CORONARY CARE UNIT (CCU) Rasim ENAR, M.D. Professor of Cardiology İstabul University Cerrahpaşa Medical Faculty Department of Cardiology
“Intensive Care Units” Development of the Concept • *Post-World War II era; Intensive Care Unıts (General, Surgical, New-born, etc..) (“ICU”..). • *1961; (‘Desmond Julian’); Cardiac Care Unıt and CCU was first mentioned
ICU - Definition: • “ Monitorization of vital parameters ( blood presure, respiration, pulse rate, temperature, hydration, electrolyte, blood gas, etc) and systemic organ functions (heart, brain, lungs, kidneys, liver) in a multi-disiplinary approach, AND maintaining those parameters in normal (physiological – healthy) limits”.
“Ideal CCU Environment” • Well-trained staff (Physician, nurse, technician) • Advanced ECG and hemodyanamic monitorization equipment (bed-side and central and print-out) • Hemodynamic support devices (IABP, temporary pace-maker) • Mechanical ventilation devices • Bed-side laboratory examination (Biomarkers, CBC, BUN, Crea, Electrolyte, etc) • Portable Imaging (X-Ray and Echocardiograpy) • Effective CPR organization
CCU Admitance Indications • Acute coronary syndromes and complications • Monitorization of serious arrhythmias • Acute cardiac emergiencies ( acute pulmonary edema,severe hypotensıon, shock, hypertensive crisis). • Cardiogenic shock. • High risk PCI. • Post-cardiac surgery; hemodynamic instability and recurrent ischemia and malign arrhythmia. • Post-CPR monitorization.
CCU and Acute Coronary Syndomes: • CCU : ”LIFE SAVING UNITS -GOLD STANDART” for the management of STE- AMI, and High-Intermediate risk NSTE-ACS, and their complications (“Mainstay of therapy”). • STE- AMI: (a)Assessment of thrombolysis and reperfusion. (b) Treatment of Sudden Cardiac Death and arrhythmic death (Defibrillation, PM). (c) Early and rescue PCI. (d) Early diagnosis and management of mechanical complications.
NSTEMI / USAP; FATAL/NONFATAL-MI RISC ►►High Risc : ■ (↑) cTnT/I, ST dep (new ?). ■ Refracter ischemia despite maksimal anti-ischemic medical therapy. ■Heart failure. ■ (+) Noninvasive, stress- test : ▼LV fuction (EF<%40). Incessant , recurrent VT. ■ Previous PCI (in last 6 months) or CABG. ►►Intermediate Risc: ■Chest pain > 10 min but relieved at enterance of ED. ■ Negative T-waves >2 mm. ■ mild cTnT ↑ (>0.01,<0.1 ng/ml).
* CCU- NSTE ACS:Mortality and non-fatal MI risc in 35 days was significantly reduced in high and moderate risc patientsi ►► Other Spesific clinical indications for CCU: (a) Persistant and recurrent ischemia with hemodynamic instability (Cardiogenic shock, left heart failure, hypotension). (b) Refractory angina. (c) Malign arrhythmia with hemodynamic instability (d) Reccurrent angina. (e) Early and urgent coronary angiography and and coronary revascularization if it is indicated.
CCU: Hemodynamic Monitorization and Supportive Therapies • 1. (a) Pulmonary artery catheterizatıon (Swan-Ganz baloon catheter) (meadurement of PCWP, right heart pressures,and estimate CO, CI). (b) Intra-arterial catheter (for continious arteriei pressure measurement). (c) Pulse- oximetry. • 2. IABP (Intra-aortik Baloon Pump) • 3. Hemofiltration (UF). • 4. Temporary Pace- maker. • 5. Mechanical ventilatıon.
İndicatıon of Hemodyanamic Evaluation in AMI: • Pulmonary artery catheter (Swan-Ganz) monitoring. 1- Progressive hypotension (++). 2- Suspected mechanical complications (if an echocardiography has not been provided) (+). 3- Progessive hypotension; unresponsive to fluid administration or when fluid administration is contraindicated (±). 4- Cardiogenic shock (±). 5- Severe or progressive CHF or pulmonary edema that does not respond rapidly to therapy (±). 6- Persistent signs of hypoperfusion without hypotension or pulmonary congestion (±).
Swan-Ganz Catheter; Baloon- tipped Pulmonary artery catheterizatıon
Swan-Ganz Catheter; Right heart pressures: Right- atrium, Right- ventricule, Pulmonary artery and Pulmonary capillary wedge pressure (ocluded PA pressure):
İndicatıons of Intra-arterial pressure monitorization in AMI *Most life treatening complications in the acute phase of AMI is hypotension; “it is the most important andindependent predictor of mortality” • 1- Severe systolic hypotension (<80 mmHg) (++) • 2- Cardiogenic shock (++). • 3- Patients receiving vasopressor / inotropic agents (+/±). • 4- Patients receiving intravenous potent Nitroodilator agents (±).
IABP Indications in AMI 1- Persistent hypotension (sistolik blood pressure <90 mmHg or >30 mmHg drop in baseline blood pressure) despite standart pharmacologic therapy) (++) 2- Low-output patients (+) 3- In patients when cardiogenic shock is not quickly reversed with pharmacologic therapy (++) 4- In patients with hemodynamic instability prior to early PCI / revascularization (+). 5- Mechanical complications ( MR,VSR) as a bridge to cardiac surgery (++). 6- Reccurrent ischemic complaints (large MI, unstable hemodynamic state, LV disfunction) (±).
AMI - Mechanical Ventilation • Major Indications: • Acute hypoksemic respiratory failure despite continous supplemental oxygen therapy ( 4-6 Lt/min O2 therapy with nasal prolongs for 2-3 hours). • * PaO2 <60 mmHg, PaCO2 >60 mmHg. • O2 satüration<%90. • Clinical States : • (a) Cardiogenic pulmonary edema, Cardiogenic shock • (b) Cardiopulmonary arrest (pulseless arrhythmia and rhythm disturbances ;VT,VF,EM dissociation) • (c) Cerebrovascular accident (cerebral emboli / hemorrage, and coma)
CCU treatment goals in Acute STEMI Patients 1-Aspirin should be chewed by patients on presentation. 2- Beta-blocker therapy should be given on presentation (IV is preferred) and continuing at discharge for indefinitly. 3- Discharge medication will include Aspirin,ACEİ,BBl,Statin. 4- ACE-I or ARB to pts with low LVEF (<%40). 5- Convincing patient to quit cigarette smoking. 6-IV Fibrinolysis; Door-needle time: mean 30 minutes (preferably ≤30 min) 7-Primary PCI; Door- Balloon time: 60- 120 minutes (preferably ≤90 min) 8- Thrombolysis or primary PCI in ≥%75 of patients with acute reperfusion indication 9- İn Hospital mortality sholud be less than %7-10 in hospitilized patients.