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as well as specific care bundles and protocols&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Advances in the therapeutic armamentarium&#44; from optimal medical treatment to increasingly complex percutaneous coronary and structural intervention&#44; have brought us to the point where we stand today&#58; ever greater patient age&#44; complexity and level of comorbidities&#46; This has profound impact on human and technical resources required in CICUs&#44; as well as on patient&#39;s length and prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Interestingly&#44; some studies on temporal trends in CCUs show a decrease in in-hospital mortality when adjusted for clinical severity&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There have been important epidemiologic changes along this way&#44; from predominantly of acute coronary syndrome &#40;ACS&#41;&#44; to a much wider variety of cardiovascular conditions&#46; It is estimated that less than half of patient admissions are nowadays due to ACS&#44; with a shift toward fewer cases of ST-elevation ACS&#44; and more of non-ST-elevation ACS&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#8211;5</span></a> Other cardiovascular conditions frequently encountered include acute decompensated heart failure&#44; valvular heart disease&#44; rhythm disturbances&#44; myocardial and pericardial disease&#44; complex congenital heart disease&#44; pulmonary hypertension&#44; pulmonary thromboembolism&#44; as well as iatrogenic complications of complex coronary and structural heart interventions&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Altogether&#44; this led to a change in terminology&#44; from coronary care units to intensive cardiovascular care units &#40;ICCUs&#41;&#44; also known as cardiac intensive care units &#40;CICUs&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The first CICU in Portugal was founded in 1969 in Lisbon by Ars&#233;nio Cordeiro&#44; and the concept spread as fast as country&#39;s financial and bureaucratic constraints allowed&#44; up to the point by the late 1990s when every tertiary hospital had its own CCU&#46; Different levels of care are found in these units&#44; and there is great variation according to geographic region&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The classification proposed by the European Society of Cardiology&#39;s Acute Cardiovascular Care Association &#40;ACCA&#41; for levels of care in the ICCU is summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> There are currently eighteen ICCUs in Portugal&#44; of which eight are Level III units&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> There are virtually no epidemiological and clinical data available on this type of unit in Portugal&#46; Here we present a picture of a contemporary Portuguese level III ICCU&#44; with a total capacity of eight beds&#44; over a period of three consecutive years&#44; 2014 to 2016 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Patients were predominantly male &#40;68&#37;&#41;&#44; with a mean age of 67&#46;1&#177;14&#46;2 years&#44; 21&#37; of patients were aged 80 years&#46; Acute decompensated heart failure patients now represent one sixth of the total&#44; and frequently need advanced therapeutic and monitoring strategies&#44; longer ICCU stay &#40;2&#46;4&#177;1&#46;9 vs&#46; 3&#46;4&#177;3&#46;3 days&#59; p&#61;0&#46;01&#41;&#44; and higher rehospitalization rates at 30 days &#40;representing almost 90&#37; of all readmissions&#44; with a global readmission rate of 2&#37;&#41;&#46; Overall in-hospital mortality was 3&#46;1&#37; in the studied time period&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Contemporary ICCU admissions are often complicated by non-cardiovascular illnesses&#44; the most frequent being acute respiratory failure&#44; acute kidney injury&#44; and sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> End-organ support is frequently needed&#44; and familiarity of staff with a range of modalities from mechanical ventilation to extracorporeal life support is key to achieving the best possible clinical outcomes&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> presents statistical data on this subject&#44; based on our recent experience over three years&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The greater prevalence of non-cardiovascular diagnosis and related end-organ dysfunctions&#44; together with the patient&#39;s increasing age and broader spectrum of interventions performed&#44; poses unique challenges&#46; Cardiologists in ICCUs are now faced with a highly specific subset of critically ill patients&#44; and yet with the need of an integrated intensive-care approach&#46; Although the need for dedicated general intensivists in Level III unit teams is widely recognized&#44; there is general consensus among cardiology societies and working groups that a cardiac intensivist should be the team leader in these units&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">A multitude of subspecialization programs for intensive cardiovascular care have been proposed&#44; none of them with good implementation rates&#46; The added difficulties caused by regional and national differences are bringing the implementation of standardized specialization programs to a halt&#46; There is no national certifications available for acute cardiac care in Portugal at the present time&#44; whether for physicians&#44; allied professionals&#44; or training centers&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> However&#44; the Portuguese Society of Cardiology recommends ACCA certification&#46; In 2014&#44; the ACCA published a core curriculum that set out optimal training standards for critical care cardiologists &#40;available for those who achieved competency in general cardiology&#41;&#44; comprising a minimum of 12 months of additional training in the ICCU&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> An alternative pathway consists in completing a two-year subspecialization program in intensive care medicine&#46; Another significant challenge over the next few years may be appropriate patient selection for the myriad of techniques and devices available&#46; This is in line with the need to develop research programs&#44; in order to provide evidence on which to base the selection criteria for certain end-organ support modalities and advanced heart failure interventions&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The concept of the heart team&#44; which was first arose in the area of structural heart interventions&#44; has a long road ahead in this mission&#46; The routine integration of cardiac intensivists in these teams is not only intuitive&#59; it is crucial&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the end of the day it is as important both to prolong patient&#39;s lives and increase quality of life and to avoid suffering and futility&#46; The bar is now settled high in what we can offer to our patients&#44; but we still have to allow Hippocratic and other essential ethical principles to guide us in the most difficult scenarios&#46; A wide-ranging discussion on palliative and end-of-life care in ICCUs is now taking place&#44; and teams should be familiarized with such protocols&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion&#44; recent decades have seen spectacular developments in this most fascinating field in cardiology&#44; but current challenges appear to be poised to surpass those that have been overcome&#46; Contemporary Level III ICCUs must have dedicated and highly specialized staff&#44; and serious commitment with clinical investigation in order to further improve patient outcomes&#46; This commitment starts with scrupulous epidemiologic and clinical data reporting&#44; and the use of self-evaluation metrics&#44; both of which have been hereby attempted by the authors&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Main diagnoses at admission to a Portuguese level III intensive cardiovascular care unit&#46; Data are from 2014-2016&#46; The total number of patients was 2641&#44; and percentages of this value are presented&#46; ACS&#58; acute coronary syndrome&#59; ICCU&#58; intensive cardiovascular care unit&#59; NSTEMI&#58; non-ST-elevation myocardial infarction&#59; PCI&#58; percutaneous coronary intervention&#59; STEMI&#58; ST-elevation myocardial infarction&#46;</p>"
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        "etiqueta" => "Table 1"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Bi-VAD&#58; biventricular assist device&#59; IABP&#58; intra-aortic balloon pump&#59; ICCU&#58; intensive cardiovascular care unit&#59; LVAD&#58; left ventricular assist device&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">LEVEL I ICCUBasic cardiovascular intensive care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">LEVEL II ICCUAdvanced cardiovascular intensive care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">LEVEL III ICCUCardiovascular critical care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&#8226; All non-invasive clinical parameters monitoring&#8226; 24&#47;7 Echocardiography and thoracic ultrasound&#8226; Direct current cardioversion&#8226; Non-invasive ventilation&#8226; Transcutaneous temporary pacing&#8226; Chest tubes&#8226; Nutrition support&#8226; Physiotherapy in ward&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">As in level I ICCU plus</span>&#8226; Ultrasound-guided central venous line insertion&#8226; Pericardiocentesis&#8226; Transvenous temporary pacing&#8226; Transoesophageal echocardiography&#8226; Pulmonary artery catheter&#47;right heart catheterization&#8226; Percutaneous circulatory support &#40;IABP&#44; percutaneous axial pump&#41;&#8226; Targeted temperature management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">As in level II ICCU plus</span>&#8226; Extracorporeal life support&#8226; Mechanical circulatory support &#40;LVAD&#44; Bi-VAD&#41;&#8226; Renal replacement therapy&#8226; Mechanical ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Levels of intensive cardiovascular care units&#44; by technical capacities and expertise required &#40;adapted from Bonnefoy-Cudraz E&#46; et al&#46;&#44; 2017&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">AKI&#58; acute kidney injury&#59; VA ECMO&#58; veno-arterial extracorporeal membrane oxygenation&#59; LVAD&#58; left ventricular assist device&#59; RRT&#58; renal replacement therapy&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of patients&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Percentage of the total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Circulatory support&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inotropic&#47;vasopressor support&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IABP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Short-term LVAD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VA ECMO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Temporary transvenous pacemaker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">147&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pericardiocentesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe respiratory dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">167&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Invasive mechanical ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">115&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Non-invasive mechanical ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AKI requiring RRT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Letter to the Editor
Intensive cardiovascular care units after half a century: Insights from the Portuguese experience
Unidades de cuidados intensivos cardíacos meio século depois: a experiência Portuguesa
Pedro Gonçalves-Teixeiraa,b,
Autor para correspondência
, Ana Raquel Barbosaa, Marisa Silvaa, João Gonçalves Almeidaa, Marta Pontea, Adelaide Diasa, Ricardo Fontes-Carvalhoa,b, Pedro Bragaa, Daniel Caeiroa
a Cardiology Department, Gaia Hospital Center, Vila Nova de Gaia, Portugal
b Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
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    "titulo" => "Intensive cardiovascular care units after half a century&#58; Insights from the Portuguese experience"
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        "autoresLista" => "Pedro Gon&#231;alves-Teixeira, Ana Raquel Barbosa, Marisa Silva, Jo&#227;o Gon&#231;alves Almeida, Marta Ponte, Adelaide Dias, Ricardo Fontes-Carvalho, Pedro Braga, Daniel Caeiro"
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        "titulo" => "Unidades de cuidados intensivos card&#237;acos meio s&#233;culo depois&#58; a experi&#234;ncia Portuguesa"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Main diagnoses at admission to a Portuguese level III intensive cardiovascular care unit&#46; Data are from 2014-2016&#46; The total number of patients was 2641&#44; and percentages of this value are presented&#46; ACS&#58; acute coronary syndrome&#59; ICCU&#58; intensive cardiovascular care unit&#59; NSTEMI&#58; non-ST-elevation myocardial infarction&#59; PCI&#58; percutaneous coronary intervention&#59; STEMI&#58; ST-elevation myocardial infarction&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">First introduced in 1960s in response to the extremely high mortality in acute coronary syndromes&#44; Coronary Intensive coronary care units &#40;CCUs&#41; were the first intensive care units dedicated specifically to cardiovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Over the years up to the present&#44; they have undergone a fantastic journey from close electrocardiographic monitoring and prompt defibrillation of malignant ventricular arrhythmias to full extracorporeal life support&#46; It is nonetheless important looking to look back to the foundations&#58; these units remain the best place to monitor and treat critically ill cardiovascular patients&#44; not only because of the availability of sophisticated end-organ support technology&#44; but also because they can call on a highly trained staff of nurses and physicians&#44; as well as specific care bundles and protocols&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Advances in the therapeutic armamentarium&#44; from optimal medical treatment to increasingly complex percutaneous coronary and structural intervention&#44; have brought us to the point where we stand today&#58; ever greater patient age&#44; complexity and level of comorbidities&#46; This has profound impact on human and technical resources required in CICUs&#44; as well as on patient&#39;s length and prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Interestingly&#44; some studies on temporal trends in CCUs show a decrease in in-hospital mortality when adjusted for clinical severity&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There have been important epidemiologic changes along this way&#44; from predominantly of acute coronary syndrome &#40;ACS&#41;&#44; to a much wider variety of cardiovascular conditions&#46; It is estimated that less than half of patient admissions are nowadays due to ACS&#44; with a shift toward fewer cases of ST-elevation ACS&#44; and more of non-ST-elevation ACS&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#8211;5</span></a> Other cardiovascular conditions frequently encountered include acute decompensated heart failure&#44; valvular heart disease&#44; rhythm disturbances&#44; myocardial and pericardial disease&#44; complex congenital heart disease&#44; pulmonary hypertension&#44; pulmonary thromboembolism&#44; as well as iatrogenic complications of complex coronary and structural heart interventions&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Altogether&#44; this led to a change in terminology&#44; from coronary care units to intensive cardiovascular care units &#40;ICCUs&#41;&#44; also known as cardiac intensive care units &#40;CICUs&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The first CICU in Portugal was founded in 1969 in Lisbon by Ars&#233;nio Cordeiro&#44; and the concept spread as fast as country&#39;s financial and bureaucratic constraints allowed&#44; up to the point by the late 1990s when every tertiary hospital had its own CCU&#46; Different levels of care are found in these units&#44; and there is great variation according to geographic region&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The classification proposed by the European Society of Cardiology&#39;s Acute Cardiovascular Care Association &#40;ACCA&#41; for levels of care in the ICCU is summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> There are currently eighteen ICCUs in Portugal&#44; of which eight are Level III units&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> There are virtually no epidemiological and clinical data available on this type of unit in Portugal&#46; Here we present a picture of a contemporary Portuguese level III ICCU&#44; with a total capacity of eight beds&#44; over a period of three consecutive years&#44; 2014 to 2016 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Patients were predominantly male &#40;68&#37;&#41;&#44; with a mean age of 67&#46;1&#177;14&#46;2 years&#44; 21&#37; of patients were aged 80 years&#46; Acute decompensated heart failure patients now represent one sixth of the total&#44; and frequently need advanced therapeutic and monitoring strategies&#44; longer ICCU stay &#40;2&#46;4&#177;1&#46;9 vs&#46; 3&#46;4&#177;3&#46;3 days&#59; p&#61;0&#46;01&#41;&#44; and higher rehospitalization rates at 30 days &#40;representing almost 90&#37; of all readmissions&#44; with a global readmission rate of 2&#37;&#41;&#46; Overall in-hospital mortality was 3&#46;1&#37; in the studied time period&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Contemporary ICCU admissions are often complicated by non-cardiovascular illnesses&#44; the most frequent being acute respiratory failure&#44; acute kidney injury&#44; and sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> End-organ support is frequently needed&#44; and familiarity of staff with a range of modalities from mechanical ventilation to extracorporeal life support is key to achieving the best possible clinical outcomes&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> presents statistical data on this subject&#44; based on our recent experience over three years&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The greater prevalence of non-cardiovascular diagnosis and related end-organ dysfunctions&#44; together with the patient&#39;s increasing age and broader spectrum of interventions performed&#44; poses unique challenges&#46; Cardiologists in ICCUs are now faced with a highly specific subset of critically ill patients&#44; and yet with the need of an integrated intensive-care approach&#46; Although the need for dedicated general intensivists in Level III unit teams is widely recognized&#44; there is general consensus among cardiology societies and working groups that a cardiac intensivist should be the team leader in these units&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">A multitude of subspecialization programs for intensive cardiovascular care have been proposed&#44; none of them with good implementation rates&#46; The added difficulties caused by regional and national differences are bringing the implementation of standardized specialization programs to a halt&#46; There is no national certifications available for acute cardiac care in Portugal at the present time&#44; whether for physicians&#44; allied professionals&#44; or training centers&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> However&#44; the Portuguese Society of Cardiology recommends ACCA certification&#46; In 2014&#44; the ACCA published a core curriculum that set out optimal training standards for critical care cardiologists &#40;available for those who achieved competency in general cardiology&#41;&#44; comprising a minimum of 12 months of additional training in the ICCU&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> An alternative pathway consists in completing a two-year subspecialization program in intensive care medicine&#46; Another significant challenge over the next few years may be appropriate patient selection for the myriad of techniques and devices available&#46; This is in line with the need to develop research programs&#44; in order to provide evidence on which to base the selection criteria for certain end-organ support modalities and advanced heart failure interventions&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The concept of the heart team&#44; which was first arose in the area of structural heart interventions&#44; has a long road ahead in this mission&#46; The routine integration of cardiac intensivists in these teams is not only intuitive&#59; it is crucial&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the end of the day it is as important both to prolong patient&#39;s lives and increase quality of life and to avoid suffering and futility&#46; The bar is now settled high in what we can offer to our patients&#44; but we still have to allow Hippocratic and other essential ethical principles to guide us in the most difficult scenarios&#46; A wide-ranging discussion on palliative and end-of-life care in ICCUs is now taking place&#44; and teams should be familiarized with such protocols&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion&#44; recent decades have seen spectacular developments in this most fascinating field in cardiology&#44; but current challenges appear to be poised to surpass those that have been overcome&#46; Contemporary Level III ICCUs must have dedicated and highly specialized staff&#44; and serious commitment with clinical investigation in order to further improve patient outcomes&#46; This commitment starts with scrupulous epidemiologic and clinical data reporting&#44; and the use of self-evaluation metrics&#44; both of which have been hereby attempted by the authors&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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                  \t\t\t\t" scope="col">LEVEL I ICCUBasic cardiovascular intensive care&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Inotropic&#47;vasopressor support&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">IABP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Short-term LVAD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VA ECMO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Temporary transvenous pacemaker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">147&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Pericardiocentesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe respiratory dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">167&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Invasive mechanical ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">115&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Non-invasive mechanical ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AKI requiring RRT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
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                            0 => "J&#46;N&#46; Katz"
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                      "doi" => "10.1016/j.jacc.2016.04.036"
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Informação do artigo
ISSN: 08702551
Idioma original: Inglês
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Idiomas
Revista Portuguesa de Cardiologia
en pt

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

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