Acute Cardiac Care – an Interdisciplinary Approach

Acute cardiac care is no longer limited to simply providing life-saving therapy to patients with acute myocardial infarction (AMI). The modern concept of an acute cardiac care unit (ACCU) integrates advanced monitoring systems for cardiovascular emergencies, most frequent in the immediate post-PCI period for patients with myocardial infarction, with cutting edge facilities for treating multi-organ failure resulting from systemic complications of acute cardiovascular conditions. Data from the BLITZ-3 registry, published by Casella et al. in 2017, encountering the pathologies admitted in the intensive cardiac care units, showed that acute coronary syndromes represent indeed the core business of ACCUs, with 52% of the cases admitted in acute cardiac facilities being represented by AMI (21% STEMI and 31% NSTEMI), while a significant proportion of 34% of patients were admitted for other cardiovascular emergencies such as acute heart failure, arrhythmia, aortic dissection, cardiac tamponade, pulmonary embolism etc.1 However, a study published by Sinha et al. in 2017 revealed that an important proportion of patients admitted in ACCUs presented significant non-cardiac comorbidities such as neurologic, hematologic/oncologic, musculoskeletal, infections, gastrointestinal or respiratory diseases.2 Another study by Holland et al., on the impact of non-cardiovascular illnesses on ACCU mortality, showed that in a model of 100 patients admitted in the ACCU, from 50 patients without acute kidney injury, acute respiratory failure, or sepsis only 1 will die, while from 50 patients with acute kidney injury, acute respiratory failure, or sepsis 11 will die, revealing the impact of coexisting morbidity on cardiovascular mortality in acute settings.3 These observations led to a paradigm shift in the concept of ACCUs, which was directly reflected in the guidelines. While the 2005 recommendations of the European Society of Cardiology considered ACCUs as facilities caring for patients in the immediate period of thrombolysis and AMI complications, the position paper published by the European Association of Acute Cardiovascular Care in 2017 defined 3 levels of complexity of ACCUs, level 3 being designed for the most complex cases, usually with associated comorbidities or in critical conditions.4,5 At the same time, there is an important interaction between cardiovascular conditions and other comorbidities which require special cardiac attention. This underlines the strong interdisciplinary approach required for providing highly specialized care for complex cardiovascular patients. For instance, preexisting chronic kidney disease, HIV infection, lung diseases, diabetes, inflammatory diseases, or oncological illnesses may lead to a more severe evolution of acute coronary syndromes, as inflammatory reactions play a pivotal role in the pathophysiology of ACS, and systemic inflammation may be exacerbated by these coexisting conditions.6–11 The history of stem cell transplantation in patients with AMI is another evidence that integrating multiple disciplines (in this case cardiology, hematology, and translational research) in a common effort may lead to better results for cardiac care.12–14 Another example of the strong multidisciplinary dimension of acute cardiac care is the requirement to provide specialized cardiac care to patients undergoing major surgery. For instance, patients undergoing radical surgical interventions for extensive cancers (pelvic exenteration, colorectal resections or lung resection etc.) are at a high anesthetic risk, which requires a careful preoperaAcute Cardiac Care – an Interdisciplinary Approach