In This Article
- Critical care cardiology training pathways across the United States lack uniform standards
- Massachusetts General Hospital's David Dudzinski, MD, JD, a national advocate for critical care cardiology training, is part of a multi-institutional panel that has proposed a standard novel critical care cardiology pathway
- The need for training standardization is apparent as the demand for specialized cardiologists in cardiac intensive care units grows due to new life-sustaining technologies and an influx of patients with multiple comorbidities
- Mass General is hosting a two-day virtual seminar designed to educate clinicians about critical care cardiology topics and share best practices
A Massachusetts General Hospital cardiologist recently served on a multi-institutional panel to outline a novel critical care cardiology training pathway. The proposed curriculum was published in the Journal of The American College of Cardiology.
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"Critical care cardiology is a new and rapidly evolving field," says David Dudzinski, MD, JD, director of the Cardiac Intensive Care Unit in the Corrigan Minehan Heart Center at Mass General. "There is robust national and international interest in broadening the scope of training, similar to every other subspecialty of cardiology. With that impetus, we can have a national discussion on standards of practice for future cardiologists who want to specialize in critical care cardiology. The American College of Cardiology is also investing heavily in this area by hosting dedicated content pathways at ACC.23, launching a brand new member section in 2022, and partnering with stakeholders to define this new training and practice area."
Current State of Critical Care Cardiologist Training
Any cardiologist boarded by the American Board of Internal Medicine can become critical care certified. But there is currently no standard curriculum for cardiologists seeking training in critical care medicine (CCM). Dr. Dudzinski says this has resulted in a lack of uniformity in training standards across institutions.
"When I was a fellow in 2009, it took me years to create my own pathway toward certification. Unfortunately, everyone is recreating the process of becoming certified in critical care cardiology within their own institutional needs and structure. Nationally we have observed a patchwork of different regulations depending on how a particular institution's graduate medical education framework is organized, and how the institution operates their clinical service lines spanning cardiology, critical care, cardiac surgery, and cardiac anesthesia," he says.
Survey data published in the Journal of the American Heart Association show that physicians practicing in cardiac intensive care units (CICUs) acknowledge the need for standard, specialized training. "We recognize the need for this training, so it is in our best interests nationally to formulate consensus standards and milestones for contemporary cardiologists to become trained in critical care medicine and practice in the modern CICU," says Dr. Dudzinski.
New Technologies and Managing Complex Patients Requires Holistic Training
Dr. Dudzinski says as recently as 15 years ago, life-sustaining technologies such as percutaneous mechanical circulatory support extracorporeal membrane oxygenation (ECMO) were not routinely needed in CICUs. CICUs were primarily occupied by patients who had experienced a heart attack and needed monitoring. Those patients typically had one issue and may not have been considered critically ill by today's CICU.
"Those are not the patients in our CICUs now," he says.
A 2017 study published in Circulation: Cardiovascular Quality and Outcomes found acute coronary syndromes declined as the primary CICU admitting diagnosis from 32.3% to 19% between 2003 and 2013. Additional studies have suggested that CICUs also care for an increasing number of patients with chronic cardiovascular conditions who present with acute noncardiac illnesses (published in Critical Care Medicine). Three factors are thought to be contributing to this increase in medically complex CICU patients:
- An aging population with an increased number of non-cardiac organ dysfunctions
- Decreases in coronary artery disease as the chief presenting issue
- Shifts in risk factors for cardiovascular disease
"Now, our CICU patients have multiple comorbidities, such as renal, infectious, and respiratory dysfunction. These comorbidities substantially impact cardiac physiology and outcomes from critical cardiac illness," says Dr. Dudzinski. "We are seeing an influx of patients dependent on a machine at their bedside for life."
Proposed Critical Care Cardiology Curriculum
Critical care cardiologists must now be experts in how best to use these life-sustaining devices.
"Cardiologists trained in this specialty bring together the best concepts of the medical intensive care unit and cardiology to manage such complex patients," Dr. Dudzinski says. At the same time, he says, the best CICU care comes from a holistic approach that takes into account how the machines affect other organs in the body and incorporates multiple disciplines, including nutrition and physical therapy, into care plans.
Delivering this kind of complex care to fragile patients requires expertise beyond general cardiology training. This emerging cardiology subspeciality based in CCM expands training for cardiologists to be able to manage this patient population.
"You need a different infrastructure and approach in order to deliver care effectively to these patients, and that's where novel training enters," says Dr. Dudzinski.
In 2019, epidemiologic data from the Critical Care Cardiology Trials Network (CCCTN) published in JAMA found that the leading indication for CICU admission was respiratory failure, and the second was shock. These data informed the specific training areas that the panel has proposed fellowships prioritize for cardiologists' training in CCM. They include:
- Airway and ventilator management
- Management of mixed shock
- Direct management of mechanical circulatory support modalities
- Familiarity with renal replacement therapy
- Management of neurological emergencies
- Postoperative cardiac surgery management
The recommended curriculum requires 12 months of training. At Mass General, the Cardiac Critical Care (CCC) fellowship, established in 2020, includes immersive rotations in the medical intensive care unit, general surgery critical care, interventional pulmonology, cardiac operating room, mechanical and circulatory support, and neurocritical care.
"The modern critical care cardiologist effectively needs the skills to be able to walk into a medical cardiac intensive care unit or a surgical cardiac intensive care unit and be able to contribute to the care of all of those patients. A large focus of the CCC curriculum here at Mass General is developing both a breadth and depth of CCM experience in senior cardiology fellows that will prepare them for future practice," says Dr. Dudzinski, who leads the CCC fellowship at Mass General.
The Future of Critical Care Cardiology
As the CCC field evolves, Dr. Dudzinski hopes that regulating bodies will further intensify care and training standards. In February of 2022, the American College of Cardiology opened a section dedicated to critical care cardiology, with an eye toward facilitating further collaboration and support for the growing number of cardiologists interested in the specialty.
The Corrigan Minehan Heart Center at Mass General is hosting a two-day virtual seminar to educate clinicians about CCC topics so they can provide comprehensive guideline-based and best-practice in care to CICU patients. The hospital will live stream the 5C: Concepts in Contemporary Critical Care Cardiology on April 28 and 29, 2023.
"We at Mass General aim to support the growing national interest in critical care cardiology. This multidisciplinary presentation is another way we contribute to that mission," says Dr. Dudzinski. "In the future, I envision the growth of more networks and collaborative clinical trials as this specialty develops in its national identity and acceptance."
With that collaboration in mind, Dr. Dudzinski invites all contemporary cardiac and cardiac critical care practitioners to 5C, including physicians, nurses, NP/PA, pharmacists, respiratory and ECMO specialists, and allied disciplines, noting that the 5C faculty draws from all of these specialities.
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