Cardiology and the Critical Care Crisis
Jason N. Katz, MD,* Aslan T. Turer, MD,* Richard C. Becker, MD†
Durham, North Carolina
With an aging U.S. population and a declining physician supply, the care of critically ill patients will soon be
reaching a level of crisis. At the same time, the evidence continues to mount in support of intensivist stafﬁng to
improve both patient outcomes and resource utilization in intensive care units (ICUs). Whereas the vast majority
of medical and surgical ICUs are staffed by physicians trained in critical care medicine, that is not commonly the
case in coronary care units (CCUs) in this country. Despite that, the breadth and diversity of comorbidities in pa-
tients that occupy our CCU beds is continuously growing. No longer is the CCU merely an observation unit for
peri-infarction complications, but rather it has truly become an ICU for patients with cardiovascular disease. With
this in mind, there becomes a growing need for intensivist-trained cardiologists and a push for the development
of critical care training pathways in our cardiovascular fellowship programs. (J Am Coll Cardiol 2007;49:
1279–82) © 2007 by the American College of Cardiology Foundation
The ﬁeld of cardiovascular medicine is constantly evolving.
New discoveries in molecular cardiology, cardiovascular
genomics, and physiology have culminated in the develop-
ment of improved diagnostic methods and treatment ad-
vances, the results of which have allowed us to extend the
lives of our patients. Millions of dollars, from both govern-
ment and industry, currently fund countless studies in
prevention, advanced cardiac imaging, and novel interven-
tional therapeutics, to name just a few. However, there is an
area of cardiovascular medicine that has been largely over-
looked; an area so vitally important to our nation’s economy
but thus far given very little attention in terms of research
support, physician education, and public awareness. Despite
being one of the largest and most expensive aspects of U.S.
health care, representing an area of patient demand growing
at a rate far exceeding that of physician supply, we have
done little as of yet, as a discipline, to address the burgeon-
ing crisis of critical care.
The care of critically ill patients accounts for approxi-
mately 1% of the gross domestic product in this country (1).
Despite ﬁnding ourselves in this already profound economic
predicament, we know that the aging of the U.S. population
will only lead to additional predictable increases in the
demand for critical care services (2). At the same time, as it
stands now, the supply of physicians trained to provide
effective critical care will remain constant. Therefore, it has
been estimated that by 2020 there will be a deﬁcit of
intensivists that is equal to 22% of demand, and by 2030 this
deﬁcit will approach 35% (3).
Whereas other intensive care units (ICUs) have been
traditionally staffed by physicians who are board-certiﬁed in
critical care medicine, we have never dictated that our own
coronary care units (CCUs) be managed by cardiologists
with advanced training in the care of critically ill patients. It
is only a matter of time, however, before the cardiovascular
community faces challenges to this long-standing tradition.
It will be our response to these challenges that will pro-
foundly shape the future of our ﬁeld.
Evolution of the CCU
The ﬁrst description of the CCU was presented by Julian to
the British Thoracic Society in 1961 (4). Soon after, the ﬁrst
CCU was established in the U.S., followed shortly by a
landmark study from Killip and Kimball (5) conﬁrming the
importance of the CCU as a beneﬁcial tool in the manage-
ment of patients with acute myocardial infarction (MI).
Although many point to that landmark study as the foun-
dation for the modern-day risk-stratiﬁcation scheme that
bears their name, the often overlooked contribution of Killip
and Kimball (5) was their ability to show demonstrable
improvements in mortality for acute MI patients treated in
a CCU rather than a regular ward setting. Largely driven by
survival gains associated with the early recognition of
life-threatening arrhythmias, those results were monumen-
tal in establishing the beneﬁts of intensive care for the
high-risk cardiology patient.
The landscape of the CCU today, however, has changed
vastly from that of the 1960s. No longer is it simply an
observation unit for patients with acute MI, but rather it has
From the *Division of Cardiology, Duke University Medical Center, Durham, North
Carolina; and the †Duke Clinical Research Institute, Durham, North Carolina.
Manuscript received October 26, 2006; accepted November 8, 2006.
Journal of the American College of Cardiology Vol. 49, No. 12, 2007
© 2007 by the American College of Cardiology Foundation ISSN 0735-1097/07/$32.00
Published by Elsevier Inc. doi:10.1016/j.jacc.2006.11.036