Evolution of the CCU from rhythm, function and protection to reperfusion and beyond: a personal journey and perspective.

OBJECTIVE: To trace the evolution of coronary care and the management of acute coronary syndromes. STUDY SELECTION: Landmark articles and selected personal experiences. DATA SYNTHESIS: The evolution of coronary care falls into four major categories and decades: the 1960s during which it was recognized that resuscitation from myocardial infarction through closed chest resuscitation (CPR) and defibrillation were possible and attention was directed towards the recognition and management of cardiac dysrhythmias; in the 1970s it became appreciated that infarct size was directly related to prognosis and modifiable. Hemodynamic monitoring was introduced and made significant contributions to the identification of prognostic subsets and the pharmacologic management of pump failure; thrombolytic therapy was introduced in the 1980s and has markedly altered the care of patients with acute myocardial infarction who have ST elevation. Primary angioplasty is an important therapeutic alternative especially in selected subsets; in the 1990s attention shifted to opportunities for favourable impact on ventricular remodelling after myocardial infarction, more cost effective therapy, enhancement of the process of care, and the identification of low and high risk subsets that might lead to more efficient diagnostic triage early after symptom presentation. CONCLUSIONS: There has been a profound evolution of the coronary care unit since its inception in Canada in 1962. It has proved a remarkable environment for education and clinical investigation through which patient care has been substantially improved. Lessons learned have favourably impacted on the process of care, the creation of new national and international standards and a fertile environment for continuous future evaluation and improvement.

Duke Scholars

Author Paul Wayne Armstrong Medicine, Cardiology