The evolution of cardiac intensive care units (CICU) comes with clinical and cost-related inefficiencies that can be soothed with targeted clinical research and updated decision-making resources, which help physicians identify the patients who would most benefit from these units, according to a recent opinion piece published in Circulation

Based on clinical advances and available medical research, the study researchers suggest a change in triage protocols for modern tertiary coronary care units, from patients with acute myocardial infarction to those with exceptionally high needs (eg, patients with primary cardiovascular diagnoses, other comorbidities, or organ failure). There is a clear variance in CICU population admission rates. For instance, among patients with acute heart failure, CICU admission should be approximately 12%, according to estimates on the incidence of hospital complications. However, observational studies show that acute heart failure CICU admissions range from 0% to 88% in the United States and Canada. 

The researchers also noted a Canadian retrospective study on admissions for non-ST-segment–elevation acute coronary syndrome that estimated $113 million in healthcare savings if “medium- and high-tertile non-ST-segment–elevation acute coronary syndrome CICU use hospitals adopted low CICU admission practices.” 

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Based on these data, the researchers recommend greater insights to inform providers about the most appropriate and cost-effective use of contemporary CICUs. To that aim, the researchers have proposed detailed criteria to aid practitioners in determining the appropriateness of CICU admissions stratified by perceived CICU benefits and goals of care; CICU-level therapies, devices, or nursing care; and risk for clinical deterioration associated with common CICU diagnoses (eg, heart failure and shock, atrial or ventricular arrhythmias, conduction disease, or endocarditis). The proposed decision pathway directs its users with criteria illustrating when a patient is generally inappropriate for CICU, potentially appropriate, and appropriate. 

The researchers acknowledged that although they have used observational data to describe and establish a rationale for CICU admissions, “formal appropriate use criteria generally rest on evidence-driven Class I professional society guidelines.” They concluded by noting that “the future development and implementation of evidence-based criteria to reduce variations in CICU admission practices, particularly among low-risk patients who do not require CICU-restricted therapies, [have] the potential to reduce healthcare costs and to ease strain on critical care capacity without an undue influence on patient-centered outcomes.”

Disclosure: One study author declared an affiliation with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


van Diepen S, Katz JN, Morrow DA. Will cardiac intensive care unit admissions warrant appropriate use criteria in the future? Circulation. 2019;140(4):267-269