From coronary care unit to acute cardiac care unit: the evolving role of specialist cardiac care

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 …