the Coronary Care
Cardiologists
Given the breadth of critical care diseases
and the remarkable patient diversity now
seen in our CCUs, we should anticipate an
imminent challenge to the general
cardiologists that currently staff these units
and call for dedicated intensivists to assume
care for these complex patients..
TAKE HOME
MESSAGE

51. Changing Role of the Coronary Care
Cardiologists
On the other hand, the situation where the
critical care physicians admitting the
patient retain responsibility of orchestrating
and implementing care for this patient is
however our model that was successfully
run over the last 40 years.
In both cases dual training is mandatory.
TAKE HOME
MESSAGE