AHA Scientific Statement

Evolution of Critical Care Cardiology: Transformation of

the Cardiovascular Intensive Care Unit and the Emerging
Need for New Medical Staffing and Training Models
A Scientific Statement From the American Heart Association
David A. Morrow, MD, MPH, FAHA, Chair; James C. Fang, MD, FAHA; Dan J. Fintel, MD;
Christopher B. Granger, MD, FAHA; Jason N. Katz, MD, MHS; Frederick G. Kushner, MD, FAHA;
Jeffrey T. Kuvin, MD; Jose Lopez-Sendon, MD; Dorothea McAreavey, MD;
Brahmajee Nallamothu, MD, MPH, FAHA; Robert Lee Page II, PharmD, MSPH, FAHA;
Joseph E. Parrillo, MD; Pamela N. Peterson, MD, MSPH, FAHA; Chris Winkelman, RN, PhD; on behalf of
the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation,
Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Council on Quality of Care and
Outcomes Research

C ritical care, defined as the diagnosis and management of

life-threatening conditions that require close or constant
attention by a group of specially trained health professionals,
is inherent to the practice of cardiovascular medicine. The
demand for cardiovascular critical care is increasing with the
aging of the population and is reflected by trends in the use of
critical care in general.1 Between 2000 and 2005, although
the total number of hospital beds in the United States declined
by 4.2%, the number of critical care beds increased by 6.5%
and the annual costs attributed to critical care increased by
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indicated that outcomes are better when critical care is
provided by specially trained providers in a dedicated inten-
sive care unit (ICU).6 –9 In the context of this evolution,
provision of optimal care in the contemporary cardiac ICU
(CICU) presents a different set of challenges and requires an
expanded set of skills compared with 10 years ago. Cardio-
vascular medicine has lagged behind other medical disci-
plines that have met the “critical care crisis”4 with ICU-
focused innovations in organization, training, and quality

improvement. Therefore, the American Heart Association

44%, representing 13.4% of hospital costs.2 Projections for
the next 15 years suggest that the need for critical care will
increase markedly in the United States and globally.1,3–5 For
example, in Canada, a 57% increase in the need for critical
care beds is anticipated during that period.5
Concurrent with increases in demand, the medical demo-
graphics of general and cardiac critical care have evolved
toward a patient population with an increasing number of
comorbid medical conditions who require more prolonged
and more technologically sophisticated invasive support. As a
result, the delivery of critical care is advancing substantially
in its complexity. Moreover, accumulating evidence has
Council on Cardiopulmonary, Critical Care, Perioperative and
Resuscitation, the Council on Clinical Cardiology, the Council
on Cardiovascular Nursing, and the Council on Quality of Care
and Outcomes Research have sponsored this writing group to
formulate a roadmap to meet the changing needs of the popu-
lation with cardiovascular disease requiring critical care.
Evolution of the CICU
Early History of Critical Care Cardiology
In the early 1960s, after the successful implementation of
open- and then closed-chest defibrillation10 –12 and the intro-

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside
relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required
to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on June 5, 2012. A copy of the
document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase
additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.
The American Heart Association requests that this document be cited as follows: Morrow DA, Fang JC, Fintel DJ, Granger CB, Katz JN, Kushner FG, Kuvin
JT, Lopez-Sendon J, McAreavey D, Nallamothu B, Page RL 2nd, Parrillo JE, Peterson PN, Winkelman C; on behalf of the American Heart Association Council
on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Council on Quality
of Care and Outcomes Research. Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new
medical staffing and training models: a scientific statement from the American Heart Association. Circulation. 2012;126:1408 –1428.
Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines
development, visit http://my.americanheart.org/statements and select the “Policies and Development” link.
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express
permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/
Copyright-Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page.
(Circulation. 2012;126:1408-1428.)
© 2012 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e31826890b0

1408
 Morrow et al
duction of the first continuous electrocardiographic monitor-
ing, the first coronary care units (CCUs) were formed with
the premise that rapid identification and termination of
peri-infarction arrhythmias could dramatically alter the natu-
ral history of acute myocardial infarction (MI).13,14 The
earliest CCUs opened almost simultaneously in 1962 in the
United States and Europe, providing electrical cardioversion
and resuscitation care for patients with MI in a single unit
continuously staffed by specially trained personnel. When
Desmond Julian, at the time a senior medical registrar of the
Royal Infirmary of Edinburgh (Scotland), presented his novel
conception of the CCU to the British Thoracic Society in
1961,13 he enumerated 4 basic mandates that have withstood
the test of time: (1) Continuous electrocardiographic moni-
toring linked to alarms, (2) rapidly initiated cardiopulmonary
resuscitation and defibrillation, (3) personnel trained to man-
age specialized equipment within a single unit, and (4) skilled
nurses empowered to independently initiate resuscitation. As
is the case today, nurses “properly indoctrinated in electro-
cardiographic pattern recognition, and qualified to intervene
skillfully with a pre-rehearsed and well-disciplined repertoire
of activities in the event of cardiac arrest” were at the
forefront of delivery of care in the early CCU.15 These same
principles were described concurrently by Morris Wilburne in
an abstract describing a CCU with an “organized program
and step-by-step plan of resuscitation” submitted to the
American Heart Association annual meeting in 1961.16 In the
late 1960s, the next phase of development of the CCU was
ushered in by Bernard Lown and colleagues at the Peter Bent
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Brigham Hospital in Boston, MA, who described a shift from
resuscitation at the time of an arrest to monitoring for early
signs of clinical change and prevention of a cardiac arrest.15
A precedent for admitting a broader group of patients with
suspected acute MI to a dedicated CCU was established, and
a rapid proliferation of CCUs throughout industrialized coun-
tries ensued.
The advent of CCUs was temporally associated with and
often credited for a substantial decrease in the in-hospital
mortality rate after MI from 30%– 40% in the 1950s to
15%–20% in the 1970s.14,17–19 For example, Killip and
Kimball, in their landmark article on acute MI management,
described a nearly 20% decline in the post-MI mortality rate
after implementation of their CCU.17 By 1980, the major
cause of death related to MI had shifted from arrhythmias to
ventricular failure. New bedside monitoring techniques such
as pulmonary artery catheterization and echocardiography
allowed evaluation of cardiac performance peri-MI, which
led to the characterization of hemodynamic subsets with
prognostic and pathophysiological implications for patient
management.20 Albeit based on observational data, the avail-
able evidence substantiated the vision of Julian and others
that meaningful improvements in outcomes could be
achieved by management of patients within the specialized
environment of the CCU.21–23
Evolving Demographics and Emergence of the
Contemporary CICU
Despite this evidence of a favorable impact of CCUs over
their first 2 to 3 decades and the continued decline in case
The Evolution of Critical Care Cardiology 1409
fatality with MI, at least 1 descriptive study has shown
negligible subsequent improvements in the overall mortality
rate since the 1980s in a major academic CCU.24 The findings
from this24 and other studies identified a dramatically chang-
ing demographic profile of the patient population in the
contemporary CCU. The proportions of the elderly, women,
and minorities admitted to the CCU have all increased
steadily over the past several decades. Likewise, chronic
illnesses, including diabetes mellitus, hypertension, renal
dysfunction, and obstructive lung disease, now commonly
coexist with cardiovascular illness in today’s CCU, which
leads to greater case-mix and escalating illness severity.25
Moreover, competitive demand for ICU beds has resulted in
triage of lower-risk patients to non-ICU settings. On a
broader scale, the aging of the US population, acute and
chronic sequelae of nonfatal MI, and a rising frequency of
complications of invasive devices have amplified the fre-
quency and morbidity of multiorgan dysfunction during
critical illness.26 At the same time, emerging technologies and
improved therapeutics have altered the natural history of
critical illness in some groups of patients previously consid-
ered unsalvageable, thereby increasing the length of stay, risk
of iatrogenic complications, and resource consumption.
As a result of each of these trends, the medical and
procedural issues that determine outcome in the contempo-
rary CCU are often ones that require substantial expertise in
general critical care medicine.26 For example, CCUs now
appear strikingly similar to general medical and surgical
ICUs with respect to patient characteristics, resource utiliza-
tion, and mortality rates.27 Moreover, overall medical com-
plexity dominates the outcomes of patients in the modern
CCU.28 In an analysis of trends over 2 decades of academic
CCU care, Katz and colleagues24 observed a marked increase
in the prevalence of sepsis and acute renal failure complicat-
ing acute and chronic cardiovascular conditions in the CCU.
Not surprisingly, this pattern was also associated with an
increase in the use of bronchoscopy and renal replacement
therapy, along with an increase in the proportion of patients
requiring prolonged mechanical ventilation and a relative
decrease in the use of cardiovascular procedures (Figure
1).24,25,29 Each of these findings underscores the evolution
from the earliest CCUs, focused on the management of acute
MI, into the modern CICU, equipped to meet the complex
critical care needs of the patient with cardiovascular disease
(Figure 2).
Advanced Technologies and Special Populations in
the CICU
The development of new technologies has heavily influenced
the practice of critical care in cardiovascular medicine (Fig-
ure 2). As a result, physicians in the modern CICU must be
experienced in managing the use and complications of ad-
vanced medical technologies, including noninvasive and
invasive hemodynamic monitoring tools, complex modes of
mechanical ventilation, renal replacement therapies, imaging
guidance for bedside vascular procedures, methods for induc-
tion of therapeutic hypothermia, and mechanical circulatory
support. In addition, the growing populations of patients with
severe pulmonary hypertension and advanced structural heart
 1410 Circulation September 11, 2012

Relative Change in Odds of Diagnosis or Procedure

-10% -5% 0% 5% 10% 15% 20% 25% 30%

-7% STEMI
STEMI

NSTEMI 13% Figure 1. Temporal trends in discharge

diagnoses and critical care procedures
Sepsis 26% within the Duke University Coronary Care
Unit from 1989 to 2006. Data from Katz et
Liver Failure 23% al.24 STEMI indicates ST-segment– eleva-
tion myocardial infarction; NSTEMI, non–
ST-segment– elevation myocardial infarc-
tion; PCI, percutaneous coronary
PCI 0% intervention; and PA, pulmonary artery.

-4% PAIABP
line

Bronchosopy 11%
Mechanical Ventilation 6%

disease merit particular consideration in the formulation of a
blueprint to meet the expanding needs of the CICU
population.
Advanced Heart Failure and Mechanical
Circulatory Support
Although the rate of admissions to the CICU for ST-
segment– elevation MI has been decreasing over time, the
number of heart failure admissions has been escalating.24,30
Patients with acute heart failure syndromes and end-stage
heart failure can now be stabilized emergently with the use of
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coordinated multidisciplinary approach that involves heart
failure specialists and CICU staff. Percutaneous support
measures are being used with increasing frequency for the
management of acute cardiogenic shock and to support
high-risk percutaneous interventions and electrophysiology
procedures.31,32 Such patients are highly susceptible to pro-
gressive critical illness, often develop multiorgan dysfunc-
tion, and consume substantial clinical resources. Some large
centers have developed specialized “heart failure ICUs” to
care for this growing population. Optimal management of this

population of patients and the technology itself requires that

mechanical circulatory support devices and extracorporeal
the providing clinicians are experienced in the appropriate
life support. As such, management of severe heart failure by
selection of candidates for implantation, the correct use of
use of advanced pharmacological agents (eg, intravenous
such devices, and the early recognition or anticipation of
inotropes, vasopressors, and vasodilators) and technologies
complications related to such devices.
(intra-aortic balloon counterpulsation, percutaneous and sur-
gically implanted ventricular assist devices, extracorporeal Therapeutic Hypothermia in Cardiac Arrest
membrane oxygenation, and renal replacement therapies) has The care of patients with out-of-hospital cardiac arrest has
become a major focus of the CICU and requires a well- improved significantly since the inception of the early CICU.

Advances in technology

Advances in medical care

Advances in training &

organiza
on
Comprehensive
Changes in popula
on Cri
cal Care Figure 2. Evolution of the cardiac inten-
sive care unit. Advances in technology,
medical care, critical care unit organiza-
Preven
ve tion, and changes in the patient popula-
tion have contributed to evolution of the
Interven
on contemporary cardiac intensive care unit
• Mechanical circulatory support
• Therapeu
c hypothermia
from a coronary care unit focused on
• Advanced modes of ven
la
on rapid resuscitation to a unit providing
• Renal replacement therapy comprehensive critical care for patients
Rapid • Invasive & non-invasive monitoring with cardiovascular diseases. MI indicates
Resuscita
on myocardial infarction; STEMI, ST-seg-
• Rapid defibrilla
on • Therapy for advanced heart failure
• An
arrhythmia therapy • Interven
ons for pulmonary HTN
ment– elevation myocardial infarction;
• Expanded pharmacotherapy • Protocols for pa
ent safety ACS, acute coronary syndrome; HTN,
• Rapid defibrilla
on hypertension; and CV, cardiovascular.
• Post-MI care • Advanced nursing prac
ce
• Post-MI care • Suspected acute ischemia • Mul
disciplinary team-based care
• Performance improvement
• Nurses as 1st responders • Specialized nursing • Heavy use of informa
on technology

• Focus on STEMI pa
ent • All ACS and heart failure • Complex CV disease, severe comorbidity
 Morrow et al
Since landmark trials demonstrated the benefits of therapeutic
hypothermia,33,34 rapid implementation of cooling has been
recommended for all eligible patients who remain comatose
after successful restoration of spontaneous circulation after
ventricular fibrillation or pulseless ventricular tachycardia.
Whether cooled invasively or through external methods, the
use of induced hypothermia mandates a carefully orchestrated
plan with substantial resource requirements. Patients treated
with hypothermic techniques commonly require specialized
monitoring, prolonged mechanical ventilation, and extended
ICU care. From a critical care perspective, those with cardiac
arrest are frequently unstable, at risk for end-organ injury,
and particularly vulnerable to infectious complications, in-
cluding severe pneumonia. Prognostication regarding neuro-
logical recovery after therapeutic hypothermia has evolved
such that longer time may be required to determine a low
chance of recovery. Although often challenging, such prog-
nostication is central to medical decision making after re-
warming.35 Multidisciplinary clinical collaboration and expe-
rienced clinical management are important to improve
outcomes for such patients. As therapeutic hypothermia
becomes applied more broadly, the evolution of the CICU
must anticipate the growing needs of the heterogeneous group
of patients with restoration of spontaneous circulation after
cardiac arrest.36
End-of-Life Care in the CICU
As a consequence of greater disease severity and expanded
supportive technologies within the CICU, end-stage disease
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states have become commonplace. Coordination of end-of-
life care, including discussions with patients and families,
decision making about deactivation of devices such as inter-
nal defibrillators, ethics consultation, pain management, and
symptom relief, is now a central part of compassionate care in
the CICU.37 Family members consistently emphasize the
importance of effective communication in the intensive care
environment and most often rank communication above
clinical skills when assessing physician quality of care.38,39
Better communication reduces psychological trauma symp-
toms, depression, and anxiety; shortens ICU length of stay;
and improves the experience during terminal care.40,41 There-
fore, a focus on family communication during the delivery of
critical care is an essential element of best practice in the
CICU.41 The CICU staff must also be familiar with options
for palliative interventions and services to provide effective
transitions in care.
Important Trends in Critical Care: Lessons
Learned From General Medical and
Surgical ICUs
Significant technical, medical, and organizational advances
have changed the face of general critical care medicine. The
evidence underlying these advances has originated almost
entirely from applied research conducted in general medical
and surgical ICUs; however, this progress bears lessons vital
to the continued maturation of the contemporary CICU and
therefore will be discussed in detail in this section before
turning back to the CICU in “Roadmap for the Future in
Critical Care Cardiology.” In particular, 3 major evidence-
The Evolution of Critical Care Cardiology 1411
based trends in critical care medicine can be identified: (1) A
focus on interventions to optimize patient safety, driven by
the recognition that ICU-related complications are a major
determinant of outcomes; (2) a shift toward staffing models
and structures of ICU coverage that place emphasis on
involvement of dedicated intensivists, with advanced training
and/or experience in critical care; and (3) recognition of the
importance of integrated multidisciplinary care with coordi-
nated activities of physicians, nurses, respiratory therapists,
pharmacists, nutritionists, social workers, and consultants.
Notably, despite the increase in admissions of elderly
patients with complicated medical conditions to general
ICUs, there has not been an increase in ICU mortality rates,
which provides indirect evidence for steady improvement in
the quality of ICU care.1,42 Moreover, these improvements in
clinical performance, tied to patient safety and quality of care,
have been recognized as important not only by ICU personnel
and hospitals but also to accrediting and public agencies.43
The evidence supporting each of these trends will be re-
viewed within this section, with a particular focus on staffing
models that have been developed and investigated in the
general critical care environment.
Patient Safety and Preventive Practices
Infections and other complications of the multitude of inva-
sive methods for monitoring and treatment used routinely in
the ICU have attracted substantial attention as potentially
preventable causes of morbidity and mortality in patients
receiving critical care. Sepsis remains a significant cause of
death in the ICU44 and is related to an aging population,
indwelling devices such as vascular and urinary catheters,
prolonged intubation with mechanical ventilation, and more
prevalent immunosuppressive therapy.44 – 46 Prudent use of
invasive devices is essential to reduce sepsis and its attendant
morbidity and mortality.47– 49 When invasive devices are
necessary, experienced operators should use rigorous proto-
cols for sterile catheter placement and maintenance. Such
protocols can substantially reduce catheter- and central line–
related bloodstream infections (CLABSI or CLABI).50 Other
interventions that may reduce ICU-related complications
include restrictive blood transfusion strategies,51,52 measures
to prevent and contain Clostridium difficile infections, and
daily awakening of patients from sedating medications to
reduce the duration of both mechanical ventilation and length
of stay in the ICU.53
Additional improvements in patient safety have become
possible through technical advances in noninvasive ICU
methods. For example, noninvasive mechanical ventilation
has reduced intubation- and ventilator-associated pneumonia
(VAP) rates for selected patients with pulmonary edema or
hypercarbic respiratory failure.54 Critical care providers are
now trained in these and other important techniques, such as
ultrasound methods that are now widely used in ICUs to
assist in line placement and other percutaneous procedures
such as thoracentesis.55,56 Noninvasive methods for hemody-
namic assessment continue to be refined.57,58 Lastly, the role
of intelligent information systems in the ICU has grown,
providing new opportunities for decision support, safety
 1412 Circulation September 11, 2012

ICU Mortality Rate

Seng N OR L95 U95 p-value Rela
ve Risk (95% CI)
Med/Surg 439 0.48 0.32 0.72 <0.001 Figure 3. Meta-analysis of 13 studies of
Med/Surg 625 0.69 0.52 0.91 0.009 high-intensity vs low-intensity intensive
Surgical 667 0.60 0.49 0.73 <0.001 care unit (ICU) staffing with an outcome
Medical 2409 0.82 0.61 1.10 0.19 measure of ICU mortality. The setting indi-
Surgical 274 0.42 0.20 0.89 0.024 cates the type of ICU (medical or surgical
Medical 1389 0.71 0.54 0.94 0.015 [Med/Surg]). N denotes the sample size;
Surgical 177 0.54 0.26 1.11 0.094 OR, odds ratio for mortality with high-
Pediatric 262 0.53 0.17 1.65 0.27 intensity vs low-intensity staffing; L95,
Med/Surg 1656 0.61 0.41 0.91 0.017 lower 95% confidence interval; and U95,
Medical 2959 0.59 0.44 0.79 <0.001 upper 95% confidence interval. Data are
Surgical 426 0.15 0.05 0.47 0.001 from Pronovost et al9 with permission of
Pediatric 619 0.38 0.27 0.53 <0.001 the publisher; individual citations for each
Medical 349 1.44 1.00 2.07 0.049 study are provided in that reference.
Overall 12251 0.61 0.50 0.75 <0.001 Copyright © 2002, American Medical
Association. All rights reserved.
0.1 0.2 0.5 1 2
Favors High- Favors Low-
Intensity Intensity

flags, and tools for improved communication and quality
improvement.
Physician Staffing Patterns and Clinical Outcomes
Each of the interventions described in the preceding sections,
including procedural practices, noninvasive methods, and
safety and communication protocols, contribute to a complex-
ity of the ICU environment that requires experience and
expertise. Because of this complexity, organizational and
staffing models for the ICU have been a focus of research in
critical care medicine. The results of this research have
motivated an ongoing global shift in the predominant struc-
Downloaded from http://ahajournals.org by on December 14, 2020
potential influence of unidentified selection or publication
biases, as well as confounding factors, such as from temporal
changes in mortality, must be considered in these observa-
tional studies with principally historical controls. Neverthe-
less, better outcomes reported in closed ICUs may plausibly
be related to the presence of an intensivist directing care, to
improved overall consistency of care and collaboration be-
tween team members inherent to the closed-unit environment,
or to both elements contributing to more sophisticated patient
management. In one retrospective study of outcomes in open
and closed ICUs simultaneously managed by the same group
of faculty intensivists, mortality was lower in the closed

ture and clinical operations in ICUs to place value on
providing an experienced, multidisciplinary team, led by an
ICU-based physician skilled in critical care medicine (the
“dedicated intensivist”).
Open Versus Closed ICUs
In the United States, several organizational models for ICUs
exist: Open, semi-open (hybrid), and closed. In an open ICU,
patients are admitted or transferred and subsequently man-
aged by their individual physicians, without routine assess-
ment by an intensivist. The admitting attending physician,
however, may seek consultation from relevant subspecialists.
By comparison, in a closed ICU, an ICU-based physician
evaluates all admissions and assumes primary responsibility
for all aspects of patient care. In a semi-open ICU, in which
the structure lies somewhere between the open and closed
models, patients are admitted under the care of a primary
attending physician, with ICU-based intensivists available for
consultation and comanagement at the discretion of the
primary attending physician.
In multiple observational studies, compared with open
ICUs, closed medical and surgical ICUs have reported lower
morbidity and mortality without an increase in resource
utilization.59 – 62 In a rigorously performed meta-analysis of 27
observational studies of critically ill adults and children that
compared outcomes in open versus closed ICUs, closed
ICUs, which by design provide high-intensity staffing (as
discussed in “Intensivist Versus Nonintensivist Coverage”),
were associated with reduced hospital and ICU mortality and
with reduced use of resources and length of stay.9 The
system, without a significant increase in cost.63 This finding
suggests that the superior outcomes observed in closed ICUs
are related to aspects of closed ICU care that are not provided
solely by the availability of a consulting intensivist. Some
experts have suggested that team care should be adopted as
an alternative term to a closed ICU to emphasize the benefits
of integrated multidisciplinary care of critically ill patients.64
Intensivist Versus Nonintensivist Coverage
The results of more than 10 nonrandomized studies indi-
cate that ICUs managed by intensivists achieve superior
clinical outcomes, including reduced length of stay and
associated costs,65,66 length of mechanical ventilation,60
and mortality.6 –9,61,67,68 In the majority of these studies,
high-intensity ICU physician staffing has been defined as
mandatory intensivist consultation or a closed ICU and
compared with low-intensity staffing, defined as no intensiv-
ist or elective intensivist consultation. In a meta-analysis of
these studies, high-intensity ICU physician staffing was
associated with a 39% lower ICU mortality rate (relative risk,
0.61; 95% confidence interval, 0.50 – 0.75) and 29% lower
hospital mortality (relative risk, 0.71; 95% confidence inter-
val, 0.62– 0.82), as well as reduced ICU and hospital length of
stay (Figure 3).8
Limitations to this evidence should be recognized. The
majority of studies of ICU staffing models were conducted
⬎10 years ago, were relatively small in size, and had
nonrandomized designs. In addition, in one analysis of a large
administrative data base of ICU patients, hospital mortality
was actually higher for patients managed by intensivists.69
 Morrow et al
However, in that study, the majority of the ICUs included
were open units with elective intensivist consultation.70 For
these reasons, multicenter, well-controlled (such as cluster-
randomized) outcome studies would be valuable to rigorously
test the hypothesis that intensivist-based ICU care confers
both a survival benefit and economic savings.71 Other studies
would also be useful to tease out the multiple factors that
influence ICU outcomes and costs, including severity of
illness, divergent therapeutic approaches, increasing physi-
cian workload,72 and patient insurance status.73
Despite the limitations to these data, the overall consisten-
cy of the available evidence and the rational basis for
improved outcomes with enhanced experience, which is a
central tenet of medical and procedural training, are compel-
ling. Intensivists may improve outcomes through common
practices, provision of urgent therapy, familiarity with acute
conditions usually seen only in the critical care setting,
facilitation of multidisciplinary care, increased use of
evidence-based measures for prevention of complications,
and provision of an ICU leadership role.7,71,74,75 Intensivists
are more likely to implement newer care technologies76 and
routinely introduce basic improvements, such as a reduction
in use of central lines50 or use of simple and effective
checklists.77 Lengthy ICU stays have been associated with
lack of access to an intensivist.78 Taken together, there is a
strong rationale for systems that are built on a pivotal role for
dedicated intensivists.
Twenty-Four-Hour In-House Intensivist Coverage
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In the United States, intensivists have traditionally provided
ICU coverage during daytime business hours, with an esti-
mated availability of intensivist care during night hours of
⬇10% of ICUs.79 Many critically ill patients are admitted to
ICUs during off hours, and if proper and rapid therapy is
delivered, mortality may be similar to daytime admis-
sions.80 – 82 However, some studies suggest that patients ad-
mitted to the ICU during off hours have higher mortality even
after adjustment for severity of illness.83– 87 This evidence has
led to consideration of continuous (“24/7”) intensivist care.
At least 4 observational studies report that introduction of
24-hour in-hospital intensivist coverage of the ICU was
associated with lower mortality,88 –90 fewer complications,
and reduced hospital length of stay.91,92
Although nocturnal intensivist coverage has been associ-
ated with shorter hospital length of stay and lower overall
cost for the sickest patients, this may not necessarily be the
case for less severely ill patients.93 Some experts have argued
that 24/7 (24 hours per day, 7 days per week) intensivist
staffing itself does not reduce mortality or length of stay.71 A
number of factors could account for the differences in
mortality rates seen when times of ICU admission are
compared, such as differences in illness severity for patients
admitted at night and general system issues such as lower
levels of medical, nursing, and administrative staffing during
off hours.86,90
One study raised the hypothesis that the presence of
training programs in many academic centers may adversely
impact care94 and that 24/7 attending physician oversight may
prove advantageous. Another benefit is that the intensivist
The Evolution of Critical Care Cardiology 1413
can continue to educate residents during evening hours. Such
new educational opportunities may become especially valu-
able as resident duty hours are restricted or further reduced.95
However, 24-hour in-hospital intensivist coverage has been
reported to reduce job satisfaction and produce “burnout” in
a manner that is correlated with the increased number of night
shifts on duty.96 Introduction of continuous in-hospital inten-
sivist coverage therefore requires a balanced assessment of
each of these issues within an individual healthcare system.
Telemedicine
Because of the obvious impact on staffing and workforce
composition necessitated by 24-hour coverage schemes, a
majority of ICUs in smaller hospitals may be unable to
support such a model. Care by remote supervision from an
intensivist using information technology–supported or video-
assisted monitoring may help to resolve this issue and lower
costs.97 Telemedicine can increase intensivist availability
through information technology– based communication and
provide direct intensivist input when a physician is not
immediately available at the bedside. Such a system may use
intelligent algorithms to monitor physiological and laboratory
data, identify concerning trends or results, and reduce errors
that could result in adverse outcomes.98 –100
Evidence showing benefits from use of telemedicine in
ICUs has supported promise for the strategy, but findings
have not been uniformly positive. Observational studies
compared with historic controls have reported reductions in
length of stay and mortality in the ICU and hospital, fewer
complications, improvements in best practices and quality of
care, and a positive financial impact.98,100 –103 However, other
studies have described no significant change in mortality or
morbidity after implementation of an electronic ICU.104,105 In
one meta-analysis, there was lower mortality and length of
stay within the ICU after implementation of telemedicine but
no difference in hospital mortality or overall length of stay.106
These inconsistent findings could be explained by crossover
effects between comparator groups or differences in applica-
tion of the telemedicine model itself.105 Moreover, telemedi-
cine as a monitoring tool is likely to be effective only in the
context of other important interventions to improve quality
care. Issues of cost, reimbursement, and legal and ethical
factors arise with consideration of telemedicine. The scope
and extent of coverage, proper licensure of participating
physicians, development of accurate performance measures,
lack of direct physician contact, and related job satisfaction
are significant but not insurmountable hurdles to
implementation.107–109
Telemedicine may be considered an adjunct to the current
ICU system to alleviate the impact of a shortage of intensiv-
ists that is not likely to be resolved in the near future.
Telemedicine may be especially useful for remotely located
ICUs and could improve physician efficiency in the manage-
ment of very large or multiple ICUs.
Physician Workforce Issues
An estimated 25% of all US ICUs have an intensivist who
manages most (⬎80%) of the patients, and ⬇50% of all ICUs
have no intensivist at all.79 Because of this lack of staff
intensivists, a large number of US hospitals employ hospital-
 1414 Circulation September 11, 2012
ists to provide ICU care.79,110 Importantly, if universal ICU
coverage by intensivists were to become an objective, the
existing workforce would be insufficient to provide such
coverage.1,79,111,112
Efforts to increase the size of the intensivist workforce
have been supported by professional societies, for example,
with the recent proposal that emergency medicine residents
train in critical care113 and subsequent approval of the
pathway by the Accreditation Council for Graduate Medical
Education (ACGME). Moreover, a pathway for dual certifi-
cation of cardiologists in critical care medicine and cardio-
vascular medicine is already in place and is discussed in
detail below (“A Model for Training in Critical Care Cardi-
ology”). In addition, to manage the expanding demand for
intensivists in the face of a constrained workforce, there is
also a need to explore more basic organizational changes,
including regionalization of services, establishment of proto-
cols for care, greater nighttime use of other medical personnel
or physician extenders, better information technology sys-
tems, and consideration of telemedicine in some settings.114
This need may be heightened in some academic settings
because of concurrent restrictions to trainee work hours.115
Multidisciplinary Care
Attention to the organizational environment in the ICU is
essential to ensure the best practice of critical care medi-
cine.2,116 –118 Specialized critical care nurses are essential to
high-quality ICU care (as discussed in “Nursing, Advanced
Practice Providers, Pharmacy, and Other Staffing for CI-
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CUs”). In addition, as the medical complexity of the patient
population has increased, so too has the complexity of
pharmacotherapy, with increased potential for adverse drug
events and drug-drug interactions. The addition of pharma-
cists to the critical care team has been associated with lower
rates of adverse drug events and complications related to drug
therapy, lower mortality rates in the ICU, and shorter length
of hospital stay.119 –121 As the profession of pharmacy has
moved from a product-focused to a patient-focused one,
pharmacists have been successful in protocol development
and implementation, therapeutic drug monitoring, adverse
drug event surveillance and reporting, orchestration of clini-
cal trials, and provision of drug information within the ICU
setting.122 Nutritional management of critically ill cardiovas-
cular patients, particularly those with multiple coexisting
disorders, is challenging. Dieticians evaluate dietary intake,
formulate tailored nutritional delivery, and help patients to
attain or maintain optimal nutritional status. Physical thera-
pists identify and treat impairments in strength, range of
motion, and potential adverse functional outcomes from
prolonged critical illness.123–125 Prolonged immobility in the
ICU can lead to ICU-acquired weakness and other neuromus-
cular impairment.126 Promotion of early mobility and physi-
cal therapy in critically ill patients, including those with
ongoing mechanical ventilation, is feasible and safe127,128 and
has been associated with reductions in the incidence of
pulmonary complications, delirium, the number of ICU and
hospital days, and subsequent readmissions.127,129,130 Social
workers contribute to the care of the complex cardiovascular
patient through counseling and case management, ensuring
that patient and family goals are communicated and incorpo-
rated in transitions and discharge plans.131
Quality Improvement in the ICU
Quality Measures in the ICU
Given the high mortality rate, increased resource utilization,
and potential for iatrogenic complications, ICUs have been a
focus of quality assessment and improvement activities. In
particular, the multiple levels of interprofessional and
professional-patient communications in an ICU result in
greater potential for gaps in such exchanges. Successful
quality assessment requires the quantification of relevant
metrics. Donabedian’s model of quality improvement guides
quality assessment and includes evaluation of structure (how
care is organized), process (care delivered), and outcomes
(results achieved).132 Others have adapted this model to
include culture (collective attitudes and beliefs of caregivers),
which is particularly relevant in the ICU given the many
individuals involved in the care of each patient and the
necessary communication and collaboration.133
Quality assessment initiatives in the ICU have traditionally
focused on outcomes, particularly on mortality rates. A
number of prediction models or acuity adjustment scores are
available for ICU or hospital length of stay and mortality,
such as the Acute Physiology and Chronic Health Evaluation
(APACHE), Simplified Acute Physiology Score (SAPS),
Mortality Probability Model (MPM), and Sequential Organ
Failure Assessment (SOFA).134,135 With such models, an
acuity adjustment score can be applied to compare the actual
mortality in an ICU and the mortality predicted by the model
(eg, the standardized mortality rate), which provides a bench-
mark for comparison.136 However, how this and other critical
care predictive models perform in patients with primary
cardiovascular disorders is less explored. In addition, many
risk models developed among cardiovascular patients (such
as risk scores in patients with MI) do not include measures of
general medical illness and may underestimate risk in patients
with severe medical comorbid conditions.
The rate of CLABI has become an important outcome
measure of morbidity in the ICU. Such infections can be
measured in a systematic manner, and focused interventions
have been shown to prevent them. Examples of other process
measures that are now widely integrated into ICU practice
include appropriate sedation guidelines, prevention of VAP,
stress ulcer prophylaxis, and deep vein thrombosis prophy-
laxis. Structural measures (organization of care) include the
presence of intensivists, higher nurse-to-patient ratios, and
pharmacist presence during rounds.
Regulators, accreditors, and professional societies have
also adopted or developed quality measures and data collec-
tion tools. The Joint Commission developed a set of 4
measures (VAP prevention, ulcer prophylaxis, deep vein
thrombosis prophylaxis, and CLABI) and 2 test measures
(ICU length of stay, hospital mortality for ICU patients)
specific to the ICU. The measure set was unique in that it was
setting-specific rather than condition-specific and that the 2
test measures required clinical data collection instead of
relying completely on administrative data for risk adjustment.
These measures were rigorously tested and reviewed by a
 Morrow et al
technical advisory panel but were suspended in 2005 before
being implemented because of prioritization of surgical-
related care. The measures remain in the Joint Commission
Measure Reserve Library,137 and it is likely that these or
similar measures will be implemented in the future as
external benchmarks of quality in the ICU.
Benchmarking and Public Reporting of
Performance Data
Collection and reporting of ICU performance data have been
encouraged by local initiatives, professional cooperatives,
and accreditors but to date are not required in the United
States.138,139 Performance can be evaluated by comparing an
ICU against itself over time, against other comparable ICUs,
or to other benchmarks such as best practice.140 Feedback is
intended to then drive performance improvement. In addition,
there are many medical domains in which performance and
benchmarking are now publicly reported, allowing consumers
and stakeholders access to the information. Beginning in
early 2012, the Centers for Medicare and Medicaid Services
began publically reporting CLABI rates in ICUs throughout
the United States.141 This reporting initiative presents data
that are predominantly voluntarily reported to the Centers for
Disease Control and Prevention’s National Healthcare Safety
Network. In addition, mandatory reporting of VAP exists in
at least 3 states (Oklahoma, Washington, and Pennsylva-
nia).141 It is anticipated that ICU-based metrics such as VAP
and CLABI rates will ultimately be subject to more wide-
spread mandated public reporting. In some instances, perfor-
mance may be tied to payment. From a cardiovascular critical
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care perspective, acute MI and heart failure core measure sets
are already benchmarked and publically reported as hospital
quality measures.142–145 In addition, established continuous
quality improvement efforts such as the American Heart
Association’s Get With The Guidelines quality program in
heart failure, stroke, resuscitation, and coronary artery disease
have well-developed in-hospital modules. Although these
measures are condition- rather than setting-specific, a number
of these measures are relevant to the CICU setting.
External Expectations for ICU Staffing
On the basis of the strong association between ICU structure,
the presence of an intensivist, and patient outcomes, a number
of groups external to individual hospital systems or medical
professional societies have articulated goals for staffing of
ICUs. For example, Leapfrog, a business group that promotes
“big leaps” in healthcare safety, quality, and customer value
through voluntary hospital surveys, has proposed that ICUs
should be closed units with a board-certified intensivist
present during the day and an intensivist immediately avail-
able by pager in off hours.146 Furthermore, Leapfrog recom-
mends that all ICU admissions should be managed or coman-
aged by intensivists. Financial estimates have suggested that
such a model would reduce hospital costs significantly and
should be adopted by hospital administrators.147 Although
their methods are not universally accepted as ideal, Leapfrog
is one example of the growing number of organizations
recognizing and promoting healthcare quality, as well as
setting external expectations toward these ends. Another
professional group, the Committee on Manpower for the
The Evolution of Critical Care Cardiology 1415
Pulmonary and Critical Care Societies, has suggested that
ⱖ80% of ICU patients be under the care of full-time
intensivists.79
Roadmap for the Future in Critical
Care Cardiology
These key lessons from general critical care medicine de-
tailed in the preceding section, including the well-founded
focus on patient safety, the more favorable outcomes when
care is delivered by clinicians with advanced skills in critical
care medicine, and the value of structured multidisciplinary
care, are vital to the continued maturation of the CICU. In the
context of a growing interest of business entities, consumer
focus groups, and public agencies tasked with improving the
quality of ICU care, there is an imperative for the cardiovas-
cular community to develop a pathway to respond to the
“critical care crisis.” Not only is this effort in the best interest
of patients, but some of these changes will likely become
externally mandated.
The substantial evidence accumulated over the past 30
years in critical care medicine may be used to guide the next
phase of evolution of the CICU. Although these data were
derived predominantly in general ICUs, they provide the best
available information on which to base rational judgments in
developing a roadmap for advancing practice in the CICU. In
particular, the available data suggest that the open model for
organization and staffing of CICUs that is prevalent in the
United States may not provide the best possible outcomes in
the setting of current practice and patient demographics in the
CICU.
Potential Models of Physician Staffing in
the CICU
Although the advanced expertise of the cardiovascular spe-
cialist is essential to providing optimal care for patients with
acute cardiovascular diseases, the increasingly challenging
and extensive medical comorbid disease of patients cared for
in the CICU has created a need for clinicians skilled in
general critical care medicine. Thus, increasing the availabil-
ity of clinicians with general critical care skills is an impor-
tant objective for sustaining and advancing the quality of care
in the modern CICU. A pathway toward achievement of this
goal must also take into account the diversity of needs and
resources across varied settings, including rural environ-
ments, community-based hospitals, and major tertiary referral
centers. As such, to be successful, the organization and
staffing of the CICU must be individualized to the care
setting. Nevertheless, the writing group believes that access
to clinicians who have specialized skills in critical care is
important for all settings in which cardiovascular critical care
is provided. The writing group also finds that the evidence
supports a closed structure with staffing by dedicated cardiac
intensivists (as discussed below in “Dedicated Cardiac Inten-
sivists”) as a preferred approach for the advanced CICU
(level 1 CICU, “Proposal for Categorization of CICUs”).
However, we present first a model of shared responsibility
that is more broadly applicable to the current predominant
structure and diverse care environments of CICUs in the
United States.
 1416 Circulation September 11, 2012
Shared Responsibility With Consulting Intensivists
The most flexible organizational paradigm is a semiopen unit
in which cardiologists and a general intensivist comanage
each patient or selected patients in the CICU. This structure
also is most adaptable for CICUs that care for patients with
both higher and lower severity of illness, such as low-risk
patients with suspected acute coronary syndrome or hemody-
namically stable arrhythmias (level 2 or 3 CICU, “Proposal
for Categorization of CICUs”). Within this model, the writing
group favors a structure in which an experienced intensivist
takes primary responsibility for the care of each critically ill
patient in the CICU (eg, patients with multiorgan dysfunction
or those requiring mechanical ventilation), with ongoing
collaborative comanagement by the cardiologist. However, a
collaborative model with a primary cardiovascular specialist
with close, daily consultative care by a dedicated intensivist
may be most appropriate in some health systems. In some
settings with limited physician resources, this approach might
include accessibility of a consulting intensivist via a tele-
medicine program.
Under this approach, physician leadership of the CICU
might include both a cardiologist and an intensivist board
certified in critical care medicine working collaboratively.
Key principles guiding the development of this structure
include high-intensity involvement of an intensivist, coordi-
nation of an experienced multidisciplinary team, established
preventive programs for complications of ICU care (VAP,
stress ulcers, and CLABI), and meaningful quality improve-
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ment initiatives. The major advantage of the shared respon-
sibility model is that it can be adapted to a broad array of
staffing environments, including smaller community-based
hospitals where the CICU might be combined with a general
medical intensive care unit or where critical care staff are few
in number or supported by other disciplines such as anesthe-
sia critical care. Its success is dependent on effective collab-
oration between the cardiologist and intensivist in creating a
unified plan for care of the critically ill patient with cardio-
vascular disease.
Dedicated Cardiac Intensivists
The creation of a staffing model with dedicated cardiac
intensivists is an alternative approach. The cardiac intensivist
must have well-developed expertise in both general critical
care and cardiovascular medicine. Such skills may have been
developed through clinical experience focusing in cardiac
critical care, as has been formalized in Europe (“The CICU:
Models in Other Countries”) or through formal advanced
training in general critical care (“Training Programs in
Cardiovascular Medicine and Critical Care”). Leapfrog has
suggested that intensivists must maintain their skills through
at least 6 weeks of full-time ICU care each year.146 Ideally,
the cardiac intensivist will function within a closed CICU
model, in which the intensivist, while caring for patients in
the CICU, provides care exclusively in the ICU, is present at
all times during daytime hours, and when not present on-site
is available for consultation with suitably skilled team mem-
bers who are on-site. This model can be adapted to provide
24-hour in-hospital intensivist coverage if desired.
This innovative paradigm more directly matches the needs
created by the dramatic changes in the CICU since its
inception 50 years ago. This model has the advantage of
providing for the most seamless direction of complex care
through the leadership of a single physician who takes
primary responsibility for the patient. In this model, the
ICU-based physician is experienced in coordinating a large
multidisciplinary team that is integral to the functioning of
the advanced contemporary CICU. The writing group also
reaffirms the value of primary responsibility for management
of patients whose dominant medical problem is cardiovascu-
lar residing with a clinician with advanced skills in cardio-
vascular disease.
Because of the need for full-time staffing by cardiac
intensivists despite a limited workforce, this model is not
likely to be suitable for many community-based hospitals;
however, it is likely to be the optimal model for the large
tertiary referral center. Widespread implementation of this
model to meet the needs of existing CICUs would require an
increase in the number of cardiologists with advanced expe-
rience or training in critical care cardiology and would likely
benefit from an increase in the number of cardiovascular
clinicians with formal training in critical care cardiology.
Such a broadly trained critical care cardiologist would be
ideally suited for leadership and staffing of the level 1 CICU,
the most advanced CICU (“Proposal for Categorization of
CICUs”).
Integration With Other ICUs
Another possible structure for CICUs would be to combine
the CICU patients with surgical or medical ICU patients,
producing a multidisciplinary unit that manages a very broad
array of patients. Such a CICU would require leadership from
cardiology, critical care medicine, surgical critical care,
and/or anesthesia critical care. This combined ICU could
have some geographic segmentation of surgical, medical, and
cardiovascular patients into pods, with flexibility to overlap
beds depending on patient demand. This model provides the
flexibility to mitigate the impact when specialty ICU bed
availability does not allow appropriate triage of patients to
particular ICUs. This model would be similar to some ICUs
formed in Europe and other parts of the world.
“Service Line” ICUs
This solution also has the potential to best serve the expand-
ing group of patients with advanced heart disease who require
complex care for chronic heart disease and acute management
for cardiogenic shock, percutaneously placed ventricular
support devices, or extended mechanical hemodynamic sup-
port from surgically placed devices while awaiting destina-
tion therapies. With this approach, a more disease-centric (or
service line) model of care can be delivered, which also
centers the care around the patient rather than the therapies
provided. In this paradigm, a CICU would care for all patients
with advanced heart disease throughout the entire course of
their critical illness. Importantly, the entire spectrum of their
care, including hemodynamic guided therapy, before and
after cardiovascular surgery, before and after complex car-
diovascular procedures, and palliative services, would be
 Morrow et al
provided in a single ICU. Specialized heart failure units are
an example of such an approach.
Nursing, Advanced Practice Providers, Pharmacy,
and Other Staffing for CICUs
From the inception of the first CCUs, specialized nursing has
been a foundation of excellence in cardiology critical care.
Cardiovascular specialty certification is available to regis-
tered nurses with experience in cardiac patient care148 or as a
subspecialty after achieving certification as a critical care
specialist as either a registered nurse or advanced practice
nurse (ie, nurse practitioner or clinical nurse specialist).149
Certification among nurses has been associated with high
quality of care, high patient satisfaction, and potential for
improved reimbursement.150,151 Moreover, the integration of
advanced practice providers (nurse practitioners and physi-
cian assistants) into the cardiac critical care team can improve
patient outcomes, including reduced length of stay and
decreased complications, particularly among the chronically
critically ill population.152–154 Advanced practice providers
with specific training and experience in cardiac conditions
contribute to cost-effective care, improved staffing, and
continuity of care.
Among pharmacists, additional specialty certification in
cardiology is available to those who are board certified in
pharmacotherapy through the Board of Pharmaceutical Spe-
cialties and have additional training or advanced experience
in cardiology. These pharmacists can petition the Board of
Pharmaceutical Specialties for the credential of Added Qual-
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ifications in Cardiology.155,156 Additionally, postdoctoral spe-
cialized residency training and fellowships exist for pharma-
cists in cardiology and critical care medicine who have also
completed a first-year general practice residency after grad-
uation with a doctor of pharmacy degree.157
Although there is less information about the effects of
specialty certification on patient care for other cardiac care
team members, certifications are available to physical thera-
pists (cardiac and pulmonary care).158 Dietitians, respiratory
therapists, and social workers do not have specialty cardio-
vascular certification but may benefit from developed exper-
tise based on continuity of experience in a CICU.
Proposal for Categorization of CICUs
Because it is not necessary nor possible for all healthcare
environments to support an advanced closed CICU with
full-time intensivist staffing, the writing group recognizes
that a variety of organizational models with different levels of
professional and technological resources will be used to care
for patients. The writing group has proposed a schema for
describing the level of care offered by the CICU within the
structure of the individual healthcare system (Table 1). This
nomenclature is similar to the American College of Surgeons
trauma center verification.159,160 In the trauma center classi-
fication system, centers must not only meet specific criteria
established by the American College of Surgeons but also
pass a site review by a verification review committee. The
official designation as a trauma center is determined by
individual state law provisions, with the level varying accord-
ing to the specific capabilities, ranging from level I being the
The Evolution of Critical Care Cardiology 1417
highest to level III as the lowest category in most states. A
level I trauma center provides comprehensive trauma care
(immediate availability of specialized surgeons, anesthesiol-
ogists, and other clinical staff, as well as all necessary
resuscitation equipment), with a minimum number of major
trauma patients per year; serves as a regional resource; and
provides leadership in education, research, and system plan-
ning. Analogously, we propose to define levels of CICUs as
follows.
Level 1 CICU
The level 1 CICU is capable of management of all cardio-
vascular conditions and major noncardiovascular comorbid
conditions. This unit may contain advanced heart failure
patients dependent on percutaneous ventricular assist devices
and in some circumstances patients who have undergone
surgical ventricular assist device placement or cardiac trans-
plantation. The level 1 CICU has all forms of invasive and
noninvasive monitoring capabilities, and advanced technolo-
gies will be available to support the cardiovascular system
and manage patients with refractory shock or resuscitated
cardiac arrest. Patient care in this setting would be of high
intensity, with management by full-time intensivists, either
cardiac intensivists or general intensivists working collabora-
tively with cardiologists. The level 1 CICU is designed to
care for patients with primary cardiovascular problems or
those in whom underlying cardiac disease is sufficiently
severe that it presents imminent risk in the context of another
medical illness. Therefore, a primary role of cardiovascular
specialists is optimal. Physicians with specialized skills in
critical care are available at all times and may be on-site
continuously. An on-site nursing director is present, and
nurse-to-patient ratios would be expected to be 1:1 or 1:2.
Pharmacy, nutrition, and respiratory therapy services would
complete the multidisciplinary CICU team. Access to inter-
ventional cardiology and cardiac surgical support is expected.
In a level 1 CICU, resident and/or fellow training programs
would usually be present, and there would typically be a
commitment to perform clinical and translational research.
Physician leadership ideally would be provided by a cardiac
intensivist or codirectorship with a cardiologist and general
intensivist. A level 1 CICU would be the likely paradigm for
most large tertiary medical centers.
Level 2 CICU
The level 2 CICU is capable of providing the initial evalua-
tion and management of most acute cardiovascular conditions
and medical comorbid conditions. All invasive and noninva-
sive monitoring is available. Mechanical hemodynamic sup-
port is available but limited to non–ventricular assist devices,
including intra-aortic balloon counterpulsation. Advanced
medical interventions such as continuous venovenous hemo-
filtration may not be available. A level 2 CICU should have
protocols in place to provide for initiation of therapeutic
hypothermia in survivors of cardiac arrest. Physician staffing
for CICU patients is generally by cardiologists, and intensiv-
ists are available for consultation or comanagement of com-
plex patients. The unit may be combined with a general
medical or surgical ICU. A nursing director is designated, and
nurse-to-patient ratios are usually 1:1 to 1:3. Training of
 1418 Circulation September 11, 2012

Table 1. Levels of Cardiovascular ICUs

Monitoring Physician Patient Nursing/Other Education
Level Patient Population Technology Therapeutic Technology Physician Leadership Management Personnel Programs Research
1 All CV diagnoses All invasive and IABP Cardiac intensivist or High-intensity management: Nursing Usually resident Commitment to
noninvasive cardiologist All care directed by Director and fellow perform clinical
cardiac (nonintensivist) and intensivist (cardiac or training programs research
monitoring general intensivist general), or intensivist
consultation
Most comorbidities PA catheter Percutaneous or Intensivist available at all RN-to-patient
implantable VADs times ratio 1:1 or
1:2
Advanced heart Echocardiography Mechanical ventilation May be 24/7 in-hospital
failure intensivist
STEMI primary PCI Therapeutic
capable hypothermia
May include Continuous renal
post-CV surgery replacement
Interventional cardiology
available 24/7
Cardiac surgery readily
accessible

2 Initial diagnosis and All invasive and IABP and/or other Cardiologist or Intensivist (cardiac or Nursing May be residents May conduct
management of noninvasive non-VAD devices intensivist general) available at all Director or fellow training research
most CV conditions cardiac times programs
monitoring
May be STEMI PA catheter Mechanical ventilation RN-to-patient
primary PCI capable ratios 1:1 to
1:3
Transfer to level 1 Echocardiography Therapeutic
ICU if patient hypothermia initiation
remains unstable
Coronary Interventional cardiology
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angiography access preferable

available on-site Cardiac surgery access
or via transfer preferable

3 Initial diagnosis and Noninvasive and Mechanical ventilation Cardiologist or Cardiology admission or Nursing
management of some invasive intensivist consultation; intensivist is Director
common monitoring (eg, available at all times
cardiovascular arterial lines)
conditions (usually
low complexity),
respiratory failure
Transfer to level 1 Echocardiography RN-to-patient
or 2 ICU if unstable ratio 1:2 to
1:3

Other cardiovascular care units that are not cardiac ICUs include chest pain units for low-risk patients with chest symptoms and intermediate-care step-down units.
Specialized units for advanced heart failure are described in the text.
ICU indicates intensive care unit; CV, cardiovascular; IABP, intra-aortic balloon pump; PA, pulmonary artery; VAD, ventricular assist device; RN, registered nurse;
24/7, 24 hours per day, 7 days per week; STEMI, ST-segment– elevation myocardial infarction; and PCI, percutaneous coronary intervention.

residents and clinical research may be present. Transfer to a
level 1 CICU should be considered for patients requiring
advanced hemodynamic support; for patients under consider-
ation for high-risk valvular, coronary, or heart failure surgery;
and for patients with intractable arrhythmias or refractory
multiorgan system dysfunction.
Level 3 CICU
The level 3 CICU is the lowest-level CICU. The level 3 CICU
should have the capacity to manage respiratory failure,
administer vasopressors and inotropes for hypotension, and
provide immediate resuscitation of cardiac arrest but may be
focused on the care of patients with suspected acute coronary
syndrome, heart failure without shock, and hemodynamically
stable arrhythmias. The latter group of patients, for example,
those with suspected acute coronary syndrome or stable
arrhythmias, may be cared for on cardiac step-down telemetry
units in hospitals with level 1 or level 2 CICUs. Like the level
2 CICU, the level 3 CICU may be combined with a general
medical ICU. Noninvasive monitoring and echocardiography
are available. Invasive monitoring and mechanical hemody-
namic support are not usually provided in this unit. Cardiol-
ogy service admission or consultation is expected for man-
agement of patients admitted with primary cardiac conditions
to this unit. Critical care primary or consultative services are
available. Nurse-to-patient ratios are usually 1:2 to 1:3.
Patients who develop the need for mechanical hemodynamic
support or advanced medical interventions not available in
 Morrow et al
the level 3 CICU should be transferred promptly to an
appropriate center with a level 1 or 2 CICU. Selection of the
appropriate timing and destination of transfer for the patient
with refractory illness is an important aspect of overall
management in the level 3 CICU.161,162
The writing group acknowledges the frequent presence of
other specialized cardiovascular care units that are not ICUs.
For example, chest pain units or clinical decision units have
been developed in many health systems to facilitate rapid
diagnosis and triage of patients with possible acute ischemic
heart disease and may identify patients who warrant transfer
to a CICU.
The CICU: Models in Other Countries
Other regions of the world have already made formal recom-
mendations for staffing of CICUs. The European Society of
Cardiology (ESC) Working Group for Acute Cardiac Care
has recommended that intensive cardiac care units (ICCUs)
be directed by board-certified cardiologists specially trained
and accredited as acute cardiac care specialists, including
training in the general intensive care unit.163 The ESC
working group recommended that intensive cardiac care units
have 24/7 coverage by physicians skilled in acute cardiac
care, with attending cardiologists available for consultation
and assistance. The ESC panel concluded that ICU nurses are
as important as ICU physicians for optimal patient care in an
intensive cardiac care unit. The ESC panel advocates the ICU
team concept to include physicians, nurses, respiratory ther-
apists, pharmacists, social workers, dieticians, physical ther-
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apists, and other ancillary staff.163
Training Programs in Cardiovascular
Medicine and Critical Care
A roadmap to keep pace with evolution of the contemporary
CICU must include enhanced training to ensure development
of the basic skills necessary to provide care in this setting, as
well as opportunities for advanced training in critical care
cardiology for those who intend to specialize as a cardiac
intensivist.
General Cardiovascular Training
Cardiovascular fellowship training offers comprehensive,
hands-on education in a variety of aspects of cardiovascular
patient care. Fellowship education is composed of bedside,
didactic, simulation, and other learning opportunities.164 The
ACGME training plan is based on the 6 core competencies,
which include medical knowledge, patient care, profession-
alism, communication and interpersonal skills, practice-based
learning and improvement, and systems-based practice,
which are meant to provide structure and standardization to
all programs.165 The American College of Cardiology Foun-
dation Recommendations for Training in Adult Cardiovascu-
lar Medicine Core Cardiology Training (COCATS) also help
to standardize the fellowship training process by defining
training levels, in which level 1 indicates the most basic
training level and level 3 indicates the highest training
level.166 COCATS is largely based on procedural numbers
and time spent in training to assess level of competency.
According to COCATS, fellowship training in cardiovascular
The Evolution of Critical Care Cardiology 1419
medicine should include 9 months in nonlaboratory clinical
practice, a portion of which is typically spent in the CICU.
Present-day critical care training in cardiovascular training
programs is varied. All programs expose the trainees to
critically ill patients, but the structure and duration of time
spent by cardiology fellows caring for patients in the ICU
setting depends on the structure of the hospital, departments,
and training programs. At the present time, there are no
specific ACGME or COCATS guidelines or recommenda-
tions for critical care training within cardiovascular fellow-
ship training. Although some programs offer fellows dedi-
cated fellowship training months in the ICU, with complex
patient populations and experienced staff and physician
teachers, others have modest ICU exposure for fellows.
Given the complexity of present-day cardiology patients,
fellows are generally exposed to a variety of critically ill
patients; however, some fellows may have more limited
experience with mechanical support, ventilator management,
renal replacement therapy, and other advanced therapies
limited to the CICU setting.
There are impediments to the expansion of critical care
training during general cardiology fellowship. Fellow duty
hours are increasingly scrutinized, and more time in the ICU
is likely to further impact training time. In addition, cardiol-
ogy training programs need to be cognizant of the expanding
need for exposure to new areas such as advanced cardiac
imaging, including magnetic resonance imaging and com-
puted tomography imaging. In light of the rapid changes in
environment and technology that are increasingly unique to
the CICU, trainees in cardiovascular medicine must have
opportunities to participate in the care of critically ill patients
with cardiovascular disease so as to build basic (COCATS
level 1 or 2) competency in this area. However, given the
constraints imposed by the essential exposure to a broad base
of clinical practice, trainees in general cardiovascular medi-
cine are not likely to be able to acquire additional exposure to
critical care medicine in the present training paradigm. As
such, there is ample rationale for the development of oppor-
tunities for advanced training in critical care cardiology (level
3 competency).
A Model for Training in Critical Care Cardiology
The progressively increasing severity of illness, the rapid
emergence of new technologies, the crucial role of experience
in mitigating the risk of iatrogenic CICU complications, and
the overall complexity of the CICU environment each point
toward value in developing training pathways for selected
cardiovascular trainees who wish to acquire advanced skills
in critical care medicine and critical care cardiology in
particular. Moreover, the obvious shortfall in intensivists
available to meet the needs of staffing models endorsed by
this writing group adds to the rationale for establishing
avenues by which to train cardiac intensivists.
Existing Pathway for Dual Certification in
Cardiovascular and Critical Care Medicine
Current ACGME recommendations require 3 years of train-
ing in cardiovascular disease, of which at least 24 months is
full-time clinical training, to meet the American Board of
 1420 Circulation September 11, 2012

Table 2. Existing Training Requirements for Dual Certification in CVD and Critical Care Medicine
Criterion
Eligibility criteria
Training requirements
Procedural competency
Additional areas of knowledge
and practical experience
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Details CVD Critical Care
Completion of 3 years of accredited CVD fellowship and certification by the ABIM ⻫
Training within a critical care fellowship program in a department of medicine ⻫
Completion of 24 mo of full-time clinical training in an accredited fellowship in ⻫
cardiovascular medicine
Completion of 12 mo of accredited clinical fellowship training in critical care medicine ⻫
Up to 6 months of critical care medicine experience in CVD and critical care medicine ⻫ ⻫
training can be applied to admission for both examinations
Minimum total full-time clinical training for dual certification in CVD and critical care ⻫ ⻫
medicine of 30 mo (total training time 48 mo)
Cardioversion; electrocardiography, including ambulatory monitoring and exercise ⻫
testing; echocardiography; insertion and management of temporary pacemakers; and
left-sided heart catheterization and diagnostic coronary angiography
Advanced cardiac life support (ACLS) ⻫ ⻫
Placement of arterial, central venous, and pulmonary artery balloon flotation catheters ⻫ ⻫
Calibration and operation of hemodynamic recording systems ⻫ ⻫
Airway management and endotracheal intubation ⻫
Ventilator management and noninvasive ventilation ⻫
Insertion and management of chest tubes; thoracentesis ⻫
Proficiency in use of ultrasound to guide central line placement and thoracentesis ⻫
strongly recommended
Indications, contraindications, complications, and limitations of the following procedures:
Intra-aortic balloon pump ⻫
Pericardiocentesis ⻫ ⻫
Transvenous pacemaker insertion ⻫ ⻫
Continuous renal replacement therapy and hemodialysis ⻫ ⻫

Fiber-optic bronchoscopy ⻫
CVD indicates cardiovascular disease; ABIM, American Board of Internal Medicine.

Internal Medicine requirement for certification in cardiovas-
cular medicine. For critical care medicine, the ACGME
suggests a minimum of 12 months of clinical training. The
American Board of Internal Medicine presently recognizes a
pathway for dual subspecialty training and certification in
cardiovascular disease and critical care medicine (Table 2).
Because of the overlapping elements of the curriculum and
clinical experience within these 2 training pathways, 6
months of cardiovascular clinical training may be applied
toward the critical care medicine training requirements.
Therefore, overall, this pathway for dual certification requires
4 years of fellowship with a minimum of 30 months of
clinical training, of which 6 months of clinical training must
be in critical care medicine within a critical care training
program accredited by the ACGME. This total period of
training is commensurate with training in other cardiovascu-
lar subspecialties, such as electrophysiology. Functionally,
trainees seeking dual certification have typically done so
through application to an ACGME-accredited 1-year program
in critical care medicine before or on completion of their
cardiovascular training program.
A summary of the curriculum and current training require-
ments for dual board certification in cardiovascular disease
and critical care medicine is provided in Tables 2 and 3. This
curriculum builds on elements already included in the car-
diovascular medicine training requirements and expands the
exposure of the trainee to aspects of management of respira-
tory failure, acute renal failure, sepsis, and multiorgan system
failure that are prevalent in the modern CICU. In addition,
more broad procedural skills are established, such as perfor-
mance of bronchoscopy and placement of chest tubes. This
enhanced expertise should well equip the cardiac intensivist
to manage the broad range of medical problems encountered
in the CICU. However, the writing group also supports the
value of establishing more innovative pathways for training
in critical care cardiology that tailor the critical care medicine
experience to develop expertise that the practitioner is likely
to apply in the CICU.
Adaptation and Innovation in Critical Care
Cardiology Training
The writing group recognizes 2 approaches toward develop-
ing enhanced training opportunities in critical care cardiology
(Table 3). The first adapts and formalizes the existing
pathway for dual certification toward providing the medical
knowledge and patient practice experience for a fellow to
become a cardiac intensivist with the requisite skills neces-
sary to work effectively in a CICU. Building on the current
general critical care medicine training requirements for com-
bined certification, a tailored program for the cardiac inten-
sivist would integrate options for rotations in the cardiac
surgical intensive care unit, emphasize focused experiences
 Morrow et al The Evolution of Critical Care Cardiology 1421

Table 3. Proposed Models for Training in Critical Care Cardiology

Clinical, mo
CVD
Noninvasive
Vascular
Catheterization laboratory
Electrophysiology
Nonlaboratory clinical practice*
Advanced heart failure
Pulmonary hypertension
Outpatient continuity clinic
Critical care
MICU or CICU
Nonmedical ICU†
Cardiothoracic surgery ICU
Research and elective, mo
Total months of training
Program faculty and leadership
Program accreditation
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Current Pathway for Dual Tailored Program for Dual-Certification Possible Dedicated Training
Certification Critical Care Cardiology Program in Critical Care Cardiology
7 7 7
2 2 2
4 4 4
2 2 2
9 9 (Inclusive of below) 6 (Inclusive of below)
… Focused experience Focused experience
… Focused experience Focused experience
36 36 36
3 to 6 3 to 6 4 to 6
3 to 6 1 to 3 3 to 6
… 2 to 3 2 to 3
12 to 18 12 to 18 12 to 18
48 48 48
Separately managed programs Integrated faculty and collaborative leadership Integrated faculty and collaborative
in CVD and critical care from CV medicine and critical care medicine leadership from CV medicine and
medicine critical care medicine
Separate accredited programs: Accredited programs in CV medicine and Integrated program in critical care
CV medicine critical care medicine exist within system cardiology with single accreditation
Critical care medicine (1-y Either the critical care medicine or CV medicine
program) programs may have 1-y accredited program in
critical care cardiology

CVD indicates cardiovascular disease; MICU, medical intensive care unit; cardiovascular; CICU, coronary intensive care unit; ICU, intensive care unit; and CV,
cardiovascular.
*Ward, consult, CICU.
†Nonmedical patients, including surgical intensive care unit, burns, transplant, and neurological ICU or equivalent.

or elective rotations in advanced heart failure and pulmonary
hypertension, and include expanded exposure to complex
adult congenital heart disease and percutaneous/surgical cir-
culatory assistance devices. Additional research and elective
time would also provide an opportunity to develop specific
skills in epidemiology, conduct outcomes research in clinical
trials, or explore laboratory-based and translational research
in areas of interest relevant to cardiovascular critical care.
The training program would be staffed by faculty in cardio-
vascular medicine and critical care medicine and require
formative and summative evaluations as required by the
ACGME. At present, such training is accredited only if
provided within an ACGME-approved 1-year critical care
program. In 2011, of the 187 training programs in cardiovas-
cular disease, only 31 had associated 1-year programs in
critical care medicine at the same institution/program. In the
future, working collaboratively with faculty from both critical
care medicine and cardiovascular medicine, the organization
of program leadership in some centers may optimally reside
within the cardiovascular medicine training program, with
accreditation of the integrated program by the ACGME. In
Europe, such cardiac intensivist training has already been im-
plemented by the European Board for the Specialty of Cardiol-
ogy with a formal curriculum and detailed COCATS-type
training to ensure clinical and procedural competence.167–169
The second approach is substantially farther from existing
programmatic options, involving the development of a dis-
crete, dedicated program for training a cardiac intensivist
with requisite skills to function expertly in the CICU, cardiac
surgical ICU, or other general ICU. In this framework for
training, a 4-year curriculum drawing from both cardiovas-
cular and critical training requirements from the American
Board of Internal Medicine would be formulated and enable
an even broader experience in general critical care medicine
but would substitute elective rotations in this domain for
some of the cardiovascular clinical training requirement
(Table 3). On the basis of input from certifying authorities,
the training would require documentation of clinical experi-
ences and procedural competence to certify dual proficiency
in critical care medicine and noninvasive and invasive
cardiology.
Recently, a leadership group within the American Board of
Thoracic Surgery has discussed the development of a critical
care certification pathway for the perioperative care of
cardiothoracic surgery patients.170 If such a program were to
be developed, it would provide an additional opportunity for
a cardiovascular intensivist to develop skills that would be
useful in the CICU, a cardiothoracic surgical ICU, or a
combined unit (“Integration With Other ICUs”). Given that
most subspecialty ICUs in the United States are located in
 1422 Circulation September 11, 2012
regional academic centers,79 such a CICU would likely be
formed as a collaborative multidisciplinary academic unit that
would include cardiologists, cardiac intensivists, medical or
surgical intensivists, and anesthesiologists.
Assessing Competency
Demonstration of proficiency is important for all medical
disciplines and has been the focus of professional societies,
individual medical systems, and independent organizations
such as the American Board of Internal Medicine that seek to
certify that physicians possess the knowledge, skills, and
attitude necessary to provide excellent care. Verification of
initial training and continued competency is crucial to main-
taining conformance to established standards of care and may
be of particular importance for those engaged in the care of
the most severely ill patients who require critical care. Such
assessment should follow a clearly established program and
consider knowledge, skills, and attitude. The detailed curric-
ulum and mechanisms for verification of competency devel-
oped by the ESC may serve as a model for similar efforts in
the United States.169 The establishment of opportunities for
continuing medical education and reassessment of profi-
ciency is also important and would be enhanced by expansion
of existing programs and development of new programs
aimed at critical care cardiology in particular.
At present, mechanisms exist for assessment, certification,
and recertification of these elements in both cardiovascular
medicine and critical care medicine through the American
Board of Internal Medicine/American Board of Medical
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Specialties Maintenance of Certification program. Future
deliberations may consider whether there is a value to
developing processes for maintenance of certification in
critical care cardiology, such as through a certification in
cardiovascular diseases with “recognition of focused prac-
tice,” as is being developed for hospital medicine.171 The
criteria for such a pathway include (1) that the discipline
includes large numbers of internists who focus their practice
in that discipline and (2) that there is evidence that focusing
practice in the discipline improves patient care and that
recognition of focused practice would serve an important
societal need for the discipline. It is reasonable to argue that
the latter criterion is already met.
Research Directions for Critical
Care Cardiology
The breadth and volume of cardiovascular research has
outpaced many other medical specialties over the past de-
cades and has made an enormous impact on improving care
and outcomes, including among patients cared for in emer-
gency and critical care settings. Randomized trials of revas-
cularization in cardiogenic shock,172 use of left ventricular
assist devices in end-stage heart failure,173 use of pulmonary
artery catheters,174 use of intra-aortic balloon pumps in MI,175
and therapeutic hypothermia for out-of-hospital cardiac ar-
rest176 are examples of research restricted to the critical care
setting with patients with primary cardiovascular conditions.
However, there has been relatively little research focusing on
the evolution of critical care cardiology to include patients
with multisystem organ dysfunction. There are also important
opportunities to study how staffing models, provider training,
team composition, and electronic systems, including decision
support, may impact process and outcomes. Moreover, there
is a need for investigation of structured approaches to
enhance communication and facilitate transitions between the
CICU and external providers inside and outside the hospital.
The important research into building regional systems of care
for acute MI with integration of emergency medical systems,
community hospitals, and specialized tertiary care centers
could be extended to other critical care conditions. As well,
recent work in the treatment of hyperglycemia177 and
shock178 and previous randomized studies of the routine use
of pulmonary artery catheters179 have highlighted the impor-
tance of prospective, well-controlled clinical investigation in
general critical care medicine and the impact that it may have
in the CICU. End-of-life care and level-of-care decisions by
patients and families are other areas that have undergone
some study180 but need more investigation.
As electronic medical records and evolving coding of
patient conditions allow more sophisticated analysis of vari-
ous aspects of care and outcomes, there will be new oppor-
tunities to characterize critically ill cardiovascular patients.
This will only be possible with standardized definitions and
accurate coding, as well as multicenter collaboration. Re-
search networks in general critical care medicine, such as the
Canadian Clinical Trials Group, the ARDS (Acute Respira-
tory Distress Syndrome) Network, and the US Critical Illness
and Injury Trials Group, have served to advance the agenda
of research in critical care. These models, combined with the
rich history and expertise of cardiovascular researchers in
conducting large clinical trials, could be used to build
important evidence to improve care for this understudied
population. With an increasing proportion of healthcare
dollars going into care during the last months of life, much of
this in intensive care units, research into efficient use of
resources is also warranted.
Summary
No longer is the cardiac ICU merely a “coronary” observation
unit for peri-infarction complications. Rather, the contempo-
rary CICU is an ICU for complex patients with cardiovascu-
lar disease who become critically ill and who are more prone
to major systemic complications, including renal failure,
respiratory failure, thrombosis, bleeding, catheter-related in-
fections, ventilator-acquired pneumonia, and multiorgan dys-
function.24,26,29,30 Coincident with significant increases in
noncardiovascular critical illnesses, the use of advanced
supportive technologies, both cardiovascular and noncardio-
vascular, has increased and requires specialized expertise that
is not in the realm of common experience for the general
clinical cardiologist.24 Together, these changes mark a steady
evolution toward progressively greater complexity of the
environment in the CICU.
In the opinion of this writing group, this transformation
necessitates innovative approaches to the staffing, structure,
and training behind the contemporary CICU. In particular, we
have proposed evidence-based staffing models that are adapt-
able to the variety of clinical settings in which cardiovascular
care is provided and adhere to the tenet that the availability of
 Morrow et al The Evolution of Critical Care Cardiology 1423

experienced cardiac intensivists, either as primary caregivers
or as consultants, is central to the optimal delivery of
advanced cardiac critical care. Such specialized skills may
have been acquired through experience or formal advanced
training. The writing group also reaffirms the value of
primary responsibility for management of patients whose
dominant medical problem is cardiovascular residing with a
clinician with advanced skills in cardiovascular disease. We
have described a classification system that could be formal-
ized to characterize the capabilities and resources of the
individual CICU or health system, with the 2 highest levels
(level 1 and level 2) requiring the availability of intensivists
and specialized multidisciplinary teams. In particular, the
writing group concluded that the evidence supports a closed
structure staffed by dedicated cardiac intensivists as a preferred
approach for the level 1 CICU. The writing group also finds that
successful implementation of such models will require the
development of new pathways for training of cardiologists with
advanced skills in critical care cardiology. We have proposed
adaptations to existing training models that tailor them toward
developing the skills of a cardiac intensivist, and we have raised
the possibility of more substantial restructuring of training in the
future. These proposals may be a useful starting point for a
meaningful dialogue between the major stakeholders in training
and certification of such specialists. The future of cardiovascular
critical care medicine is rapidly evolving, with an opportunity to
improve the education and skills of clinicians and the care of
their patients.

Disclosures
Writing Group Disclosures
Other Research Speakers’ Expert Ownership Consultant/
Writing Group Member Employment Research Grant Support Bureau/Honoraria Witness Interest Advisory Board Other
David A. Morrow Brigham & Women’s None None None None None None None
Hospital/Harvard
Medical School
James C. Fang University Hospitals None None None None None None None
Case Medical Center
Dan J. Fintel Northwestern None None None None None None None
Memorial Faculty
Foundation
Downloaded from http://ahajournals.org by on December 14, 2020

Christopher B. Granger Duke University Astellas†; AstraZeneca†; None None None None AstraZeneca*; Boehringer None
Medical Center Boehringer Ingelheim†; Ingelheim†; Bristol-Myers
Bristol-Myers Squibb†; CSK†; Squibb†; GlaxoSmithKline*;
GlaxoSmithKline†; Medtronic Hoffmann-La Roche*;
Foundation†; Merck†; Pfizer†; Novartis*; Pfizer*; Roche*;
Sanofi-Aventis†; The Sanofi-Aventis†; The
Medicines Co† Medicines Co*
Jason N. Katz University of North None None None None None None None
Carolina
Frederick G. Kushner Heart Clinic of None None None None None None None
Louisiana
Jeffrey T. Kuvin Tufts Medical Center None None None None None None None
Jose Lopez-Sendon Hospital Universitario None None None None None None None
La Paz, Madrid, Spain
Dorothea McAreavey National Institutes of None None None None None None None
Health
Brahmajee K. University of Michigan NIH* None None None Prescription Abbott Vascular* None
Nallamothu Solutions*
Robert Lee Page II University of Colorado None None None None None None None
School of Pharmacy
and Medicine
Joseph E. Parrillo Cooper University None None None None None None None
Hospital
Pamela N. Peterson Denver Health None None None None None None None
Medical Center
Chris Winkelman Case Western NIH* None AACVPR* None None None None
Reserve University
and MetroHealth
Medical Center

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (1) the person receives $10 000
or more during any 12-month period, or 5% or more of the person’s gross income; or (2) the person owns 5% or more of the voting stock or share of the entity, or owns
$10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
 1424 Circulation September 11, 2012

Reviewer Disclosures
Research Other Research Speakers’ Ownership Consultant/
Reviewer Employment Grant Support Bureau/ Honoraria Expert Witness Interest Advisory Board Other
Gerasimos Fillipatos Evangelismos Hospital, Athens, Greece None None None None None None None
Mike Kontos Virginia Commonwealth University/ NIH* None AstraZeneca* Plaintiff, postoperative MI* None AstraZeneca* None
Medical College of Virginia
Steve Pastores Memorial Sloan-Kettering Cancer None None None None None None None
Center
Ileana L. Piña Case Western Reserve University None None None None None None None
Cathy Ryan University of Illinois at Chicago None None None None None None None
C.A. Sivaram University of Oklahoma None None Medtronic* None None Medtronic* None

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (1) the person receives $10 000 or more
during any 12-month period, or 5% or more of the person’s gross income; or (2) the person owns 5% or more of the voting stock or share of the entity, or owns
$10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.

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KEY WORD: AHA Scientific Statements 䡲 cardiovascular diseases 䡲
critical care 䡲 heart-assist device 䡲 resuscitation