The Next Frontier in Critical Care Cardiology: Transforming Care, Training, and Research

In the 13 years since the preceding Scientific Statement, Critical Care Cardiology (CCC) has matured into a well-recognized and in-demand subspecialty of cardiology. There is increased trainee interest and pursuit of advanced training in CCC, and demand for critical care cardiologists is greater than the workforce supply. Within the United States, two CCC-specific conferences, the University of Minnesota Critical Care Cardiology Educational Symposium and the New York University Langone Critical Care Cardiology Symposium, now attract hundreds of attendees each year. In 2021, the Critical Care Cardiology Section of the American College of Cardiology (ACC) was formed, codifying the specialty within the professional society for cardiovascular disease. Most recently, the Society of Critical Care Cardiology was founded to provide a dedicated professional home for CCC. Within AHA, the Acute Care and General Cardiology Science Committee of the Council on Clinical Cardiology, as well as the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation (3CPR) , have continued to foster publications and educational programs in various topics related to CCC. Critical Care Cardiology programming continues to increase at both AHA Scientific Sessions and the ACC. Moreover, other non-cardiology professional associations, such as the American College of Chest Physicians (CHEST) and the Society for Critical Care Medicine (SCCM), have also started to embrace the importance of CCC, as evidenced by the growing number of sessions and publications at their annual meetings and within their affiliated journals.

Since the publication of the 2012 Scientific Statement, three large multicenter registries – the Cardiogenic Shock Working Group, the Critical Care Cardiology Trials Network and the AHA Cardiogenic Shock Registry - have formed, capturing the data for thousands of Cardiac Intensive Care Unit (CICU) patients and generating dozens of publications. Through these registries, CCC research is morphing from retrospective single-center publications, to multicenter, prospective studies, supporting implementation of evidence-based medicine within the CICU population and adoption of best practices.

In their AHA Scientific Statement "Evolution of Critical Care Cardiology: An Update on Structure, Care Deliver, Training and Research Paradigms," Sinha et al. highlight the evolution of CCC and the modern CICU, beginning with a historic overview of the provision of critical care for cardiac patients, followed by an updated description of the current CICU, including organizational structures, staffing models and definitions for levels of CICU care, previously proposed in the original statement by Dr. Morrow. While the structure of this Scientific Statement is similar to that of the 2012 statement, the present document benefits from a decade of data and experience to further refine the 2012 statement.

It is noteworthy, that for perhaps the first time in a Scientific Statement, the authors define a critical care cardiologist as a board-certified clinician with dual training and certification in cardiovascular disease and critical care medicine, noting the existence of a legacy pathway where board-certified cardiologists with significant historic CCC experience practice as critical care cardiologists. This definition is a major accomplishment – herein the authors clearly define the identity of these subspecialists in a way that will help inform future discussions as to necessary clinical competencies, training pathways, and scope of practice.

CICU Operations and Staffing

With respect to CICU operations and staffing, the authors' suggestions for best practice is a high-intensity, CICU-based staffing model (with high-intensity being synonymous with presence of a critical care medicine trained physician) where care is led by a critical care cardiologist or clinical cardiologist with consultation by a critical care physician. Furthermore, the authors state that Level 1 centers (those hospitals offering the highest level of critical care and cardiology services) should be staffed by clinicians with advanced expertise in CCC through dual-certification in cardiology and critical care, or engage in a collaborative co-management model whenever CCC expertise is not readily available. With these statements, the authors clearly define a Critical Care Cardiologist as well as the best practice model for Level 1 CICUs.

Notably, since the publication of the 2012 Scientific Statement, at least 5 studies have demonstrated ‘high-intensity staffed' CICU care is associated with an improvement in mortality as well as a reduction in length-of-stay and CICU costs per patient.^2–6 The availability of CICU-specific data stands as a notable achievement of the preceding 13 years. It must be acknowledged these data are still largely retrospective, single-center, and derived from small sample sizes, however, these data mark the emergence of a CICU-specific evidence base.

Consistent with the European Society of Cardiology and the Canadian Cardiovascular Society, the authors of the Scientific Statement support a three-tiered CICU structure whereby CICUs are categorized by patient acuity, monitoring and therapeutic capabilities, availability of subspecialty staffing, nursing ratios, and allied health resources. Sinha et al. suggest that CICUs of all levels function collaboratively within regional systems-of-care and suggest healthcare systems implement standardized criteria for consultation, admission, transfer and repatriation. The regional system approach can also help solve for access to care issues in underserved regions as well as the heterogeneity of CICU acuity across the country. New to this discussion since the prior version of this Scientific Statement is the use of the SCAI shock classification to guide patient triage and the suggestion for the utilization of cardiogenic shock teams and protocols given the growing body of evidence for their ability to improve patient outcomes.^7–10

The updated Scientific Statement provides the opportunity to highlight which of the proposed best practices have been accomplished and those not yet implemented. Thirteen years have passed since Dr. Morrow and colleagues suggested "the evidence supports a closed structure with staffing by dedicated cardiac intensivists… as a preferred approach for the advanced CICU." This, as previously mentioned, is re-iterated in the current Scientific Statement.

Unfortunately, Sinha et al., highlight the current state of the American CICU does not yet reflect this vision. In fact, in a 2012 survey of predominantly academic medical center CICUs, 68% of hospitals had a dedicated CICU, of which only 55% had a CICU-based physician, and only 32% routinely had involvement of a critical care physician.¹¹ In a broader survey published in 2017, almost three-quarters of CICUs in the United States were ‘open or low intensity'.¹² This data underscores the reality that there must be significant investments into systems of care, CICU infrastructure, hospital and clinician staffing, critical care education, and other necessary resources to standardize and actualize a closed CICU.

Furthermore, Sinha's statement also highlights the importance of multidisciplinary team members in the CICU, and their impact on the current mismatch in supply and demand for CCC health care professionals. They discuss staffing models currently used in many CICUs, where specialized nurse practitioners and/or physician assistants, broadly referred to as "advanced practice providers", have become a key part of the workforce demonstrating a positive impact in patient outcomes, quality metrics and trainee experience.^13,14

As cardiovascular diseases remain a leading cause of morbidity and mortality globally, integrating CCC into healthcare systems ensures timely, expert management of life-threatening cardiac events, such as shock, MI, acute heart failure, arrhythmias, or post-surgical complications. From a business and operational perspective, this crucial specialty can reduce the length of ICU stays, improve survival rates, and decrease the incidence of long-term complications, all of which contribute to cost savings and enhanced resource utilization. Additionally, with increasing demand for high-quality, intensive care services, CCC allows hospitals to attract specialized talent, improve reputation, and provide comprehensive care to patients with complex cardiovascular conditions, positioning healthcare institutions for long-term success in an evolving, patient-centric market.

Critical Care Cardiology Training

The authors continue to grapple with the lack of clinical competencies and defined training pathways. Despite existing literature surrounding necessary clinical competencies and potential training pathways, there is still extreme heterogeneity and lack of consensus as to what CCC must encompass, how long this should take, and the order in which these skills should be achieved.

In the 2012 Scientific Statement, Morrow et al. described the existing pathway for dual certification in cardiovascular and critical care medicine, noting trainees seeking dual certification most commonly do so by enrollment in an ACGME-accredited 1-year program in critical care medicine after completion of a cardiovascular medicine fellowship. They noted the appeal of integrating cardiovascular and critical care medicine fellowships into a 4-year fellowship, but acknowledged this would require significant changes to existing programmatic options. The 2025 Scientific Statement again supports the development of an integrated 4-year fellowship but notes the current state of CCC training remains the same as in 2012, with most trainees pursuing a traditional model of training in cardiovascular medicine and critical care medicine. The lack of progress on this recommendation highlights the challenges of combining fellowship programs across multiple medical specialties with a lack of unified leadership, differential resources and funding, as well as limitations for which hospitals and training programs have the ability to offer such combined pathways.

Conclusion

The updated AHA Scientific Statement on CCC serves as a vital reflection on the progress made since the 2012 landmark AHA statement and underscores the ongoing evolution of this dynamic subspecialty. While significant strides have been made in defining the identity of critical care cardiologists, enhancing CICU operations, and expanding CCC research efforts, the statement also highlights persistent gaps in achieving a standardized, high-intensity care model and comprehensive and inclusive training pathways

As acute cardiovascular disease continues to pose substantial systemic health burden, the integration of CCC into healthcare systems is both a clinical imperative and a strategic opportunity. The advancements and best practices outlined in this statement serve as a roadmap for addressing educational, operational, and workforce challenges, ensuring the delivery of high-quality, evidence-based care. The clear vision and actionable suggestions offered in this document provide a strong foundation for the next decade of progress in critical care cardiology.