Coronary Care

I was recently reading an article published in the British Journal of Medicine in 1987 on the history of coronary care units.  As you may know, the coronary (or cardiac) care unit (CCU) is the specialized ward of the hospital where patients with cardiac problems are closely monitored and intensively treated.  They are staffed by experienced nurses and monitored around the clock by technicians trained in recognizing heart rhythm problems.  The concept of the CCU is now so commonplace that it’s hard to imagine a time when it was considered revolutionary.

The CCU was developed in the 1960s in response to a rise in the perceived incidence of coronary artery disease and heart attacks.  Prior to World War II most of our civilian health casualties were victims of infectious diseases such as tuberculosis and pneumonia.  The recognized heart problems were principally those involving congenital abnormalities and acquired valvular problems (acute rheumatic fever).  In the entire year of 1959 only six articles in the British Heart Journal centered on coronary artery disease.  People were simply too busy dying from other things to bother themselves with heart attacks.

The advent of antibiotics, good nutrition, and workplace safety led the way for people to live long enough to develop coronary atherosclerosis.  Unfortunately there wasn’t much anyone could really do about it.  The mainstay therapy for a heart attack in the 1960s was to simply let the disease runs it’s course and offer bypass surgery only if the patient survived long enough to develop chronic chest pain.  Consider this quote cited in the BJM article by the early CCU advocate Gunnar Biörck:

“There are few diseases in the sphere of internal medicine where the average mortality during four to six weeks hospitalization is over 30%, and if the patients with shock are particularly considered, the figure is more than twice as large.”

Imagine that—30% death rate among heart attack patients (over 60% if the patient presents with shock)!  It was out of the recognition of this abysmal survival statistic that the concept of the CCU was born.

As time progressed the medical community began to recognize the importance of aggressive therapies to restore blood flow to the blocked artery.  In the early 1970s the median time from the onset of symptoms to the initiation of therapy (at the time it was mainly nitroglycerin, oxygen and morphine) was greater than 8 hours.  These days the standard of care dictates that we reestablish blood flow within the first 90 minutes of the patient entering the emergency department.  It’s not unusual to have a patient resting in a CCU bed—having already undergone successful placement of a coronary stent—within an hour after presenting with chest pain.

Bear this historical progression in mind as I relate a conversation I recently had with a young man who came to our hospital with a heart attack.  When I met him in the emergency department he was sweaty and pale, wide-eyed with fear.  His EKG showed abnormalities reflective of a significant heart attack.  Because he came in during the day we were able to whisk him into the catheterization lab with very little delay and open his occluded artery.

The following morning, as I exhorted him to give up his cigarette habit, he interrupted me to share his thoughts on the need for change in his health habits:

“I don’t need to quit smoking.  This heart attack thing was a piece of cake. I figure if this happens again I’ll just come in here and you guys will take care of it just like you did yesterday.  By the way, when can I go home?”

I have to admit I couldn’t fault his logic even if his level of understanding was sorely deficient.  Dr. Biörck in the quote above spoke of a “four to six weeks hospitalization” as the norm for patients with heart attacks.  In the 1950s and 60s the average cardiac patient would lounge around the hospital for weeks with strict instructions to engage in no more exertion than was required to summon the pinafore-clad nurse for his daily constitutional.  The hard-driving business executive laid low by a coronary event would spend months away from the office as he recuperated amid doting family members.  Manual laborers would find themselves permanently disabled and incapable of resuming their usual employment.

Now, as suggested by my impulsive patient, it’s a totally different world.  These days, thanks to advances in coronary reperfusion (angioplasty, stents, bypass surgery), medications (beta-blockers, statins, aspirin), and aggressive early detection and treatment standards, we’ve chopped Dr. Biörck’s 4 to 6 weeks down to a mere 48 hours.

Of course, this is all a very good thing and we should be nothing short of ecstatic that a heart attack is no longer the death sentence that it was 50 years ago.  I just wish sometimes that a few of my patients would get a little more spooked over the whole ordeal, that they would recognize this experience as a brief introduction to their own mortality and sincerely commit to the changes they need to make.