CORONARY CARE CORONARY CARE UNIT (CCU)UNIT (CCU)

Rasim ENAR, M.D.Rasim ENAR, M.D.Professor of CardiologyProfessor of Cardiology

İstabul Universityİstabul UniversityCerrahpaşa Medical FacultyCerrahpaşa Medical FacultyDepartment of CardiologyDepartment of Cardiology

““Intensive Care Units” Intensive Care Units” Development of the ConceptDevelopment of the Concept

*Post-World War II era; *Post-World War II era; Intensive Care Unıts (General, Surgical, New-born, Intensive Care Unıts (General, Surgical, New-born,

etc..) (“ICU”..).etc..) (“ICU”..).

*1961; (‘Desmond Julian’*1961; (‘Desmond Julian’); Cardiac Care Unıt and CCU ); Cardiac Care Unıt and CCU was first mentionedwas first mentioned

“…“…INTENSIVE CARE….INTENSIVE CARE….!!!?!!!?””

ICU - Definition:ICU - Definition:

“ “ Monitorization of vital parameters ( blood presure, Monitorization of vital parameters ( blood presure, respiration, pulse rate, temperature, hydration, respiration, pulse rate, temperature, hydration, electrolyte, blood gas, etc) and systemic organ electrolyte, blood gas, etc) and systemic organ functions (heart, brain, lungs, kidneys, liver) in a functions (heart, brain, lungs, kidneys, liver) in a multi-disiplinary approach, multi-disiplinary approach, ANDAND maintaining those maintaining those parameters in normal (physiological – healthy) parameters in normal (physiological – healthy) limits”.limits”.

““Ideal CCU Environment”Ideal CCU Environment”

Well-trained staff (Physician, nurse, technician)Well-trained staff (Physician, nurse, technician)

Advanced ECG and hemodyanamic monitorization Advanced ECG and hemodyanamic monitorization equipment (bed-side and central and print-out)equipment (bed-side and central and print-out)

Hemodynamic support devices (IABP, temporary Hemodynamic support devices (IABP, temporary pace-maker)pace-maker)

Mechanical ventilation devicesMechanical ventilation devices Bed-side laboratory examination (Biomarkers, CBC, Bed-side laboratory examination (Biomarkers, CBC,

BUN, Crea, Electrolyte, etc) BUN, Crea, Electrolyte, etc) Portable Imaging (X-Ray and Echocardiograpy)Portable Imaging (X-Ray and Echocardiograpy)

Effective CPR organizationEffective CPR organization

CCU Admitance IndicationsCCU Admitance Indications Acute coronary syndromes and complicationsAcute coronary syndromes and complications Monitorization of serious arrhythmiasMonitorization of serious arrhythmias Acute cardiac emergiencies ( acute pulmonary Acute cardiac emergiencies ( acute pulmonary

edema,severe hypotensıon, shock, hypertensive edema,severe hypotensıon, shock, hypertensive crisis).crisis).

Cardiogenic shock.Cardiogenic shock. High risk PCI.High risk PCI. Post-cardiac surgery; hemodynamic instability and Post-cardiac surgery; hemodynamic instability and

recurrent ischemia and malign arrhythmia.recurrent ischemia and malign arrhythmia. Post-CPR monitorization.Post-CPR monitorization.

CCU and Acute Coronary Syndomes:CCU and Acute Coronary Syndomes:

CCU : ”LIFE SAVING UNITS -GOLD STANDART” CCU : ”LIFE SAVING UNITS -GOLD STANDART” for for the management of STE- AMI, and High-Intermediate the management of STE- AMI, and High-Intermediate risk NSTE-ACS, and their complications (“Mainstay risk NSTE-ACS, and their complications (“Mainstay of therapy”). of therapy”).

STE- AMI: STE- AMI: (a)(a) Assessment of thrombolysis and reperfusion. (b)(b) Treatment of Sudden Cardiac Death and arrhythmic Treatment of Sudden Cardiac Death and arrhythmic

death (Defibrillation, PM).death (Defibrillation, PM). (c)(c) Early and rescue PCI. Early and rescue PCI. (d)(d) Early diagnosis and management of mechanical Early diagnosis and management of mechanical

complications.complications.

NSTEMI / USAP;NSTEMI / USAP; FATAL/NONFATAL-MI RISC FATAL/NONFATAL-MI RISC

►►►►High Risc :High Risc : ■ ■ (↑) cTnT/I, ST dep (new ?).(↑) cTnT/I, ST dep (new ?).

■■ Refracter ischemia despite maksimal anti-ischemic Refracter ischemia despite maksimal anti-ischemic medical therapy.medical therapy.■■ Heart failure.Heart failure.

■■ (+) (+) Noninvasive, stress- test : Noninvasive, stress- test : ▼▼LV fuction (EF<%40).LV fuction (EF<%40).-Incessant , recurrent VT. Incessant , recurrent VT.

■ ■ PreviousPrevious PCI (in last 6 months) or CABG. PCI (in last 6 months) or CABG. ►►►►IIntermediate Risc:ntermediate Risc:

■■ Chest pain Chest pain > 10 min but relieved at enterance of ED.> 10 min but relieved at enterance of ED.■■ Negative Negative T-waves >2 mm. T-waves >2 mm.

■■ mild cTnTmild cTnT ↑ (>0.01,<0.1 ng/ml). ↑ (>0.01,<0.1 ng/ml).

* * CCU- NSTE ACS:CCU- NSTE ACS: Mortality and non-fatal MI risc in Mortality and non-fatal MI risc in 35 days was significantly reduced in high and 35 days was significantly reduced in high and moderate risc patientsimoderate risc patientsi

►► ►► Other Spesific clinical indications for CCU:Other Spesific clinical indications for CCU:(a)(a) Persistant and recurrent ischemia with Persistant and recurrent ischemia with

hemodynamic instability (Cardiogenic shock, left hemodynamic instability (Cardiogenic shock, left heart failure, hypotension).heart failure, hypotension).

(b)(b) Refractory angina. Refractory angina.(c)(c) Malign arrhythmia with hemodynamic instability Malign arrhythmia with hemodynamic instability (d)(d) Reccurrent angina. Reccurrent angina.(e)(e) Early and urgent coronary angiography and and Early and urgent coronary angiography and and

coronary revascularization if it is indicated.coronary revascularization if it is indicated.

CCU:CCU: Hemodynamic Monitorization and Hemodynamic Monitorization and Supportive TherapiesSupportive Therapies

1. (a)1. (a) Pulmonary artery catheterizatıon (Swan- Pulmonary artery catheterizatıon (Swan-Ganz baloon catheter) (meadurement of PCWP, Ganz baloon catheter) (meadurement of PCWP, right heart pressures,and estimate CO, CI). right heart pressures,and estimate CO, CI).

(b)(b) Intra-arterial catheter (for continious arteriei Intra-arterial catheter (for continious arteriei pressure measurement).pressure measurement).

(c)(c) Pulse- oximetry. Pulse- oximetry. 2.2. IABP (Intra-aortik Baloon Pump) IABP (Intra-aortik Baloon Pump) 3.3. Hemofiltration (UF). Hemofiltration (UF). 4.4. Temporary Pace- maker. Temporary Pace- maker. 5.5. Mechanical ventilatıon. Mechanical ventilatıon.

İndicatıon of Hemodyanamic Evaluation in AMI: İndicatıon of Hemodyanamic Evaluation in AMI:

• Pulmonary artery catheter (Swan-Ganz) monitoring.Pulmonary artery catheter (Swan-Ganz) monitoring.1-1- Progressive hypotension ( Progressive hypotension (++++).).2- 2- Suspected mechanical complications (if an Suspected mechanical complications (if an

echocardiography has not been provided) (echocardiography has not been provided) (++).).3- 3- Progessive hypotension; unresponsive to fluid Progessive hypotension; unresponsive to fluid

administration or when fluid administration is administration or when fluid administration is contraindicated (contraindicated (±±).).

4-4- Cardiogenic shock Cardiogenic shock ((±±).).5- 5- Severe or progressive CHF or pulmonary edema that Severe or progressive CHF or pulmonary edema that

does not respond rapidly to therapy (does not respond rapidly to therapy (±±).).6- 6- Persistent signs of hypoperfusion without hypotension or Persistent signs of hypoperfusion without hypotension or

pulmonary congestion (pulmonary congestion (±±).).

INTENSIVE CAREINTENSIVE CARE

Swan-Ganz Catheter;Swan-Ganz Catheter; Baloon- tipped Baloon- tipped Pulmonary artery catheterizatıonPulmonary artery catheterizatıon

Localization of Swan- Ganz Catheter Localization of Swan- Ganz Catheter (Chest radiograph)(Chest radiograph)

Swan-Ganz Catheter; Right heart pressures: Swan-Ganz Catheter; Right heart pressures: Right- atrium, Right- atrium, Right- ventricule, Pulmonary artery and Pulmonary Right- ventricule, Pulmonary artery and Pulmonary capillary wedge pressure (ocluded PA pressure):capillary wedge pressure (ocluded PA pressure):

İndicatıons of Intra-arterial pressure İndicatıons of Intra-arterial pressure monitorization in AMImonitorization in AMI

** Most life treatening complications in the acute phase Most life treatening complications in the acute phase of AMI is of AMI is hypotensionhypotension; “it is the most important ; “it is the most important andindependent predictor of mortality”andindependent predictor of mortality”

1- 1- Severe systolic hypotension (<80 mmHg) (Severe systolic hypotension (<80 mmHg) (++++)) 2- 2- Cardiogenic shock (Cardiogenic shock (++++).). 3- 3- Patients receiving vasopressor / inotropic agents Patients receiving vasopressor / inotropic agents

(+/(+/±±).). 4-4- Patients receiving intravenous potent Patients receiving intravenous potent

Nitroodilator agents (Nitroodilator agents (±±).).

IABP Indications in AMIIABP Indications in AMI

1-1- Persistent hypotension (sistolik blood pressure <90 Persistent hypotension (sistolik blood pressure <90 mmHg or >30 mmHg drop in baseline blood pressure) mmHg or >30 mmHg drop in baseline blood pressure) despite standart pharmacologic therapy) (despite standart pharmacologic therapy) (++++))

2- 2- Low-output patients (Low-output patients (++))3- 3- In patients when cardiogenic shock is not quickly In patients when cardiogenic shock is not quickly

reversed with pharmacologic therapy (reversed with pharmacologic therapy (++++))4-4- In patients with hemodynamic instability prior to early In patients with hemodynamic instability prior to early

PCI / revascularization (PCI / revascularization (++).).5-5- Mechanical complications ( MR,VSR) as a bridge to Mechanical complications ( MR,VSR) as a bridge to

cardiac surgery (cardiac surgery (++++).).6- 6- Reccurrent ischemic complaints (large MI, unstable Reccurrent ischemic complaints (large MI, unstable

hemodynamic state, LV disfunction) (hemodynamic state, LV disfunction) (±±). ).

IABP LOCALISATIONIABP LOCALISATION

AMI - Mechanical VentilationAMI - Mechanical Ventilation

• Major Indications:Major Indications:• Acute hypoksemic respiratory failure despite Acute hypoksemic respiratory failure despite

continous supplemental oxygen therapy ( 4-6 Lt/min continous supplemental oxygen therapy ( 4-6 Lt/min O2 therapy with nasal prolongs for 2-3 hours). O2 therapy with nasal prolongs for 2-3 hours).

• * PaO2 <60 mmHg, PaCO2 >60 mmHg.* PaO2 <60 mmHg, PaCO2 >60 mmHg.• O2 satüration<%90.O2 satüration<%90.

• Clinical States :Clinical States :• (a)(a) Cardiogenic pulmonary edema, Cardiogenic shock Cardiogenic pulmonary edema, Cardiogenic shock• (b)(b) Cardiopulmonary arrest (pulseless arrhythmia and Cardiopulmonary arrest (pulseless arrhythmia and

rhythm disturbances ;VT,VF,EM dissociation)rhythm disturbances ;VT,VF,EM dissociation)• (c)(c) Cerebrovascular accident (cerebral emboli / Cerebrovascular accident (cerebral emboli /

hemorrage, and coma)hemorrage, and coma)

INTENSIVE CARE; Patient monitorization and INTENSIVE CARE; Patient monitorization and treatment..!!treatment..!!

CCU treatment goals in CCU treatment goals in Acute STEMI PatientsAcute STEMI Patients

1-1- AspirinAspirin should be chewed by patients on presentation. should be chewed by patients on presentation.2- Beta-blocker2- Beta-blocker therapy should be given on presentation (IV is therapy should be given on presentation (IV is

preferred) and continuing at discharge for indefinitly.preferred) and continuing at discharge for indefinitly.3- 3- Discharge medication will include Aspirin,ACEİ,BBl,Statin.Discharge medication will include Aspirin,ACEİ,BBl,Statin.4- ACE-I or ARB4- ACE-I or ARB to pts with low LVEF (<%40). to pts with low LVEF (<%40).5-5- Convincing patient to Convincing patient to quit cigarette smoking.quit cigarette smoking. 6-6- IV Fibrinolysis;IV Fibrinolysis; Door-needle time: mean 30 minutes (preferably ≤30 Door-needle time: mean 30 minutes (preferably ≤30

min)min)7-7- Primary PCI;Primary PCI; Door- Balloon time: 60- 120 minutes (preferably ≤90 Door- Balloon time: 60- 120 minutes (preferably ≤90

min)min)8-8- Thrombolysis or primary PCI in ≥%75 of patients with acute Thrombolysis or primary PCI in ≥%75 of patients with acute

reperfusion indicationreperfusion indication9- 9- İn İn Hospital mortalityHospital mortality sholud be less than %7-10 in hospitilized sholud be less than %7-10 in hospitilized

patients. patients.