Elsevier

American Heart Journal

Volume 175, May 2016, Pages 172-174
American Heart Journal

Editorial
Hospital triage of acute myocardial infarction: Is admission to the coronary care unit still necessary?

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Evidence base for the role of the CCU in AMI care

A nearly 50% reduction in the case fatality rate in patients admitted to a CCU compared with historical controls provided a rationale for the early widespread adoption of CCUs.5 However, even in the 1960s, some experts questioned the benefits of obligatory admission to a CCU, calling for appropriately designed controlled trials.6 As well, advocates of the CCU noted that the “expensive, specially equipped unit…can be justified only if it significantly decreases morbidity and mortality”

Changing landscape of AMI care

If we take the early studies demonstrating a mortality reduction with CCU-based care at face value, why might this benefit have diminished over time? There are 2 major areas of change in the landscape of AMI care that likely address this question: (1) the epidemiology and natural history of AMI have evolved and (2) hospital environments outside the CCU have also changed. Between 1960 and now, the incidence of STEMI has decreased, reperfusion therapy was introduced, immediate or early coronary

A proposed approach to triage of AMI

Current professional society guidelines for the management of AMI (STEMI and NSTEMI) no longer provide formal recommendations for the location of care. The guidelines encourage triage based on risk assessment, suggesting that high risk patients be admitted to the CCU, whereas low-risk patients be admitted to an intermediate-care or SDU with cECG monitoring. Our approach to triage is consistent with these guidelines and provides a practical framework for triage decisions in AMI.

Patients with AMI

Cited by (9)

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    Some STEMI patients may be treatable outside of the CCU. This might be the result of reduced mortality rates due to improvements in treatment methods, equipment, and management in other wards outside the CCU [13,21,22]. The ED has equipment and specialized care similar to that of the step-down unit.

  • The necessity of conversion from coronary care unit to the cardiovascular intensive care unit required for cardiologists

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    Meanwhile, in patients with medically complex conditions admitted to intensive care unit (ICU) or CCU, the ratio of acute coronary syndrome in ICU or CCU has decreased relatively [3]. Therefore, there is a recognition that ICU management is not necessary for AMI without complications [4], and cardiologists’ care at all times has decreased [5,6]. In addition to cardiogenic shock due to AMI, there is an increase in other cardiovascular diseases including intractable heart failure accompanying multiple comorbidities.

  • The high cost of critical care unit over-utilization for patients with NSTE ACS

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    Second, in NSTE ACS care, reporting of adherence to clinical practice guidelines has been traditionally centered on adherence to pharmacotherapy and test selection. We propose that selection of the appropriate care environment would be justified based on a growing body of observational evidence reporting no mortality benefit associated with routine admission of NSTE ACSs to CCUs.3, 6, 7, 9, 22 Finally, reducing the number of low acuity admissions may help defray existing capacity strain on the limited number of CCU beds in individual institutions.10, 23

  • A user-friendly risk-score for predicting in-hospital cardiac arrest among patients admitted with suspected non ST-elevation acute coronary syndrome – The SAFER-score

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    The CCU was introduced in the early 1960s, enabling patients with ACS to have continuous ECG monitoring where life-threating arrhythmias could be swiftly detected and treated by trained personnel [13]. With the development and improvement of care and outcomes for patients with ACS, questions have been raised about the need and cost effectiveness for low-risk patients to be admitted to the CCU [14]. Current guidelines recommend that patients with non-ST elevation myocardial infarction and low risk for arrhythmias could be initially monitored in a CCU or an intermediate care unit likewise [5].

  • Evidence-Based Redesign of the Cardiac Intensive Care Unit <sup>∗</sup>

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