The coronary care unit: a 35-year perspective

More than 35 years have elapsed since Day reported his first experience with an ‘intensive coronary care area’. During this substantial period, the concept of intensive coronary care has been studied many times. It is interesting to note that many of the early studies were unable to document benefit from this expensive form of hospital management. As recently as 1987, Reznik et al. concluded that the ‘increased resources for coronary care units . . . may not be required’. However, such negative findings did not go unchallenged. Hofvendahl, in Sweden, and Christensen et al., in Denmark, reported benefits for patients with acute myocardial infarction who were hospitalized in coronary intensive care units (CCUs) compared with patients cared for on general internal medicine wards. The debate over the value of the CCU was vigorous during the 1970s and 1980s. I was once told by an attending physician during my training years, that coronary care was an expensive but rather useless form of ‘infarct baby sitting’. With the introduction of thrombolytic therapy — both pharmacological and interventional — this debate largely evaporated. The opponents of coronary care may have retired or died while their younger colleagues, having grown up with CCUs, never questioned the validity of this form of care. Perhaps it seemed obvious that the new aggressive direction that coronary care had taken during the late 1980s required the support of a dedicated CCU where patients could be closely monitored before and after potentially life-threatening interventions. Regardless of the reasons, coronary care has become the gold standard for patients with acute myocardial infarction and/or unstable angina. There have always been some reservations about the cost-effectiveness of coronary care for every patient with chest pain. This scepticism was particularly intense in my case when dealing with patients admitted for ‘soft rule-out myocardial infarction’, i.e. those patients whose history, physical examination, ECG and early enzyme results suggested that the correct diagnosis was not an acute coronary syndrome. Recent work suggests that