The Difficult Evolution of Intensive Cardiac Care Units: An Overview of the BLITZ-3 Registry and Other Italian Surveys

Abstract

Coronary care units, initially developed to treat acute myocardial infarction, have moved to the care of a broader population of acute cardiac patients and are currently defined as Intensive Cardiac Care Units (ICCUs). However, very limited data are available on such evolution. Since 2008, in Italy, several surveys have been designed to assess ICCUs' activities. The largest and most comprehensive of these, the BLITZ-3 Registry, observed that patients admitted are mainly elderly males and suffer from several comorbidities. Direct admission to ICCUs through the Emergency Medical System was rather rare. Acute coronary syndromes (ACS) account for more than half of the discharge diagnoses. However, numbers of acute heart failure (AHF) admissions are substantial. Interestingly, age, resources availability, and networking have a strong influence on ICCUs' epidemiology and activities. In fact, while patients with ACS concentrate in ICCUs with interventional capabilities, older patients with AHF or non-ACS, non-AHF cardiac diseases prevail in peripheral ICCUs. In conclusion, although ACS is still the core business of ICCUs, aging, comorbidities, increasing numbers of non-ACS, technological improvements, and resources availability have had substantial effects on epidemiology and activities of ICCUs. The Italian surveys confirm these changes and call for a substantial update of ICCUs' organization and competences.

Figure 1

Discharge diagnosis of patients enrolled in the Italian BLITZ-3 Registry. (a) General population. Modified from Casella et al. for the BLITZ-3 investigators [9]. (b) Effects of aging. Modified from Casella et al. for the BLITZ-3 investigators [12]. CAD: coronary artery disease; PCI: percutaneous coronary intervention; VT: ventricular tachycardia; VF: ventricular fibrillation; AF: atrial fibrillation; SVT: supraventricular tachycardia; STE ACS: ST-elevation acute coronary syndrome; NSTE: ACS non-ST-elevation acute coronary syndrome; PE: pulmonary embolism; Post-EF procedure: postelectrophysiological procedure complications.

Figure 2

Classes of risk of mortality during admission to the ICCU. Modified from Oltrona Visconti et al. [13]. Legend as Figure 1.

Figure 3

Effects of ICCUs' facilities on epidemiology of admissions. Modified from the BLITZ-3 study, Oltrona Visconti et al. [13]. Legend. AHF: acute heart failure; ICCU-PCI: Intensive Cardiac Care Units with percutaneous coronary intervention facilities; ICCU-PCI/Surg: Intensive Cardiac Care Units with percutaneous or surgical interventional facilities. Others as Figure 1.

Figure 4

Effects of ICCUs' facilities on diseases management and resource utilization. Modified from the BLITZ-3 study, Oltrona Visconti et al. [13]. Legend as Figures 1 and 3.

Figure 5

Effects of STEMI network implementation in Emilia-Romagna on ICCUs' activities. The reduction of direct admission to Spoke (Level 1) ICCU is not compensated by the transfer back from the Hub (Level 2 or 3) ICCU of patients initially triaged by EMS directly to the interventional center for reperfusion. Modified from Pavesi et al. [10]. Legend. STEMI: ST-elevation myocardial infarction.