The ESC Textbook of Intensive and Acute Cardiac Care is a key reference for training and accreditation in this specialty. It serves as a reference for experienced and trainee cardiologists and intensivists from all over Europe, establishing a common basis of knowledge in the field and a uniform and improved quality of care.

1. 2
The ESC Textbook of
Intensive and
Acute Cardiac Care
editor-in-chief
MARCO TUBARO
co-editors
NICOLAS DANCHIN
GERASIMOS FILIPPATOS
PATRICK GOLDSTEIN
PASCAL VRANCKX
DORON ZAHGER

2. CHAPTER 1
Intensive and acute cardiac
care: an introduction
Nicolas Danchin, Gerasimos Filippatos ,
and Marco Tubaro
Cardiovascular diseases (CVDs) are the leading cause of death in the Western
world and for most of them rapid (within minutes) diagnosis and intervention
are necessary to improve patient prognosis. Cardiologists must be trained and
cardiovascular institutions equipped accordingly, to deal with the emergencies
in cardiology. That is why intensive and acute cardiac care (IACC) is the core of
cardiology. IACC is carried out in many different settings—from the patient’s
home to the ambulance, hospital emergency department (ED), intensive cardiac
care unit (ICCU), and cardiology ward—and patient care also includes hospi-
tal discharge and implementation of secondary prevention strategies. Complex
cases (with renal failure, diabetes, respiratory insufficiency, or sepsis) are now-
adays treated by different specialists, without proper cardiological training:
the knowledge, skills, and training of IACC cardiologists are essential to the
provision of high quality care.
The history of IACC in modern cardiology began with the early experiences
of open-chest defibrillation, demonstrating the feasibility resuscitating a patient
from cardiac arrest; subsequently, Zoll introduced the external defibrillator,
which was used in combination with mouth-to-mouth ventilation and chest
compression to perform cardiopulmonary resuscitation (CPR) in patients with
ventricular fibrillation. Desmond Julian was the first to suggest the concept of
the coronary care unit (CCU) to the British Cardiothoracic Society in 1961; in
1962 he set up the first CCU in Sidney for the monitoring of patients with acute
myocardial infarction (AMI), and in 1964 he established the first CCU in Europe
(in Edinburgh). A few years later, Killip and Kimball demonstrated a reduction
in mortality from 28 to 7% in AMI patients without shock treated with ‘aggressive’
pharmacological therapy in a CCU.
To begin with, CCUs were particularly devoted to the identification and
treatment of ventricular arrhythmias. In the 1970s, the role and importance of
CCUs began to be recognized, together with the development of seminal experi-
ences of fibrinolytic therapy in humans. In 1980, the seminal paper of De Wood
et al. demonstrated that the vast majority of AMIs were caused by a thrombotic
obstruction of a coronary artery. Consequently, thrombolytic therapy was con-
sidered to be the best possible approach, and after the GISSI and ISIS-2 studies
thrombolytic therapy became the accepted standard treatment of AMI. These
megatrials led the way to an extremely active development of clinical trials in
acute heart diseases, particularly in the field of antithrombotic therapy, and there

3. 2 CHAPTER 1 intensive and acute cardiac care: an introduction
is no doubt that CCUs have been the port of entry of many with heart disease increased the number of patients admit-
new medications now widely used in cardiology. ted to the ICCU with acute decompensated heart failure
The first comparison between primary percutaneous (ADHF). As in the case of ACS, the use of new biomarkers,
coronary intervention (PCI) and thrombolysis (in this such as natriuretic peptides, has helped reascertain the diag-
case, intracoronary thrombolysis) date from the same year nosis of acute heart failure; in addition, these new markers
(1986) as the seminal GISSI paper: in the following years, are potent discriminators of outcomes and are now used as
several studies were carried out, showing the advantage of prognostic tools in many different clinical settings. ADHF
mechanical over pharmacological coronary reperfusion. patients are admitted to the ICCU if they are poor respond-
Driven by the wider use of interventional cardiology, in ers to first line therapies, with low cardiac output, oliguria,
more recent years CCUs have been integrated into systems myocardial ischaemia, or cardiogenic shock: they require
of care: the beginning of the treatment of ST-elevation complex and intensive care, high-tech equipment, skilled
myocardial infarction (STEMI) moved from the CCUs to ICCU staff, and a prolonged stay. Patients with ADHF
ED and then to the pre-hospital stage (with pre-hospital deserve more knowledgeable, skilful, and better-trained
thrombolysis) and networks between peripheral hospitals ICCU physicians and multispecialty treatment, with the
and STEMI-receiving centres were implemented, linked use of complex equipments such as intra-aortic bal-
to the emergency medical service (EMS) operated by phy- loon pumping (IABP), renal replacement therapy (RRT),
sicians and/or paramedics and nurses. Parallel to these implantable cardioverter-defibrillators (ICD), cardiac
changes in the early management of patients with STEMI, resynchronization therapy (CRT), and ventricular assist
changes could be observed in the definition of myocardial devices (VAD). Other diseases are also becoming more
infarction, based on the more and more widespread use of commonly seen in the ICCU, such as acute pulmo-
troponin measurement; the use of these new highly sensi- nary embolism, severe dysrhythmias, electric storms and
tive biological tools has led to a reclassification of many ICD malfunctions, sepsis, and multiorgan failure. An
patients from unstable angina to non STEMI. example of the case mix in modern ICCUs is shown in
In the meantime, the transition from CCUs to ICCUs was E Fig. 1.1.
in progress. The proportion of elderly patients with acute The combination of elderly patients, severe multiorgan
coronary syndromes (ACS) increased: patients with complex diseases, and technically demanding diagnostic and thera-
and multiorgan diseases, who need recourse to high-tech peutic strategies provides the treating staff with a special
treatment and interventional/surgical procedures represent challenge, requiring dedicated training. To accomplish this
a large proportion of the ICCU population. Moreover, age- task, the Working Group on Acute Cardiac Care (WGACC)
ing of the population and better management of patients of the European Society of Cardiology (ESC) established
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Figure 1.1 BLITZ 3. Italian registry
card
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of ICCUs, conducted for 15 days
(7–21 April 2008) in 332 out of 409
Diagnosis at ICCU discharge (81%)I talian ICCUs.

4. intensive and acute cardiac care: an introduction 3
a training programme and an accreditation process in The need for a shift from CCUs to ICCUs is also linked to
IACC. The aim was to properly train cardiologists to offer the application of several complex therapeutic techniques,
state-of-the-art treatment for severe cardiac diseases such as ventilation (both noninvasive and mechanical), cardiac
throughout the many countries belonging to the ESC, support (IABP and VAD), and RRT, among others.
reducing inequalities of care and improving overall Laboratory medicine is widely used in IACC, both for
outcome. IACC is a new and important subspecialism in prompt diagnosis of acute conditions and for prognostic
cardiology, and the role of intensive care cardiologist is stratification, which frequently drives patient allocation
depicted in a new core curriculum (CC) in IACC, based and treatment strategies.
on a comprehensive combination of knowledge, skills, and ACS, ADHF, and serious arrhythmias deserve a whole sec-
attitudes: this CC outlines the education and training for tion each, being the three most important groups of diseases
cardiologists working in ICCUs, with log books, a written managed in ICCUs: they are dealt with in great detail, includ-
examination, and final accreditation (and re-certification) ing pharmacological and nonpharmacological treatments. As
(see E Chapter 11 for details). well as the three main groups of acute diseases, many other
Application of evidence-based medicine to complex cardiovascular acute conditions are treated in ICCUs, and a
high-risk cardiac patients in the ICCU needs a formal, whole section of the book is devoted to myocardial, valvular,
intensive training in the field; moreover, both the provision and aortic emergencies, among many others.
of a very high quality of care and the need for reporting and The largest section of the book is dedicated to the many
audit make necessary to establish a process of accreditation acute noncardiovascular conditions that contribute to the
of ICCU cardiologists by the scientific societies. patients’ case mix in ICCU and widen the concept of IACC:
This book has been written with the purpose of serving the acute and intensive management of this vast variety of
IACC accreditation: all the various aspects of this pivotal sub- acute illnesses requires a deep and at the same time wide
specialty of cardiology are treated in a comprehensive way. clinical training, not only in acute cardiac care, but in acute
The first two sections are devoted to the first points where medical care in broad terms.
acute cardiac diseases are treated: the pre-hospital setting Each chapter has been written by a real expert in the field,
and the ED. Particularly in ACS the treatment must be ini- and is fully in agreement with the ESC guidelines and the
tiated as soon as possible, and the main field of operation CC in IACC; multiple choice questions (MCQs) on many
is the heart attack site: cooperation with other professional of the chapters are available for continuing medical educa-
figures is pivotal in this setting. tion (CME).
The ICCU is the main cardiological institution perform- A particular asset of this textbook is the online edition,
ing IACC, and its structure, equipment, staff, and opera- which includes many more figure and tables, a long refer-
tions are addressed, as well as monitoring and procedures. ence list for each chapter and original material like photos
Patients are monitored more closely in the ICCU than in and videos, to better show diagnostic and therapeutic tech-
other departments, not only for cardiovascular function niques and procedures in IACC.
is concerned, but also for brain, pulmonary, and renal We believe that this textbook will be very useful in estab-
function: close monitoring allows the implementation of lishing a common basis of knowledge and a uniform and
intensive treatments for acute diseases, with the important improved quality of care in all European countries, for the
help of imaging techniques, particularly echocardiography. benefit and better care of our patients.