curriculum for training in intensive - acute cardiac care in

Draft – 26 October 2008 - ACC Curriculum page 1 of 49

CURRICULUM FOR TRAINING IN INTENSIVE, ACUTE CARDIAC CARE IN

EUROPE

7


TABLE OF CONTENTS:

PREAMBLE

PART 1

1. INTRODUCTION

2. RATIONALE

2. AIMS/LEARNING OUTCOMES

3. LEARNING OBJECTIVES

4. TEACHING AND LEARNING METHODS

5. ASSESSMENT METHODS

PART 2

1. THE TRAINING PROGRAMME

2. ENTRY REQUIREMENTS FOR CARDIOLOGISTS

3. REQUIREMENTS FOR TRAINING CENTRES AND

TRAINING SUPERVISORS

4. ADVANCED TRAINING

PART 3

SYLLABUS

ANNEX: “ Recommendations for the structure, organization and operation of intensive

cardiac care units” Eur Heart J 2005; 26: 1676-82

________________________________________________________________________

DETAILED DESCRIPTION


PREAMBLE:

Medical knowledge has expanded rapidly in recent decades, as have advances in cardiology. Not

only new drugs have become available, but also different diagnostic, interventional and

therapeutic procedures have been developed. Many have resulted in better patient treatment and

improved outcomes.

Increasingly, patients and society in general are aware of medical progress and demand state of

the art therapies. Because, much of cardiology has become very technical and sub-specialised,

specific training is needed to assure that the process of investigation and management is of the

high standards required by both the medical profession and their patients. One of the fields in

which these complexities are apparent is acute cardiac care (ACC).

Since the early 1970s, ACC has been delivered in coronary care units that were initially

developed to treat lethal arrhythmias in patients with acute myocardial infarction (AMI).

Subsequently, the scope of therapies offered in these units has greatly expanded. In the last

decade there has been an increase in the number of patients with severe cardiological conditions

requiring ACC, many of whom are elderly, presenting with acute coronary syndromes, severe

heart failure, rhythm disturbances or severe valvular dysfunction. Thus, coronary care units are

required to treat not only patients with acute coronary syndromes, but a wide range of severe

cardiac conditions. Currently, these areas are generally known as called intensive cardiac care

units (ICCUs) to reflect this change in patient demographics. Appropriately trained cardiologists

should remain involved in the management of complex cardiac problems that may be associated

with multi-system organ dysfunction, as they will be able to address not only the investigation and

management of the underlying cardiological disease, but also the effects of other organ system

(dys)function on the cardiovascular system. To disregard this responsibility is not in the best

interests of our patients.

PART 1

1. INTRODUCTION

Patients with acute cardiac conditions (i.e. acute myocardial infarction, severe unstable coronary

syndrome, acute myocarditis, decompensated heart failure, complex cardiac arrhythmias, etc.)

require continuous monitoring with special medical and nursing care. Therefore they should be

admitted to ICCUs, designed, equipped and staffed by specially trained nurses. Although the


number of patients with acute cardiovascular disorders or severe cardiac co-morbidities requiring

special treatment is increasing, there is to date no pan-European standardized and accepted

training program for physicians in charge of the ICCU. This document proposes a program for

training and credentialing needed to become an accredited ICCU physician.

2. RATIONALE

A physician in charge of the ICCU should be able to recognize and treat a wide variety of acute,

as well as chronic cardiac conditions leading to cardiac decompensation. In addition, such a

physician should be able to investigate and manage resulting organ system failure, in addition to

determining more long-term management following stabilization. ICCU physicians should be well

acquainted with the diagnostic and therapeutic means available to the modern cardiologist

including electrocardiography, echocardiography, nuclear cardiology, hemodynamic

measurements and their interpretation, cardiac and coronary angiography, cardiac

pharmacotherapy, and interventional cardiology. They should be familiar and fluent in the

operation of the available equipment including monitoring (invasive and non-invasive), cardiac

pacemakers, defibrillators, artificial respirators (invasive and non-invasive), renal replacement

therapy and mechanical cardiac support. A comprehensive knowledge of interventions to treat

cardiac pathology and also associated conditions such as liver and renal dysfunction is

mandatory, in addition to knowledge regarding the management of infection, nutrition, sedation,

and analgesia. To meet these requirements demands training in cardiology (all applicants must

be fully certified cardiologists) with additional training in intensive care medicine.

3. AIMS/LEARNING OUTCOMES

The aims of the learning process detailed in this document are:

1.To provide guidance on the training requirements for cardiologist in charge or working

in the ICCU

2.To delineate the core competencies and curriculum for such physicians (see Part 3)

3.To define the techniques in which the ICCU cardiologist should be proficient

4.To describe the minimum numbers of procedures that trainees must have done before

applying for accreditation

5To determine the need for recertification

The main expected outcome is to have appropriately trained cardiologists in the subspecialty of

acute cardiac care, to support state of the art treatment for patients with severe cardiac

dysfunction. In order to have credibility, the proposed programme contained in this document will


need to be accepted by all the National Societies in Europe. This will result in a more uniform

treatment of critically ill cardiac patients all over Europe, reducing inequalities among countries

and improving outcomes.

4. LEARNING OBJECTIVES

Cardiologists wishing to be trained appropriately to manage an ICCU applying for accreditation in

ACC must achieve the following objectives in the following items during their learning process:

Many of the skills outlined in this Curriculum are supplementary to those expected from

general cardiologists not working regularly in an ICCU, or general intensivists not working

regularly in an ICCU.

Definition of Levels of Competence

The levels of competence required below follow the recommendations of the Core Curriculum for

the General Cardiologist (ref) and are defined as follows:

Level I: Experience of selecting the appropriate diagnostic modality and interpreting the results or

choosing and appropriate treatment. Does not include the performance of a technique

Level II: Practical experience, but not as an independent operator (the technique is performed

under the guidance of a superior)

Level III: Able to independently perform a technique unaided.

GENERAL, CORE INTENSIVE CARE MEDICINE

The basis of optimal patient management in the ICCU includes many of the principles required in

the management of acutely and/or critically ill patients with non-cardiac disease. In order to

achieve this, the ICCU cardiologist will be required to understand the pathophysiology, clinical

presentation, investigation, treatment options, complications and secondary prevention measures

which underpin the general management of the acute cardiac care patient who is critically ill.

These objectives will be achieved by:

1.- A complete theoretical knowledge of the principles underlying general care of the

ICCU patient

2.- Application of this theoretical knowledge in the management patients admitted to an

intensive care unit to level III competence.


ACUTE CORONARY SYNDROME (ACS)

To understand the pathophysiology, clinical presentation, investigation, differential diagnosis,

treatment options, complications and secondary prevention measures. These objectives will be

achieved by:

1.- A complete theoretical knowledge of the principles underlying this syndrome

2.- Application of this theoretical knowledge in the treatment of a minimum of 300 patients

or all patients with ACS admitted to an ICCU during 1-year residency/fellowship, (level III

competence).

ACUTE HEART FAILURE (AHF) AND CARDIOGENIC SHOCK



achieved by:

1.- A complete theoretical knowledge of the principles underlying these syndromes


with AHF and cardiogenic shock admitted to an ICCU (level III competence).

MYOCARDITIS



achieved by:



with myocarditis admitted to an ICCU (level III competence).

CARDIAC TAMPONADE



achieved by:



with cardiac tamponade admitted to an ICCU (level III competence).


ACUTE VALVULAR DISEASE (endocarditis, degenerative valve, artificial valves, chest

trauma and AMI)



achieved by:

1 - A complete theoretical knowledge of the principles underlying these pathological

processes

2 - Application of this theoretical knowledge in the treatment of a minimum of 10 patients

with severe acute valve disease admitted to an ICCU (level III competence).

TRAUMA AND DISEASES OF THE AORTA



achieved by:

1 – A complete theoretical knowledge of the principles underlying these pathological

processes

2 - Application of this theoretical knowledge in the treatment of a minimum of 10 patient

with aneurysm or dissection of the aorta admitted to an ICCU (level III competence).

RESPIRATORY INSUFFICIENCY



achieved by:

1.- A complete theoretical knowledge of the principles underlying respiratory insufficiency

and its treatment

2 - Application of this theoretical knowledge in the treatment of 100 patients in need of

respiratory support, invasive or non-invasive and to perform a minimum of 30 endotracheal

intubations (level III competence)..

ARRHYTHMIAS



achieved by:




with ventricular tachycardia, 50 with supraventricular tachycardia, 20 patients with atrio-

ventricular block admitted to an ICCU (level III competence).

PULMONARY EMBOLISM (PE) AND PRIMARY PULMONARY

HYPERTENSION (PPH)



achieved by:



with PE and 10 patients with significant pulmonary hypertension (level III competence).

SEPSIS AND INFLAMMATORY SYNDROMES



achieved by:

1 – A complete theoretical knowledge of the principles underlying these syndromes

2 – Application of this theoretical knowledge in the treatment of a minimum of 50 patients

(level III competence).

SPECIAL SKILLS

It is expected that during the learning process, the trainee will undertake the following techniques

to the level of competence requested, with additional supporting evidence in provision of the

logbook:

TECHNIQUE MINIMUM

NUMBER OF CASES

IN THE LOGBOOK

LEVEL OF

COMPETENCE

(Accreditation)

LEVEL OF

COMPETENCE

(Revalidation)

Primary angioplasty 50 I II

Right heart

catheterization

20 III III

Invasive and non- 100 III III


invasive haemodynamic

monitoring

Intraaortic balloon

pump

10 III III

Advanced renal

support

30 III II

Non-invasive

ventilation

50 III III

Endotracheal

intubation

30 III III

Mechanical

ventilation

50 III III

Pericardiocentesis 10 III III

Temporary

pacemaker implantation

50 III III

Current ACLS

(advanced cardiac life

support certificate)

N/A N/A N/A

Care of the Post

resuscitation patient *

20 Level III III

Extra corporeal

cardio pulmonary

support

10 I I

Transthoracic &

Transoesophageal

Echocardiography

125 (TTE)

50 (TOE)

Level III (TTE)

Level III (TOE)

II

* including the process of arranging organ donorship.

To achieve the above outlined goals, the trainee must be a fully trained cardiologist, who has

worked full time in an ICCU of a Department of Cardiology for a total of at least 12 months and

has been on call for the equivalent of at least 1 night per week for at least three years. In addition,

the following time training will be required: anaesthesiology 1 month, pulmonology/respiratory


medicine 1 month, nephrology 1 month, and general ICU 3 months. A total of 6 months ICCU

during general cardiology training, 6 months training as junior attending physician (post-

residency) and 6 months in the other listed specialties should be undertaken.

In order to ascertain that the trainee has fulfilled the above requirements they will be assessed by

an examination, and presentation of a log-book. In addition, the base hospital will be a certified

training centre (see below).

5. TEACHING AND LEARNING METHODS

The trainee will assume appropriate responsibility in obtaining the theoretical knowledge

outlined in the syllabus (see below). To do this, it is advisable to use the Core Curriculum

book of Cardiology from the ESC (CD, tutorials in the web page of the ESC), recent ESC

guidelines and other teaching materials from the different and relevant Working Groups of the

ESC, especially those from the WG on ACC, and also from other textbooks. Reference to

training materials from the ESICM and/or national intensive care societies may also be useful.

The trainee will therefore be required to engage in continuous, independent self-directed

learning and self-assessment.

It is also recommended that other learning resources be used, such as:

Ward rounds and supervised consultation in outpatient clinics

Case presentations

Bedside teaching

Lectures, tutorials

Seminars

Simulation-based teaching

Web-based teaching

Courses

Journal clubs

Annual meetings of Scientific Societies

6. ASSESSMENT METHODS

The Accreditation Committee (see below) is responsible for ensuring that the theoretical

examination is based on the Curriculum and that the questions asked are relevant. Thus, to

assess the proficiency in Acute Cardiac Care, several methods will be used to ensure that both

the theoretical and practical skills have been mastered by the applicant. The trainees must prove


that they have undergone the appropriate training (listed above) in a accredited Unit under the

guidance of accredited staff. They will be required to provide a log-book in which all procedures

and patients have been listed, and signed by the trainee‘s tutor. They will also provide a list of

other educational activities in which they have actively participated This documentation must be

provided before applying for the examination. Only trainees with an adequate CV will be allowed

to sit the written examination. The examination will be in English.

Theoretical assessment

The theory examination will consist of 100 multiple-choice questions which will be based on the

Syllabus (see part 3). The examination will be compiled by the Accreditation Committee and

designed to be completed in a 3 hours session. The examination will be marked by the

examination team, and the pass mark set at 60%.

Candidates will be notified of the results by mail. The names of candidates will remain

confidential. However, the WG on ACC reserves the right to publish lists of successful

candidates. A period for appeals will be opened after the candidates have been notified of their

results.

There is no limit on the number of times a candidate may sit the examination. Upon re-

examination, it will not be necessary for documentation to be re-presented with the exception of

the receipt for payment of the applicable fees.

Frequency

Examinations will be held annually during the ESC annual meeting and biannually during the WG

on ACC meeting; this may subsequently be modified depending demand. In the event there are

insufficient candidates, the Accreditation Committee will be authorised to cancel an examination

round.

Future developments

The web-based platform will be available for both trainees and established cardiologists in Spring

2009. This will be too late to affect the assessment methods used in Autumn 2009, which will

remain as outlined above.

In Autumn 2010, the methods for accreditation in Intensive and Acute Cardiac Care will be

entirely based on the EBSC / ACC web-based platform.


6.1 ASSESSMENT ORGANIZATION

The Accreditation System structure comprises:

An Accreditation Committee

The WG Nucleus

Evaluation teams

Accreditation Committee

Composition

The committee will be composed of 7 previously accredited WG members, one of these

necessarily being a member of the WG Nucleus. One member will be nominated by the

UEMS cardiology section. Other members will be appointed by the WG chairman.

1. The first Accreditation Committee will be formed by 5 WG members with

recognised prestige and merit in the field of acute cardiac care The members of

this first committee will also be appointed by the WG chairman.

Initially, an automatic accreditation to founding fathers (ICCU directors at the date of

October 2006) may be given. They will need to supply formal documents from hospital

administration indicating that they hold a permanent formal position as head of ICCU.

Those who do not apply within the first three years will be required to sit the examination

and present a log-book.

Functions

The functions of the Accreditation Committee are:

To announce and open the period for the presentation of applications for

examination from both professionals and training centres, as well as the

management of the same.

Co-ordination of degree and diploma verification, and audit to evaluate the merits of

those professionals and centres applying for accreditation, as well as participation

in carrying out the same when deemed necessary.

Preparation and composition of theoretical examination exercises.

Maintenance of a question database and practical cases for the composition of

future examinations.

Co-ordination and management of examination results.

Offer and attend appeals from candidates regarding the evaluation of the merits

they present or the results of the examination.


Submit ratification of accreditation of those candidates who are considered suitable

by virtue of the results obtained in examination to the WG Nucleus.

Maintain a register of those who are accredited together with their merits and

requisites accomplished.

Maintain a register of activities of the current and previous Accreditation

Committees.

Promote, plan and organise training courses in co-ordination with the WG Nucleus.

Notify the WG Nucleus of any changes in the accreditation system which is

deemed necessary to adapt to changes and evolution in Acute Cardiac Care.

Implement any changes which are deemed necessary to adapt the accreditation

system to changes and evolution in Acute Cardiac Care.

Co-ordinate with the relevant bodies of other national or European accrediting

entities, and if considered proper, those of non-European, international standing.

Take steps to publicise the accreditation system so it can serve as a reference for

third parties.

Keep the WG Nucleus informed about the activities, status and changes in the

accreditation system.

Meetings

Frequency

The Accreditation Committee will hold ordinary meetings at least twice a year. The

Secretary to the Committee may call extraordinary meetings at the request of the

Chairman of the WG when there are matters of sufficient urgency or importance to

warrant the same.

Attendance

Accreditation Committee meetings will always be held with a quorum equal to half

the members plus one.

Dependence

The Accreditation Committee will be appointed by and organically dependent on the WG

Nucleus.

Elections


Designation for committee members will be held every three years, but not coinciding with

elections for the WG Nucleus members. With the objective of guaranteeing a degree of

continuity, no more than 4 members may be re-elected to the committee.

The WG Nucleus

The WG nucleus is formed by a Chairman, past-chairman, secretary, treasurer and other 8

members from different National Societies.

Duties

The fundamental duties of the WG Nucleus will be to ratify and legitimise the decisions

taken by the Accreditation Committee, and at all times to supervise and rectify any

deviation which endangers the integrity of the system. These functions will be as follows:

Settle appeals where there is disagreement with decisions taken by the

Accreditation Committee.

Ratify and approve Accreditation of those candidates presented to this end by the

Accreditation Committee.

Ratify and approve any proposals for adaptation presented by the Accreditation

Committee.

Perform an annual review of the Accreditation System procedures and results, and

present the report to the WG members and the ESC‘s Board of Directors.

Ensure the integrity, impartiality and independence of the Accreditation Committee

and System.

Teams and Evaluators

The Accreditation Committee will assign teams of evaluators to assist in the preparation of

the examination and to audit merits presented by accreditation candidates.

Composition

These will comprise WG members who have previously been accredited (initially by

members with recognised prestige and merit in the field of acute cardiac care).

Duties

Evaluators will have the following duties:


Assist in preparing and carrying out the theoretical and practical examination.

Assist in auditing the merits presented by accreditation candidates.

Maintain the confidentiality of all data obtained.

Maintain impartiality.

Dependence

Evaluation teams will be selected directly by the Accreditation Committee and will also be

dependent on the same.

Note: This composition is proposed as a minimum at the beginning of the activity.

Subsequent circumstances will determine the necessities for change of duties and/or the

incorporation of additional personnel.

PART 2

THE TRAINING PROGRAMME

This training is available to board certified or country recognised cardiologists. A

comprehensive cardiological background is necessary not only to master the technical

aspects of the invasive techniques, but also to recognise the indications, and the

contraindications of different treatments for patients in need of intensive acute cardiac care.

In addition, the trainee will need to obtain experience in the field of intensive care medicine.

In order to achieve these objectives:

The trainee will be a fully trained cardiologist who will have been working for a

minimum of over a1 year period in one centre authorized to give this training, and

participate fully and regularly in formal and informal training provided by the centre.

the trainee will have been an on-call junior cardiologist responsible for the ICCU for

the equivalent of at least 1 night per week for at least three years.

The trainee will undertake a 1-year period to at least 6 months as an ICCU

attending physician, 3 months in a general intensive care unit, 1 month in intensive

pulmonology/respiratory unit, 1 month in nephrology and 1 month in

anesthesia.The trainee should keep a log book to register the patients he/she has

taken care of, and invasive and non invasive diagnostic and therapeutic

procedures used in each patient. The logbook will be verified by the supervisor.


This training should be done in certified training centres for acute cardiac care and under

the supervision of certified supervisors (see below). The requirements of the procedures

that the trainee needs to perform are listed above (see Part 1, paragraph 4 LEARNING

OBJECTIVES).

In addition to clinical activities and training, the trainee will be directly involved in the

research activities of the training institution. Further, the trainee should attend relevant

national and international meetings during their training.

ENTRY REQUIREMENTS FOR CARDIOLOGISTS

Applicants for accreditation must meet each and every one of the following requisites:

1. Theoretical and practical training in the diagnosis and treatment of all types of

cardiac pathologies and, especially, in cardiac catheterisation techniques,

mechanical ventilation, renal replacement therapy and mechanical cardiopulmonary

support, insertion of pacemakers , and echocardiographic techniques. (transthoracic

and transesophageal)

2. Hold a Cardiology Specialist Qualification issued by a National Authority of

Health (or equivalent) or the European Union or, in the future, by the UEMS.

Similarly, accreditation will be contemplated for those professionals who hold a Cardiology

Specialist qualification issued by a foreign country, always provided that the same is homologated

by an equivalent in Europe.

Other non cardiologist physicians will be allowed to sit the theoretical examination and will be

issued a certification of this examination but will not be accredited as an intensive acute cardiac

care cardiologist.

3. Theoretical and practical training in Acute Cardiac Care.

Until the system is implemented and available to future professionals, it must be

possible to recognise the training of those trained prior to the same. Thus training

may be proven by the following two methods:

i. Standard method. Full time training of at least one year (in addition to ICCU for

Cardiology specialization training) in a centre which is recognised and

accredited. Subspeciality training may take place at any time during training in

cardiology as well as after its completion.


ii. Exceptional method. Formal heads of CCU‘s accredited for training (valid for

three years following the implementation of the system) may be awarded

accreditation. All staff cardiologists working full time in an ICCU will be

immediately recognized as fully trained in ACC

3. Theoretical and practical examinations in Intensive and Acute Cardiac Care:

Examination of clinical cases and theoretical questions prepared and co-ordinated

by the Accreditation Committee.

Accreditation procedure

Professionals

Applications

The Accreditation Committee will announce the period for the submission of accreditation

applications through diverse media (letter to all WG on ACC members, WG Web page and

other means). Accreditation candidates must submit the following documentation within the

aforementioned period:

MD degree (or equivalent)

License to practice medicine

Standard form completed with records and a recent photograph.

Receipt showing payment of Accreditation fees

Curriculum vitae.

Certified photocopy of the Cardiology Specialist qualification issued by the National

Authority of Health or the European Union (or equivalent).

Original letter signed and stamped by the Director of the ICCU Accredited for

Training, as well as the Head of the Cardiology Department/Service of the

corresponding centre, certifying that the applicant has completed a full-time stay of at

least one year in the unit detailing the activities undertaken, and the degree of

competence attained.

The log-book

After evaluation, the Accreditation Committee will send candidates a letter indicating the

result of their application and setting a date and place for the examination. The

Accreditation Committee retains the right to investigate any applications.


REQUIREMENTS FOR TRAINING CENTRES AND

TRAINING SUPERVISORS

Training centres will be located in hospitals certified by the local/national authorities to train

general cardiologists. The ICCU must be part of the Cardiology Department and directed by a

cardiologist who has been accredited by the WG on ACC. The hospital may also have other

intensive care units where the trainee may complete his/her training. Training centres must be

able to offer minimum capacity for training which will be evaluated by the Accreditation

Committee in accordance with the following recommendations:

Patient care capacity:

Have a staff level which includes at least 2 cardiologists that hold ACC accreditation and

a minimum of 4 beds

Research capacity:

Maintain a minimum level of scientific activity and interest in Acute Cardiac Care which is

endorsed by the presentation of at least 3 Acute Cardiac Care related scientific

communications to recognised speciality congresses during the previous three 3 years (

ESC, American Heart Association, American College of Cardiology and European

National annual congresses) and the publication of at least one scientific article related to

ACC in a journal with an objective ‗impact factor‘ during the previous 3 years.

It is expected that the training supervisor is an accredited cardiologist in ACC and the director of

the hospital‘s ICCU. Those centres that comply with all the above-mentioned requisites, with the

exception of accreditation of their professionals may apply for accreditation for training imparted

during the 3 years prior to the implementation of the Accreditation System provided that these

obtain accreditation as professionals during the first three years following implementation of the

Accreditation System. The training supervisor will supervise training during the whole period and

ensure that the trainee becomes fully competent in the subjects and techniques specified in this

document. The supervisor should certify the learning skills of the trainee at the end of the training

period

Application of Training Centres

The Accreditation Committee will announce the period for the submission of accreditation

applications through diverse media (letter to all WG on ACC members, WG Web page and other


means). Accreditation candidates must submit the following documentation within the

aforementioned period:

Standard form.

Receipt showing payment of Accreditation fees (audit and evaluation).

Report on the ICCU detailing all the merits for patient care, research and training

performed the previous two years.

If there are any doubts on the merits of the centre an audit must be done, the

Accreditation Committee may delegate it to the National Working Groups on ACC

which would act as team of evaluators under the support and expertise of the

Accreditation Committee. For this purpose, candidates for accreditation by this

method must attach a standard signed letter of authorisation agreeing to facilitate and

cooperate with the eventual audit.

After evaluating the applications, checking the documentation and performing appropriate

investigations where indicated, the Accreditation Committee will notify candidates about the result

of their application by letter.

Frequency

Accreditation rounds for Training Centres will coincide with those for accrediting professionals.

ADVANCED TRAINING

Candidates may wish to undertake a second year of training, with the aim of extending their skills

in more specialised techniques.

Recertification

Professionals and centres must recertify their accreditation at least every 5 years or

whenever there is any substantial change in their structure or operation, the latter case may

result in the centre requiring recertification by the Accreditation Committee

FUNDING

The Accreditation System requires a solid organisational base and this implies structural

and personnel costs. Therefore, accreditation fees that cover procedural costs will be


established. The costs will include: Travelling fees for Accreditation Committee members

and examination teamsand other, miscellaneous expenses.

Fees for individuals and training centres must also be defined.

PART 3

2. SYLLABUS

Cardiologists applying for accreditation on Acute Cardiac Care must be fully trained in

general cardiology. Therefore, the following syllabus provided below focuses on the

additional, specific aspects of patient care in the ICCU. Thus, other basic cardiologic

knowledge is considered a given.

1 – General Core Intensive Care Medicine

OBJECTIVES KNOWLEDGE SKILLS ATTITUDES

- To obtain the

knowledge, skills

and behaviours

underlying the

management of the

critically ill, in

order to effectively

care for patients

with cardiac

pathology in an

intensive care unit

setting

ref Cobatrice*

ref Cobatrice*

ref Cobatrice*

*CoBaTrICE is the Competency Based Training programme in Intensive Care Medicine for

Europe and other world regions, and was developed as an international partnership of

professional organisations and critical care clinicians (www.cobatrice.org).

2.- MYOCARDIAL INFARCTION AND ACS


- To diagnose and

treat patients with:

STEACS

- Identify clinical

characteristics, ECG

changes and

- Analyse clinical,

ECG and laboratory

data to diagnose AMI

- Choose properly the

best treatment

strategies for each

http://www.cobatrice.org/


NSTEACS

Unstable

angina

laboratory results that

are diagnostic of

acute myocardial

infarction (AMI).

- Explain initial risk

stratification for

STEACS and

NSTEACS and the

utilization of the

different risk scores

- Describe the

importance of time to

treatment and the

choices of reperfusion

- Outline antithrombin

and antiplatelet

therapies and other

pharmacological

treatments:

Indications and

contraindications

- Explain

hemodynamic

problems related to

AMI (left ventricular

failure and

cardiogenic shock,

right ventricular

infarction, mechanical

problems)

- Describe associated

arrhythmias

(bradyarrhythmias,

ventricular

- Apply risk scores to

stratify patients with

ACS

- Evaluate time delays

and hospital setting to

determine the best

reperfusion option

- Participate in

primary angioplasty

- Select the optimal

pharmacological

treatment

- Discuss

hemodynamic

measurements and

imaging findings

patient

- Recognise

complications as soon

as they appear

- Participate in the

treatment decision

from the emergency

room until discharge

- Consult with other

colleagues on specific

matters (image,

cardiac

catheterization,

surgery,

electrophysiologists,

etc…)

- Inform the patient

and family members

of the prognosis and

treatment decisions

- Educates patient

and family members

on secondary

prevention measures

- Refers to ESC

guidelines to choose

the best evidence-

based therapies


arrhythmias and

supraventricular

arrhythmias).

- Outline risk

stratification after AMI

- Explain secondary

prevention measures

-Interpret rhythm

disturbances

- Evaluate short and

long-term risk

- Select the best

secondary prevention

strategies

3.- ACUTE HEART FAILURE (AHF) AND CARDIOGENIC SHOCK


- To diagnose and treat

patients with AHF

secondary to:

Myocardial

disease

Hypertension

Valve disease

Pericardial

disease

High output

syndromes

- Identify the

maladaptative

responses to heart

failure.

- Explain symptoms

due to heart failure

and physical

examination findings

- Describe diagnostic

procedures to:

confirm diagnosis,

identify causes,

prognosis and

response to

treatment

- Outline diagnostic

tests: chest X-ray,

ECG, oxygen

saturation, , general

- Interpret clinical

findings, chest X-ray,

ECG and laboratory

data to diagnose

AHF

- Analyse the causes

of AHF in

relationship with

patients medical

history

-Interpret results of

diagnostic tests to

- Choose properly

the best treatment

strategies for each

patient

- Recognise

complications as

soon as they appear


treatment decision

from the emergency



colleagues on

specific matters

(imaging, cardiac

catheterization,

surgical options,

arrhythmia ablation,

etc)


biochemistry and full

blood count,

natriuretic peptides

imaging (echo, MRI),

endomyocardial

biopsy.

- Identify the need for

invasive

hemodynamic

monitoring

- Describe the use of

diuretic, vasodilators,

and inotropes:

Indications and

contraindications

- Explain when and

how to use

mechanical

ventilation (invasive

and non-invasive)

- Describe

associated

arrhythmias

- Outline ventricular

support (IABP,

ventricular assist

devices), surgical

treatment (CABG,

valve replacement,

heart transplantation)

- Explain predictors

of survival and

determine the best

treatment options


noninvasive and

invasive tests to

obtain the

appropriate

diagnosis

-Insert PAC or other

haemodynamic

monitoring devices

as necessary

- Interpret

hemodynamic

(invasive and non-

invasive)

measurements and

imaging findings

Select the best drug

treatment according

to changes in patient

condition

- Apply invasive or

non-invasive

mechanical

ventilation, when

needed

- Interpret and treat

acute rhythm

disturbances


and family members


treatment decisions

- Educate patient

and family members

on secondary

prevention measures

- Refer to ESC


the best evidence-

based therapies


outcomes - Select the best

ventricular support,

when needed

-Insert IABP, if

needed (level III);

cooperate with

surgeons with

ventricular

assistance devices


long-term risk

- Select the best

secondary

prevention strategies

4.- MYOCARDITIS


- To diagnose and

treat patients with

myocarditis

- Describe the

aetiology of acute

myocarditis

- Explain the

pathology of viral,

non-viral and non-

infective myocarditis

- Outline clinical

features (fever, chest

pain, acute heart

failure,

arrhythmias,…)

- Identify diagnostic


of myocarditis



ECG and laboratory

data to diagnose

myocarditis


best treatment

strategies for each

patient

- Recognise


as they appear


treatment decision

from the emergency





tests: chest X-ray,

ECG, natriuretic

peptides, general


blood count, imaging

(echo, MRI),

endomyocardial

biopsy.

- Describe the use of

diuretic, vasodilators,

inotropes and

anthyarrhytmics

drugs: Indications and

contraindications

- Outline the need for

ventricular support

(IABP, ventricular

assist devices) heart

transplantation)

- Explain predictors of

survival and

outcomes

-Select the best drug

treatment according

to changes in patient

condition

- Interpret rhythm

disturbances

- Select the best

ventricular support,

when needed

-Insert IABP, if

needed (level III);

cooperate with

surgeons with

ventricular assistance

devices


long-term risk

- Select the best


strategies

matters (imaging,

cardiac

catheterization,

surgical options,

control of arrhythmia,

etc)


and family members


treatment decisions

- Educate patient and

family members on


measures

- Refer to ESC


the best evidence-

based therapies


5.- CARDIAC TAMPONADE


- To diagnose and

treat patients with

cardiac tamponade

- Describe the

aetiology of cardiac

tamponade

- Explain the

pathology of cardiac

tamponade

- Outline signs and

symptoms of cardiac

tamponade


tests: chest X-ray,

ECG, general


blood count, and

echocardiography

- Indicate the need for

pericadiocentesis

(percutaneous or

surgical)

- Explain outcomes

according to

diagnosis


of cardiac tamponade



ECG,

echocardiographic

findings and

laboratory data to

diagnose cardiac

tamponade

-Perform

pericardiocentesis

(level III) or refer

patient to surgical

drainage


long-term risk


best treatment

strategies for each

patient

- Recognise


as they appear


treatment decision -

Consult with other


matters

(echocardiography,

surgical option,

oncologist)


and family members


treatment decisions

- Refer to ESC


the best evidence-

based therapies

6.- ENDOCARDITIS


- To diagnose and - Identify bacteria, - Discuss the - Choose properly the


treat patients with

endocarditis

fungi and other

microorganisms as

the cause of

endocarditis

- Explain the

pathophysiology of

endocarditis

(predisposing lesions,

cardiac tissue

destruction,

anatomic location,

immunologic process,

embolisation)

- Outline clinical

findings (cardiac,

systemic)


tests: general

biochemistry, full

blood count and

inflammatory markers,

chest X-ray, ECG,

microbiology,

echocardiography

- Identify the use of

antibiotics, medical

and surgical

treatment: Indications

and contraindications


survival and

outcomes

relationship between

infection and cardiac

disease

- Analyse the cause of

endocarditis in

relationship with

patient‘s medical

history


findings.

-Analyse chest X-ray,

ECG, laboratory data

and

echocardiographic

findings to diagnose

endocarditis

-Select the adequate

antibiotic regimen and

other medical

treatment or surgical

procedure


long-term risk

- Select the best


strategies

best treatment

strategies for each

patient

- Recognise


as they appear


treatment decision

from admission until

discharge



matters (imaging,

surgical options,

infectious disease

specialist,

microbiologist)


and family members


treatment decisions


family members on


measures

- Refer to ESC


the best evidence-

based therapies

7.- DISEASES OF THE AORTA



- To diagnose and

treat patients with

Aortic

dissection/

hematoma

- Describe and

classify aortic

dissections

/hematoma

- Explain the aetiology

of dissection

/hematoma (intimal

tear, hematoma,

ulcer, involvement of

the media, false

lumen)

- Outline clinical signs

and symptoms (pain,

syncope, emboli,

pulses, murmurs)


tests: chest X-ray,

transesophageal

echocardiography,

CT, MRI, angiography

- Identify the use of

medical and surgical

treatment: Indications

and contraindications


survival and

outcomes

- Outline long-term

treatment

- Discuss the


dissection and

previous medical

history


findings.

- Analyse chest X-ray,

and findings from

imaging techniques

- Select the adequate

hypotensive regimen

and surgical treatment


long-term risk

- Select the best


strategies


best treatment

strategies for each

patient according to

presentation

- Recognise


as they appear


treatment decision


discharge



matters (imaging,

surgical options)


and family members


treatment decisions


family members on


measures

- Refer to ESC


the best evidence-

based therapies

8.- TRAUMA TO THE HEART AND AORTA


- To diagnose and - Describe incidence - Discuss the - Choose properly the


treat patients with

Trauma to

the aorta

Trauma to

the heart

and causes of trauma

to the aorta / heart

- Explain the

pathophysiology of

different trauma

(deceleration,

penetrating, blunt and

electrical trauma.

-Identify injured

structures and

location of rupture

- Outline clinical signs

and symptoms (pain,

hypovolemia,

tamponade…)


tests: chest X-ray,

aortography, CT,

echocardiography,

myocardial enzymes

- Explain the urgency

of surgical repair and

medical management

of

pain and other

complications

- Outline predictors of

survival and

outcomes


the type of accident

and lesions


findings according to

injury and clinical

findings.

- Analyse chest X-ray,

and findings from

imaging techniques

- Select the adequate

surgical treatment and

other therapies to

treat complications

(heart failure,

arrhythmias, pain..)


long-term outcomes

best treatment

strategies for each

patient according to

presentation

- Recognise


as they appear


treatment decision


discharge



matters (imaging,

surgical options)


and family members


treatment decisions

- Refer to ESC


the best evidence-

based therapies

9.- ARRHYTHMIAS



- To diagnose and treat

patients with

Bradyarrhythmia

Atrial fibrillation

Supraventricular

tachychardia

Ventricular

tachycardia

VT storm

- Identify different

rhythm disturbances

on surface ECG

- Explain symptoms

due to bradycardia

or tachycardia and

physical

examination findings

- Describe

diagnostic

procedures: ECG,

Holter, carotid sinus

massage, tilt-test,

invasive

electrophysiology,

exercise test, echo,

MRI

- Outline the use of

drugs to treat rhythm

disturbances and

prevention of emboli

- Explain indications

for: cardiac pacing,

external and internal

defibrillation,

cardioversion,

catheter ablation,

- Classify

tachyarrhythmia by

QRS width

- Explain the use of

imaging techniques

to study size and

function of cardiac

chambers

- Interpret surface

ECG and clinical

findings

- Analyse the

causes of rhythm

disturbances in

relationship with

patient medical

history

-Interpret results of

diagnostic tests to

determine the best

treatment options


treatment to end an

arrhythmic episode

(provisional

pacemaker,

cardioversion,

defibrillation, level

III)

- Interrogate

devices

(pacemakers and

ICDs) and make

measurements and

parameter changes

- Implant a

temporary

pacemaker (level

- Choose properly

the best treatment

strategies for each

patient

- Recognise

complications as

soon as they

appear


treatment decision

from the

emergency room

until discharge

- Consult with

other colleagues

on specific matters

(arrhythmia

ablation,

permanent

pacemaker, ICD..


and family

members of the

prognosis and

treatment

decisions

- Educate patient

and family

members on

secondary

prevention

measures

- Refer to ESC

guidelines to

choose the best


- Outline predictors

of survival and

outcomes in the

different categories

III)

- Evaluate short

and long-term risk

- Select the best

secondary

prevention

strategies

evidence-based

therapies

10.- SUDDEN CARDIAC DEATH AND RESUSCITATION


- To diagnose and

treat patients with

Sudden

cardiac

death (SCD)

- Identify causes of

sudden cardiac death

- Explain the

pathology underlying

SCD

- Describe the

pathophysiology

(tachyarrhythmias,

bradyarrhythmias,

cardiac arrest)

- Identify clinical

characteristics (onset,

survivors..)

- Outline techniques

of CPR

- Identify legal and

ethical issues of CPR

- Describe use of

cardioversion,

pacemaker, drugs in

advanced life support

- Analyse SCD in

relationship with

patients medical

history

-Interpret rhythm

recordings and

circumstances

previous to SCD

- Select the best

treatment to

resuscitate the

patient: perform CPR,

endotracheal

intubation, insert a

temporary

pacemaker,

cardioversion,

defibrillation (all at

level III)


best strategies for

each patient

- Recognise the need

for termination of CPR

or ―do not resuscitate‖

orders

- Participate actively

in the CPR



matters (arrhythmia

ablation, permanent

pacemaker, ICD..

- Inform the family

members of the

prognosis and

treatment decisions


family members on



and resuscitation

- Explain associated

cardiac conditions

leading to SCD

- Outline therapies to

prevent cardiac arrest

(ICD, catheter or

surgical ablation,

CABG)

- Analyse the best

drug treatment

according to patients

response

- Interpret associated

medical conditions

that may have

triggered cardiac

arrest


long-term risk

- Select the best


strategies

measures

- Refer to ESC


the best evidence-

based therapies

11.- PULMONARY EMBOLISM


- To diagnose and

treat patients with

Pulmonary

embolism (PE)

- Identify incidence

and risk factors of PE

- Describe clinical

characteristics

(dyspnea, syncope,

tachycardia,

hypotension…)

- Outline findings on

ECG, blood markers

(troponins, D-Dimer,

BNP), chest X-ray,

echo, CT angio

- Explain differential

diagnosis of acute PE

- Describe use of

Thrombolytics,

embolectomy and

- Analyse PE in

relation to patients

medical history

-Interpret clinical

signs and symptoms

in patients with PE

- Evaluate the results

of laboratory and

imaging in relation to

PE

- Select the best

treatment for PE

(need for

thrombolysis, support

ventilation; level III)


long-term risk


best strategies for

each patient


in the diagnosis and

treatment



matters (radiologists,

surgeons)


and family members


treatment decisions


family members on



other medical

measures

- Outline secondary

prevention

- Select the best


strategies

measures

- Refer to ESC


the best evidence-

based therapies

12.- PULMONARY HYPERTENSION


- To diagnose and

treat patients with

Primary

pulmonary

hypertension

(PPH)

Secondary

pulmonary

hypertension

- Describe definition,

classification and

epidemiology of PPH

and secondary PH

- Identify the

pathology of PPH and

secondary PH

- Outline clinical

findings

- Explain the value of

blood tests, blood

gases, chest X-ray,

CT, MRI, cardiac

catheterization, lung

scan,…

- Outline

management:

medical and surgical

treatments.

- Define prognosis

-Interpret clinical

signs and symptoms

in patients with PH


of laboratory and


PH

- Select the best

treatment for PH

- Evaluate prognosis

in relation to the

response of

management


best strategies for

each patient



treatment



matters (radiologists,

surgeons,

pneumologists)


and family members


treatment decisions


family members

disease management

- Refer to ESC


the best evidence-

based therapies


13.- Sepsis


- To diagnose and

treat patients with

Sepsis

Related

inflammatory

syndromes

- Describe definition,

classification and

epidemiology of

sepsis

- Characterize the

pathology of sepsis

- Summarize clinical

findings

- Explain the value of

blood tests, blood

gases, chest X-ray,

abdomen X-ray, CT,

ultrasonography,

echocardiography,

etc.

- Review

management: medical

and surgical

treatments.

- Define prognosis

-Interpret clinical

signs and symptoms

in patients with sepsis


of laboratory and


sepsis

- Select the best

treatment for sepsis

(e.g. early goal

directed therapy, early

antibiotic therapy etc.)

- Select the best

treatment for sepsis:.

early goal directed

therapy, early

antibiotic therapy etc.

- Describe monitoring

techniques

- Adequate

hemodynamic

monitoring and

interpretation of

hemodynamic

findings


best strategies for

each patient



treatment



matters

(microbiologists,

infectious disease

specialists,…)


and family members


treatment decisions


family members

disease management

- Refer to ESC


the best evidence-

based therapies


ANNEX : ESC Report

Recommendations for the structure, organization, and operation of intensive cardiac care

units

Yonathan Hasin1*, Nicolas Danchin2, Gerasimos S. Filippatos3, Magda Heras4, Uwe Janssens5,

Jonathan Leor6, Menachem Nahir1, Alexander Parkhomenko7, Kristian Thygesen8, Marco

Tubaro9, Lars C. Wallentin10, and Ilia Zakke11 on behalf of the Working Group on Acute Cardiac

Care of theEuropean Society of Cardiology

1 Poria Medical Center, M.P. Lower Galilee, Tiberias, Israel; 2 Hopital Europeen Georges

Pompidou, Paris, France;

3Evangelismos General Hospital, Athens, Greece; 4 Cardiovascular Institute, University of

Barcelona, Spain; 5 Universitat

Klinikum, Aachen, Germany; 6Sheba Medical Center, Ramat Gan, Israel; 7 Ukrainian Institute of

Cardiology, Kiev, Ukraine;

8Aarhus University Hospital, Aarhus, Denmark; 9San Fillippo Neri Hospital, Rome, Italy; 10

Uppsala Cardiothoracic Center,

Uppsala, Sweden; and 11P. Stradins Clinical University Hospital, Riga, Latvia

Received 15 September 2004; revised 1 February 2005; accepted 10 February 2005; online

publish-ahead-of-print 21 March 2005. Eur Heart J 2005 Aug; 26(16):1676-82

Keywords

Intensive care unit; Acute cardiac care; Functional recommendations; Medical equipment

Abstract

Two major changes in patient characteristics and management occurred recently that demand

distinctive alterations in the function of the intensive cardiac care unit (ICCU). These changes

include the introduction of an early invasive strategy for the treatment of acute coronary

syndromes, enabling early recuperation and shorter need for intensive care on the one hand,

while the number of older and sicker patients requiring prolonged and more complex intensive

care is steadily increasing. A task force of the European Society of Cardiology Working Group on

Acute Cardiac Care was set to give a modern updated comprehensive recommendation

concerning the structure, organization, and function of the modern ICCUs and intermediate

cardiac units. These include the statement that specially trained cardiologists and cardiac nurses

who can manage patients with acute cardiac conditions should staff the ICCUs. The optimum

number of physicians, nurses, and other personal working in the unit is included. The document

indicates the desired architecture and structure of the units and the intermediate cardiac unit and


their relations to the other facilities in the hospital. Specific recommendations are also included for

the minimal number of beds, monitoring system, respirators, pacemaker/defibrillators, and

necessary additional equipment. The desired function is discussed, namely, the patients to be

admitted, the length of stay, and the relocation policy. A uniformed electronic chart for ICCUs is

advised, anticipating a common European database.

Introduction

The following represents an expert consensus document written by the nucleus members of the

European Society of Cardiology (ESC) Working Group for Acute Cardiac Care (ACC).

The first description of the intensive cardiac care units (ICCUs) was presented by Julian (1) to the

British Thoracic Society in 1961 and was based on monitoring patients with acute myocardial

infarction (AMI) for the early diagnosis and treatment of ventricular fibrillation. Nevertheless,

significant benefit of the units was not obtained until some decisive policy changes were made,

including treatment protocols and structural organizations (2). The current objectives of the

ICCUs are the monitoring and support of failing vital functions in acute and/or critically ill cardiac

patients, in order to perform adequate diagnostic measures followed by medical and invasive

therapies to improve outcome.

The current published literature regarding the structure, operation, and function of ICCUs is

insufficient because of the following reasons: it focuses on non-cardiac care (3), it is limited to

part of the needs(4), it describes only local standards (5) it is published in non-English literature

(6) or it is very old (7).

In a continental survey among hospitals from different parts of Europe, a great deal of divergence

was found concerning the whole spectrum of organization and function of ICCUs (ESC WG on

Acute Cardiac Care; unpublished results).

The ESC Working Group on ACC was established in 2001. One of its declared tasks is to

improve and unify the function of ICCUs across Europe.

A task force composed of the nucleus members of the Working Group set out to write the

following document in order to provide an updated guide indicating the minimal optimal

requirements for the modern functioning ICCU. The manuscript is based on the current available

literature; it reflects the existing working states in different European

countries and the personal opinion of the task force members.

The manuscript has undergone extensive revision by the Guideline Committee of the ESC and by

the editorial board of the European Heart Journal.

Local modifications should be implemented according to the local special needs derived from

specific patient case-mix, available resources, and different laws and regulations.


Two changes occurred over the past two decades that demand distinctive alterations in the

function of the ICCUs in the next decade. Changes will take place both in the patient population

admitted to the ICCU and in the medical care supplied.

(i) Emergency reperfusion treatment policies (non-invasive or invasive) were adopted as an

accepted standard of care in patients with AMI (8). These policies dictate the necessity for

special attention and immediate treatment of the patients early on, but after the success of the

initial treatment, the patients show immediate drastic improvement in many cases. Follow-up and

management are simpler and easier than in the past, recovery is faster, and the average length of

stay is shorter.

(ii) The medical profession has reached a level of specialization in which the cardiologists and the

intensive care physician are impelled to establish a long-term treatment policy for their patients

rather than take care of only the patient‘s immediate and urgent problems.

Patient population

Acute coronary syndrome (ACS) will probably remain the most frequently primary admission

diagnosis in ICCU in the next decade. Today these patients are treated effectively

and quickly in different ways, thus the length of stay both in the unit and in the hospital is

expected to decrease. On the other hand, the aging population in Europe, with increasing co-

morbidities will probably change the ICCU population. Dramatic improvement in therapeutic

measures will lead to a better outcome, with a prolonged survival for patients with coronary artery

disease, with either a normal or a depressed left ventricular function. Therefore, the case-mix of

our patients in the ICCU will change dramatically in the next decades.

As the population is aging, the unit will have to treat elderly patients who tend to suffer from

multisystem diseases; the number of patients treated by multiple percutaneous or surgical

revascularization procedures will increase; moreover, the ICCU is becoming the treatment centre

for patients suffering from severe cardiac arrhythmias and decompensate heart failure or different

combinations of diseased heart and other organs. As a result, it may likely be that the ICCU will

be utilized for more complex patients who require a relatively longer length of stay in the Unit and

will provide the treating staff with a special challenge. For these reasons, the requirements of the

ICCU will increase, not decrease.

A special group of patients are those suffering from complications following invasive treatments in

the catheterization lab. The still growing number of severe cases with multivessel disease,

complex lesions, reduced left ventricular function, and a multitude of co-morbidities treated in the

catheterization lab may increase the number of complications during and after coronary


intervention procedures. These patients represent a special group of patients admitted to the Unit

and need specific cardiological nursing and medical expertise.

Treatment policies

Reperfusion in acute ST-elevation myocardial infarction patients is undoubtedly an emergency

(9). Direct mechanical revascularization is becoming more and more popular, even though its

availability is still restricted owing to lack of trained staff and budget constraints. In the near

future, the catheterization laboratory and the ICCU will become more and more inseparable.

In the coming decade, the cardiologists will continue to observe constant efforts of the

pharmaceutical industry to improve reperfusion at the patient‘s bedside, with new, more efficient

thrombolytics, anticoagulants, and antiplatelets agents, and more effective interventional therapy,

which, in combination with newly developed drugs aimed at the salvage of the microvasculature

and of the myocardium from ischaemia/reperfusion injury, will hopefully improve outcome in these

patients.

This pre-vision has clear implications for the necessity of constantly updating the Units about

novel resources for diagnosis and treatment, as well as preparing them to participate in

multicentre research in order to determine the efficacy of the new therapeutic developments.

Professionalization of medicine is becoming more intense, with the need for cardiac patients be

treated preferentially by properly trained cardiologists. In those hospitals in which the patients are

transferred directly to the internal medicine ward, the physician in the Unit is compelled to

determine a long-term treatment policy, in addition to being obliged to provide acute treatment.

Thus, the different Units will develop methods for prognostic stratification (index-risk

stratification), which will most probably include a combination of clinical data (age, sex, heart rate,

blood pressure); ECG (ST-segment depression or elevation, T-wave inversion); cardiac markers

of elevation, especially troponin; evaluation of the left ventricular function; residual ischaemia; and

electrical instability.

Staff

The change in patient population and treating policies necessitate appropriate staff training. An

increase in the number of complex and/or elderly patients (who may need respiratory treatment,

intra-aortic balloon counter pulsation, haemodynamic complex monitoring, or dialysis) and

participation in multicentre research projects require suitable training of the physicians and the

nursing staff. It is reasonable that for specific specialization, there will be suitable training and

accreditation both for physicians and for nurses, especially for the research nurses who will be

an integral part of the ICCUs nursing staff.


Equipment

The standard monitoring equipment, including invasive and non-invasive electrocardiographic,

haemodynamic, and respiratory assessment, will continue to be the basis of the ICCU (10)

Monitoring for the evaluation of autonomous function and electrical instability (heart rate

variability, baroreceptor sensitivity, signal average electrocardiogram, and built-in continuous

ECG Holter monitoring (11) is likely to be added to standard equipment. Non-invasive

assessment of cardiac function such as cardiac output (12,13) as well as continuous CO2 and

O2 saturation monitoring, is becoming available and is routinely used in the modern ICCU.

Computers are a part of the everyday monitoring of the patients; it is used for collecting and

analysing patient‘s data. A uniform electronic database management system of all the European

ICCUs is an important task for the Working Group on ACC, including at least basic demographic

and clinical data, modes of interventions, and in-hospital outcome. This will make communication

among the different ICCUs simpler and could serve as database with an enormous source of

information both for research and for quality control purposes.

Functional recommendations

ICCU patients

The decision to admit a patient will be made by the ICCU physician on duty; in case of physician

disagreement, the decision will be made at the senior physician level. It is advisable

for the following patients to be routinely admitted to the ICCU (14,15)

(i) any patient with suspected acute ST-elevation myocardial infarction, up to 24 h from the onset

of symptoms, especially if suitable for thrombolytic or primary angioplasty treatment;

(ii) patients with AMI, presenting .24 h after onset of symptoms with complications, or unstable

high-risk patients (heart failure that requires intravenous therapy or haemodynamic monitoring or

support of an intra-aortic balloon, serious cardiac dysrrhythmias, conduction disturbances,

temporary pacemakers);

(iii) patients in cardiogenic shock;

(iv) patients with high-risk unstable coronary syndromes (e.g. ongoing or repeated anginal pain,

heart failure, significant diffuse ST-depression, dynamic ST-shift, elevated troponins);

(v) unstable patients after a complicated percutaneous coronary intervention (PCI), who need

special attention (at the discretion of the PCI operator);

(vi) patients with life-threatening cardiac arrhythmias, as a result of ischaemic heart disease,

cardiomyopathy, rheumatic heart disease, electrolyte disturbances, drug effects, or poisoning;


(vii) patients with acute pulmonary oedema unresolved by initial therapy and depending on the

underlying conditions;

(viii) patients in need of haemodynamic monitoring for evaluation of therapy;

(ix) patients after a heart transplant with acute problem, i.e. infection, haemodynamic

deterioration, electrolyte imbalance, suspected acute rejection, and so on;

(x) massive pulmonary embolism.

This list is conclusive and should be adapted according to each individual case.

Length of stay in the ICCU

. The length of stay in the ICCU should be primarily planned to be at least 2–4 days, dictated by

the individual clinical presentation.

. Patients with ST-elevation myocardial infarction without complications should continue the

treatment in the ICCU for 48 h.

. Patients with unstable coronary syndromes with dynamic ST-shift and elevated cardiac

troponins should stay in the ICCU until 24 h after the latest episode of ischaemia (non-invasive or

planned invasive treatment, as dictated by ESC guidelines).

. High-risk ACS patients after acute PCI (with GP IIb/IIIa antagonists) should stay in the ICCU

until the stable phase.

Relocation policy

. Once stabilized, patients are transferred from the ICCU to a cardiac intermediate care unit (with

a simple electrocardiographic monitoring and run by cardiology oriented staff) or to the general

ward, according to the local policy. After a short stay, an out-of-hospital specialized recreation

facility is recommended prior to going back home. An alternative route is outpatient rehabilitation

clinic.

. It is advisable to discuss the following with the patient in the presence of one of their dominant

family members: medications, return to activities, risk factors and life-style modifications, a

healthy diet, and recommendations for future tests (invasive and non-invasive) including an

appointment for the outpatient follow-up clinic; this should be done shortly before their discharge

from the ICCU.

Intermediate cardiac care unit patients

Decision to admit a patient to the intermediate ward is at the discretion of the treating physician,

and according to the local policy at the particular institution (16). It is recommended to consider

the following conditions:


(i) intermediate risk unstable coronary syndrome patients;

(ii) patients in first stages of recovery from myocardial infarction;

(iii) patients with uncontrollable cardiac insufficiency not responsive to regular oral therapy,

especially those with co-morbidities;

(iv) patients with heart disease in need of medical therapy adjustment, special cardiac

investigations (e.g. electrophysiological study, cardiac catheterization, etc.), or some of the

patients after special cardiac procedure (e.g. implantation of permanent pacemaker or internal

cardiac defibrillators).

Number of beds in the ICCU

The number of beds in the ICCU must suit the size of the reference population and the relative

specific workload of the hospital. The hospital‘s specific workload can be evaluated in a number

of ways: the simplest measure of the relative workload is the number of visits to the hospital‘s

internal emergency room.

Recommended formula for calculation:

(i) for each 100 000 inhabitants, four to five ICCU beds;

(ii) for every 100 000 visits per year in the internal emergency room, 10 ICCU beds.

The number of beds will be determined according to the highest of the two.

Number of beds in the intermediate cardiac care unit

The desired ratio of beds between ICCU and the intermediate CCU is 1:3.

ICCU equipment

(i) Patient monitoring unit: the basic patient monitoring unit must include at least two ECG

channels, invasive pressure channel, non-invasive blood pressure monitor, and an SaO2 metre. It

is desirable that 50% of the beds include the following additional basic parameters: five ECG

channels, two additional haemodynamic channels, end tidal CO2, non-invasive cardiac output,

and thermometer.

(ii) Nurse station: to be used for central monitoring and analysing. At least one ECG lead from

each patient as well as relevant haemodynamic and respiratory data should continuously be

present on a central screen. Slave monitors should be installed to enable monitoring of patients

from different sites of the unit, as well as working stations for retrospective analysis of index

events, i.e. changes in heart rate, rhythm disturbances, ST-events (ST-segment changes

algorithm), heart rate variability, blood pressure, O2 saturation, and so on.


Patients beds for the ICCU

Beds in the ICCU have to allow vertical movement, with the possibility of up and down head and

leg positioning. Every bed must be equipped with oxygen, vacuum, and compressed- air intakes.

It is desirable that one of the beds be suitable for patients with active contagious infectious

diseases (e.g. methicillin resistant Staphylococcus aureus, HIV, tuberculosis, etc.) and filtered

accordingly. It is important to make sure that the patient can be X-rayed on the bed.

Additional equipment (17)

. Volumetric pump/automatic syringe: four to six per bed;

. mechanical respirators (including CPAP delivery system to use with face mask): one machine

per two beds;

. intra-aortic balloon pump: one consol every three beds, up to the first six patients;

. haemodyalisis/haemofiltration machine: should be available (probably more cost effective if

supplied by the nephrology department);

. pacemaker defibrillator (possibly biphasic): one apparatus every three beds;

. external pacemaker: one to two every six to eight beds;

. temporary pacemakers: three to four VVI and one DDD every six to eight beds;

. mobile echocardiography machine: one (consider a portable one, according to future technology

development), including a TEE probe;

. blood clot metre (ACT): one;

. biochemical markers kits, for myocardial infarction, optional (to be omitted provided that the

biochemistry tests are in the central laboratory in ,30 min;

. glucose level measurement kit: one;

. blood gasses and electrolyte analyser: optional (to be omitted provided that the results of the

blood gas and electrolyte tests come back from the central lab within 10 min);

. X-ray system for fluoroscopy: digital cardiac mobile C-arm enabling coronary angiography is

recommended;

* Ideally, a fully equipped catheterization and PCI laboratory should be in close association with

the Unit and ready to perform invasive procedure on a 24 h basis.

* An alternative route would be an available mobile unit to transfer a patient in need to a near by

catheterization laboratory.

. mechanical compression devices used for groin and radial homeostasis: optional.

ICCU and intermediate CCU staff

. (physicians: cardiologists/residents in cardiology/cardiology fellows)

. Physicians (day time shift):


. Department head: a certified cardiologist.

. First six beds: one physician every three beds.

. If more than six beds: one physician every four beds.

The ICCU should be staffed by at least one physician for every three to four patients, including

the Unit director. The director of the Unit should be a board certified cardiologist, specially trained

and accreditated as an acute cardiac care specialist, as cardiologists are the physicians

better trained to assist patients with ACS and lifethreatening cardiac diseases.

The cardiologist in charge of the ICCU should be skilled in treating urgent cardiac situations,

including rhythm and haemodynamic disturbances and acute ischaemia. The cardiologist must be

skilled at inserting an endotracheal tube, a temporary pacemaker, a catheter in the pulmonary

artery, and a balloon in aorta for counter-pulsation. The cardiologist should be able to perform a

transthoracic echo study on a basic level (i.e. evaluate the left ventricle systolic function, identify

severe valvular disease, and find pericardial fluid) and should have further training in the general

intensive care unit.

On-duty and on-call physicians

A skilled physician on duty should be present in the Unit at all times. This physician should be

able to handle acute cardiac emergencies after short local training and approval for night duties

by the director of the unit. An attending cardiologist on call should always be available for

consultation and assistance.

Nurses

Nurses are as important as physicians. Proper nursing staff is the strength of the ICCU. A head

nurse for the ICCU is appointed with authority and responsibility for the appropriateness of

nursing care; they must have extensive experience in intensive care nursing and proper medical

managerial skills, must be able to conduct routine nursing activity of the unit, must be involved in

the on-going training of the unit staff, and must take an active part in research activities. The

ICCU will employ only registered nurses. At least 75% of them should have completed formal

intensive care training (which includes formal cardiology training)(18).

A unified recommendation for the size of the nursing staff is an intricate issue hampered by the

divergence of nursing working habits and skills, case-mix of patients, and different Therapeutic

Interventions Scoring System levels (19).

The following recommendation is based on the estimated workload of an average ICCU, the

calculated Whole Time Equivalents (20), and the personal experience of the authors.


Furthermore, allocating nursing manpower should take into account the need for the number of

shifts per day, the number of beds in the units, the desired occupancy rate, extra manpower for

holidays, and the ability to transfer the nurses from one facility to the other (intensive to

intermediate to cardiology and vice versa).

The nursing staff should be constructed of at least 2.8 nurses per bed, to cover three shifts per

day, so that the minimal number of nurses in a given time will be at least one nurse per two beds

during day time and one per three beds during night shift (21,22).

The intensive care nurse should have further training once in at least 5 years in the general

intensive care unit. It is also advisable that further training courses be reciprocal so that

the nurses working in the general intensive care unit could work in the cardiac intensive care unit

as well.

Intermediate cardiac care unit staff

. Department head: a certified cardiologist.

. First 12 beds: one physician every six beds.

. If more than 12 beds: one physician every eight beds.

. Nurses: 1.8 nurses per bed.

Additional staff

. Secretary and nurse assistant- full time.

. Dietician, computer expert (hardware and software), ventilation technician, social worker,

physiotherapist, porters, and cleaners—part time.

ICCU and intermediate CCU: construction (23–25)

(i) The cardiac intensive care unit/intermediate unit/ cardiac ward should be constructed as an

independent ward in the hospital (26)

(ii) The desired intensive care unit standard is a separate room for each patient and up to two to

three patients per one room in the intermediate unit.

(iii) There should be at least one single bedroom with thepossibility to isolate patients with

contagious infection.

(iv) The architecture of the unit should be designed to make it possible to observe the patients

from the nurses‘ monitoring station and to have easy and fast access.

(v) The station should be in a central position and well equipped, and the surrounding area will be

spacious so as to afford optimal working conditions.


(vi) The separate intensive care procedure room should be spacious enough so that it can

contain all the physicians (cardiologists, anaesthesiologists, nurses, technicians) and multitude of

bulky equipment (X-ray machine, heavy monitoring, intra-aortic balloon pump) necessary

to initiate treatment for a complicated acute case. The minimal area should be 25 m2. The room

must have washable walls for 2 m in height. Construction should fit requirement for the use of X-

ray fluoroscopy.

(vii) The electrical equipment should have an emergency feeding and a continuity apparatus.

(viii) Windows in the intensive care ward are desirable, but not a pre-requisite.

(ix) The lighting should be good, but not dazzling; lightning should be indirect.

(x) A dialysis facility (source of water and sewage) should be established in a few rooms as

necessary.

(xi) In larger intensive care units, one should consider dividing the nurses station into two or three

according to the number of beds. It is advised that one nurses station should serve not more than

six to eight beds.

(xii) The cardiac intensive care unit should be situated as close as possible to the emergency

room, the catheterization lab, general intensive care unit, and operating theatres (if available in

the institution).

(xiii) It is also desirable that the intensive care ambulance may have a direct access to the unit, so

that in appropriate cases, a patient may be directly admitted, bypassing the emergency

department.

Other areas to be included

(i) staff rooms (meeting the demands of the secretary, medical staff, nursing staff, patient

relatives‘ interview, physician on-call dormitory, head nurse, and director of the unit);

(ii) meeting room;

(iii) family waiting room;

(iv) office;

(v) store room (a lot of electronic equipment that requires constant electricity recharge);

(vi) computer communications—inter-departmental. Departments and laboratories—an external

system.

Database

The computer system is regarded as a positive means of collecting information, at local, national,

and international levels. It facilitates everyday activities in patient management and data

archiving. It can be used as database and enables analysis of information and quality control.


Nevertheless, there are objective difficulties and obstacles on the way to adopt a uniform

programme to be used as a continental database.

(i) Currently, there is no accepted optimal software for cardiac intensive care patients.

(ii) Many of the cardiology departments in Europe have a computer system with or without

connections to similar systems within or out of the hospital.

(iii) Development of computerized systems depends on strategic decisions made by different

Health System Authorities, both at national and at hospitals levels. Therefore, it will be impossible

to introduce a uniform programme across Europe.

(iv) The existing programmes, and those to be developed in the near future, are based on

different software systems. Effort and resources should be invested for the connection of those

systems into a common database.

It is recommended that the ICCU will use an electronic chart routinely. This could facilitate patient

admission, discharge, and follow-up as well as research and quality control. As several hardware

and software facilities are available, and obviously many Units in Europe have already

implemented their own electronic chart, a common European electronic chart would be an

impractical dream. Yet, some key items common to all electronic charts could be chosen,

transmitted through the internet, and will be used as a common European database for patient

admitted to the different ICCUs.

Recently, the European Society of Cardiology launched the Cardiology Audit and Registration

Data Sets (CARDS) initiative, under the auspices of the European Union (27). One of the three

main issues in CARDS is ACS, and the related Expert Committee on ACS published a report on

the data standards for a ICCUs DB on ACS. This data set can constitute the common basis for all

the different databases in European ICCUs, allowing interoperability and data sharing.

Quality assurance should be an integral part of the organization and standards of a ICCU:

processes currently considered effective for patients outcome, such as adequately

timed reperfusion and evidence-based care at discharge, should be monitored and quality control

performed reviewed at least on an annual basis, together with personnel and administrators.

Conclusion

The current recommendations have been written as a guide and a rule for the function of a

modern ICCU. The exponential speed of changes in technology, procedures, and treatment

policies will undoubtedly provide a repeated need for updating these guidelines. For instance,

what will be the effect of chest pain units (which are emerging throughout Europe) on the ICCU?

In the near future, reference centres for primary or facilitated PCI for ST-elevation myocardial

infarction, as well as for early intervention in patients with non-ST-elevation myocardial infarction,


will play a key role in the treatment of patients with ACS. The concept of networking for the

coordination among tertiary centres, community hospitals, emergency rooms, and transportation,

might also result in a need for updating.

The lack of evidence-based recommendation on the structure and function of ICCUs call upon

properly designed studies looking at unresolved issues such as numbers of ICCU beds required

for a given populations size, specific equipment, required personnel, and alike.

References

1. Julian DG. The history of coronary care units. Br Heart J 1987; 57:497–502.

2. Killip T, Kimball JT. Treatment of myocardial infarction in a coronary care unit: a two year

experience with 250 patients. Am J Cardiol 1967;20:457–464.

3. Ferdinande P. Members of the Task Force of the European Society of Intensive Care

Medicine. Recommendations on minimal requirements of Intensive Care Departments. Intensive

Care Med 1997;23:226–232.

4. Merkouris A, Papathanassoglou ED, Pstolas D, Papagiannaki V, Floros J, Lemonidou C.

Staffing and organizations of nursing care in cardiac intensive care units in Greece. Eur J

Cardiovasc Nurs 2003;2:123–129.

5. Valle Tudela V, Alonso Garcia A, Aros Borau F, Gutierrez Morlote J, Sanz Romero G, Spanish

Society of Cardiology. Guidelines of the Spanish Society of Cardiolgy on requirements and

equipment of the coronary care unit. Rev Esp Cardiol 2001;54:617–623.

6. Ruda Mla. Intensive care units for patients with acute coronary insufficiency. Kardiologiia

1976;16:148–158.

7. Shachtman J, Fields J, Craig S. Basic design and equipment needed for a coronary care units.

Isr J Med Sci 1967;3:287–294.

8. Fuster V. 50th anniversary historical article. Myocardial infarction and coronary care units. J

Am Coll Cardiol 1999;34:1851–1853.

9. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy

for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet

2003;361:13–20.

10. Mangan B. Structuring cardiology services for the 21st century. Am J Crit Care 1996;5:406–

411.

11. Leeper B. Continuous ST-segment monitoring. AACN Clin Issues 2003;14:145–154.

12. Cotter G, Moshkovitz, Y. Kaluski E, Cohen AJ, Miller H, Goor D, Vered Z. Accurate,

noninvasive continuous monitoring of cardiac output by whole-body electrical bioimpedance.

Chest 2004;125:1431–1440.


13. Mielck F, Buhre W, Hanekop G, Tirilomis T, Hilgers R, Sonntag H. Comparison of continuous

cardiac output measurements in patients after cardiac surgery. J Cardiothorac Vasc Anesth

2003;17:211–216.

14. Nasraway SA, Cohen IL, Dennis RC, Howenstein MA, Nikas DK, Warren J, Wedel SK.

Guidelines on admission and discharge for adult intermediate care units. American College of

Critical Care Medicine of the Society of Critical Care Medicine. Crit Care Med 1998;26:607–610.

15. Bone RC, McElwee NE, Eubanks DH, Gluck EH. Analysis of indications for intensive care unit

admission. Clinical efficacy assessment project: American College of Physicians. Chest

1993;104:1806–1811.

16. Task Force of the American Society of Critical Care Medicine. Guidelines on Admission and

Discharge for Adult Intermediate Care Units. Crit Care Med 1998;26:607–610.

17. Quinio P, Baczynski S, Dy L, Ferrec G, Catineau J, de Tinteniac A. Evaluation of a medical

equipment checklist before intensive care room opening. Ann Fr Anesth Reanim 2003;22:284–

290.

18. Depasse B, Pauwels D, Somers Y, Vincent JL. A profile of European ICU nursing. Intensive

Care Med 1998;24:939–945.

19. Miranda DR, Nap R, de Rijk A, Schanufeli W, Lapichino G, TISS Working Group. Therapeutic

intervention scoring system. Nursing activities score. Crit Care Med 2003;31:374–382.

20. Galley J, O‘riordan B, Royal College of Nursing. Guidance for nurse staffing in critical care.

Intensive Crit Care Nurs 2003;19:257–266.

21. Williams G, Clarke T. A consensus driven method to measure the required number of

intensive care nurses in Australia. Aust Crit Care 2001;14: 106–115.

22. Pronovost PJ, Jenckes MW, Dorman T, Garrett E, Breslow MJ, Rosenfeld BA, Lipsett PA,

Bass E. Organization characteristics of intensive care units related to outcomes of abdominal

aortc sugery. JAMA 1999;281: 1330–1331.

23. Wedel S, Warren J, Harvey M, Hitchens Biel M, Dennis R. Guidelines for Intensive Care Unit

Design. Crit Care Med 1995;23:582–588.

24. Ferdinande P. Recommendations on minimal requirements for Intensive Care Departments.

Members of the Task Force of the European Society of Intensive Care Medicine. Intensive Care

Med 1997;23:226–232.

25. Valle Tudela V, Alonso Garcia A, Aros Borau F, Gutierrez Morlote J, Sanz Romero G;

Spanish Society of Cardiology. Guidelines of the Spanish society of cardiology on requirements

and equipment of the coronary care unit. Rev Esp Cardiol 2001;54:617–623.

26. Fracchia C, Ambrosino N. Location and architectural structure of ICCU. Monaldi Arch Chest

Dis 1994;49:496–498.


27. Flynn MR, Barrett C, Cosio FG, Gitt AK, Wallentin L, Keamey P, Lonergan M, Shelley E,

Simmons ML. The Cardiology Audit and Registration Data Standards (CARDS), European data

standards for clinical cardiology practice. Eur Heart J 2005;26,208–313.