From the rich and beautiful palaces and gardens in Versailles to management of the acute cardiac patient

Rafi Beyar

Marco Tubaro

The Third International Congress on Acute Cardiac Care, held in Versailles (France) on 25–28 October 2008, has addressed in a comprehensive way all the topics on Intensive and Acute Cardiac Care. Key issues have been thrombosis in acute coronary syndromes, the pre-hospital treatment of STEMI, acute heart failure in patients with coronary disease, the use of biomarkers in acute cardiac care and the accreditation of cardiologists working in ICCUs. More than 1100 delegates have taken part in this congress, as well as many ICCUs nurses in the nursing sessions.

This biannual congress (next edition in Copenhagen 2010), that will become annual starting 2011, has the main task of gathering cardiologists involved in Acute Cardiac Care from 50 countries and more belonging to the ESC, with the aim of creating a network of the European ICCUs for research and education and of improving the quality of acute cardiac care throughout Europe. The concept of providing a framework to acute cardiac conditions, including acute percutaneous interventions, acute cardiac and respiratory failures and acute arrhythmias was presented by a series of landmark presentations on various related issues. The important backbone of the meeting was the overall interrelationships between the different aspects of maintaining the cardiac patients in the acute setting. It is noteworthy that the acute setting is not confined to the coronary or respiratory acute care units, but rather spans the entire spectrum of the patient management from the ambulatory environment, through the hospital units and up to the acute hemodynamic, pharmacological, interventional, or surgical therapies.

In this issue of the Journal we find some important studies covering various aspects of acute care. A comprehensive review on the value of biochemical markers for risk stratification prior to hospital admission for acute chest pain is provided by Herlitz and Svensson [1] from Sweden. The ability to accurately diagnose acute myocardial infarction using novel biomarkers, as early as possible, is critical for the proper management of the patient. While many of the biomarkers have failed to do so accurately at the pre-hospital setting, some new studies show a potential use of such markers with what seems to be adequate accuracy. Obviously, we need larger studies and improved technologies to achieve major advances in this field.

With a similar rationale, our ability to profile the patient in the chest pain units bear similar consequences, better and earlier diagnosis of treatable conditions and optimizing medical care and cost. Martínez-Sellé s et al. [2] from Spain have studied a group of patients who had a catheterization after noninvasive testing in that setting and have found that one third of the patients will be diagnosed with normal coronary arteriography and the rest will be split between one and multivessel disease. A CPU-65 index proposed was found useful in determining the probability of significant coronary artery disease. We can rely on noninvasive tests in the setting of a chest pain unit. More specific studies should refine our combined clinical and laboratory results to guide us in our therapeutic approach.

Acute heart failure continues to be a challenge to medicine, with high short and long term mortality. Rossinen et al. [3] from Finland report results from the FINN-AKVA multicenter observational study that high mortality is associated with the use of more than one inotropic drug. While this may be the result of natural selection of patients, the use of multiple inotropes should be reserved for the patients who do not respond adequately to one inotrope. Our take home message from that ‘If you have to beat a severely ill horse, you should better do it with one whip which is relatively safe. Many whips will kill him’.

Therapy is always a risk adjusted intervention, weighing the benefits versus risks. Is routine heparin use during intra-aortic balloon counterpulsation, which is currently the standard of care, the right strategy? An original study is presented by Cooper et al. [4] from the USA, using a prospective analysis of consecutive patients. A selective heparin strategy appears to be superior to universal heparin use in these patients.

In another paper in this issue, Niedeggen et al. [5] report the use of Agratoban for treatment of cardiac thrombi. The therapy was effective in all patients and was associated with cerebral embolization which completely resolved in one patient. This paper guides us to a form of therapy that we can apply to our very complex patients in our emergency settings.

A few other interesting concepts and issues are presented. Elahi and Matata [6] from the UK comment on whether cardiotomy suction blood is ‘cell-saver’ processed, before re-transfusion. The risk of increased coagulation and potential excessive embolic load on the patient is presented. Processing this blood with a cell saving device is an approach that has been proposed to deal with this challenge. Successful percutaneous management of coronary dissection with extensive intramural hematoma is presented by Walsh et al. [7] from Canada. Pulmonary artery isolation complicated by Dressler syndrome is presented by Lucie et al. [8] from the UK. Appearance of a myocardial bridge after a successful intervention is shown by Georgiadou et al. [9] from Greece and finally a rare image of PCI of a single saphenous vein ‘snake’ bypass graft supplying eight target vessels is shown by Jokhi and Ricci [10] from Canada.

Overall, this interesting combination of burning issues as well as daily life questions in cardiac patients in the acute setting are nicely balanced in this issue. Enjoy the reading of this paper.