1 Intensive and acute cardiac care: an introduction

Cardiovascular diseases (CVDs) are a major cause of premature death worldwide and an important cause of loss of disability-adjusted life years. For most types of CVD, early diagnosis (within minutes) and intervention are independent drivers of patient outcome. Clinicians must be properly trained and centres appropriately equipped in order to deal with these critically ill cardiac patients.

The history of intensive and acute cardiac care (IACC) began with early experiences of open-chest defibrillation, which demonstrated the feasibility of resuscitating a patient from cardiac arrest. Subsequently, Paul M Zoll demonstrated that external electrical stimulation of a patient’s chest during cardiac arrest could produce an effective heartbeat. Zoll later introduced the external defibrillator, which was then used in combination with mouth-to-mouth ventilation and chest compressions to perform cardiopulmonary resuscitation (CPR) in patients with ventricular fibrillation (VF). Desmond Julian was the first to suggest the concept of the coronary care unit (CCU) to the British Cardiothoracic Society in 1961 [1]—an innovation widely recognized as one of the great developments in cardiology. In 1962, he set up the first CCU for the monitoring of patients with acute myocardial infarction (AMI) in Sydney (Australia), and, in 1964, he established the first European CCU in Edinburgh. A few years later, Killip and Kimball demonstrated that ‘aggressive’ pharmacological therapy in a CCU could significantly reduce mortality (from 28% to 7%) in AMI patients without shock [2]. Although the use of CCUs was initially related primarily to the identification and treatment of ventricular arrhythmias, throughout the 1970s, their importance was increasingly recognized for the safe application of pharmacological therapy to the critically ill cardiac patient.

In 1980, the pivotal paper of De Wood et al. [3] demonstrated that the majority of AMIs were caused by thrombotic obstruction of a coronary artery. Consequently, thrombolytic therapy was considered to be the best approach in the management of AMI, and, following the publication of GISSI and ISIS-2 studies [4–5], it became the accepted standard of care. These landmark studies heralded the development of clinical trials in acute coronary disease. Indeed, the first direct comparisons between primary percutaneous coronary intervention (PCI) and thrombolysis (albeit intracoronary) date from the same year (1986) as the seminal GISSI paper. Subsequently, a number of studies demonstrated the advantage of mechanical over pharmacological coronary reperfusion [6–8], and the implementation of PCI as the preferred reperfusion strategy in ST-segment elevation myocardial infarction (STEMI) became widespread. Over the last decade, CCUs have become integrated into systems of care, with STEMI management being initiated as soon as possible, if feasible, in the pre-hospital stage (with pre-hospital thrombolysis) and with the development of networks between non-PCI centres and myocardial intervention centres (providing state-of-the-art facilities for PCI 24 hours per day, 7 days per week), with all the centres linked to the emergency medical service operated by physicians and/or paramedics and nurses [9] In parallel with these changes in the early management of patients with STEMI, changes were observed in the definition of myocardial infarction (MI), with the advent of more sensitive and specific cardiac biomarkers (i.e. cardiac troponins), leading to the reclassification of many patients from unstable angina (UA) to non-STEMI.

More recently, terminology has changed, with CCUs being regarded as cardiac care units or intensive cardiac care units (ICCUs), reflecting a shift in patient case mix and the level and scope of care required to manage these patients. Over the last decade, there has been an increased number of patients with severe cardiological conditions requiring acute cardiac care. Many of them are elderly, have multi-organ pathology and multiple comorbidities, and present with acute coronary syndromes (ACS), severe heart failure, rhythm disturbances, or severe valvular dysfunction. The immediate and longitudinal clinical management of these complex critically ill cardiac patients has thus become an important element of the specialized ICCU.

Based on this background, IACC has become recognized as a subspecialty in cardiology. The Acute Cardiovascular Care Association (ACCA) of the European Society of Cardiology (ESC) has been at the forefront of establishing best practice in acute cardiac and intensive care, first as a working group and subsequently from 2012 onwards as an association. The ACCA was the first to publish a textbook in its field (first edition, 2011) with the goal to provide a comprehensive, multidisciplinary review of all recent advances in acute and intensive cardiovascular care medicine for professionals involved in these processes: cardiologists, emergency care physicians, intensive care physicians, internists, surgeons, cardiothoracic anaesthetists, and paramedical staff. The ACCA also established an evidence-based training programme and a certification process in IACC. The aim was to harmonize the treatment for critically ill cardiac patients throughout the many countries belonging to the ESC, reducing inequalities of care and improving overall outcome. The ESC core curriculum (CC) in IACC outlines the education and training goals for cardiologists working in ICCUs, with a written examination, logbook, and certification process (see Chapter 2 for details). The ESC e-learning (ESCeL) platform on IACC provides a structured online educational framework, with teaching and learning processes designed to help the trainee to acquire the required competencies, and processes of assessment to test whether he/she has met the goals requested to progress at each stage and finally to practise in the specialty at an appropriate standard.

The ESC textbook of intensive and acute cardiac care, second edition, follows the IACC training CC and is designed to be used as a text of teaching and a guide for learning. The chapters also serve as basis for the ESCeL teaching modules.

Section I is devoted to pre-hospital and immediate in-hospital (emergency department, ED) emergency cardiac care. In Sections II–IV, the ICCU structure, equipment, staff, and operations are addressed and monitoring and procedures are described. Laboratory medicine is widely used in IACC, both for prompt diagnosis of acute conditions and for prognostic stratification, which frequently drives patient allocation and treatment strategies (Section V). ACS, acute decompensated heart failure (ADHF), and serious arrhythmias deserve a whole section each, being the three most important groups of diseases managed in ICCUs (Sections VI—VIII). These entities are dealt with in great detail, including pharmacological and non-pharmacological treatments. The main other cardiovascular acute conditions are grouped in Section IX. The largest book section (Section X) is dedicated to the many concomitant non-cardiovascular acute conditions that contribute to the patient case mix in ICCU. The acute and intensive management of this variety of acute illnesses requires a deep and, at the same time, wide clinical training in all aspects of critical care. The ESC Textbook of Intensive and Acute Cardiac Care, second edition, contains in total six new chapters: patient safety and clinical governance, the heart team, ultrasound-guided vascular access, implanted cardiac support devices, donor organ management, and palliative care in the ICCU. We have also combined topics (such as blood gas analysis and acid–base disorders, fluid and electrolyte disorders, hyperglycaemia and diabetes, and endocrine emergencies) that were previously covered in two chapters into one chapter. This new edition is slightly larger than the first edition of the book to integrate these changes.

As in the previous edition, each chapter has been written by a real expert in the field and is in line with the ESC guidelines and the CC in IACC; multiple choice questions (MCQs) on many of the chapters are available for continuing medical education (CME). A particular asset of this textbook is the online edition (available at:  www.oxfordmedicine.com). Purchasers of the print and online bundle can assess the online material via the access codes printed at the front of this book. The online version contains all the materials from the printed book, as well as many more figures and tables, an extended reference list for each chapter, and original materials like photos and videos, to better illustrate diagnostic and therapeutic techniques and procedures in IACC.

We believe that this textbook will be very useful in establishing a common basis of knowledge and a uniform and an improved quality of care in all European countries, and beyond, for the benefit and improved care of our patients.