2. History of coronary care in the United States

In the early 1960s, there was no established treatment strategy for dealing with heart attack patients in the US [17]. Patients with crushing chest pain and evidence of myocardial infarction were admitted to the hospital for supportive care, but little could be done to halt the heart attack or minimize damage to the heart muscle. The development of the first coronary care unit (CCU) in a community hospital in Bethany, Kansas, by Hughes Day, MD, USA, marked a revolutionary change in provision of care. Within 6 years, every hospital in the US had a coronary care unit [18].

Early coronary care units treated patients suffering myocardial infarctions by providing prompt resuscitation for ventricular fibrillation and later prevented this lethal dysrhythmia with administration of intravenous lidocaine. Overall, during the 'dysrhythmia phase' of coronary care, mortality from heart attacks was reduced from 30 to -15% [19]. Development of the Swan-Ganz catheter, which allowed measurement of cardiac dysfunction and monitoring of inotropic therapy for shock and congestive heart failure, furtherreduced mortality related to heart attacks to 12% [19], but care was still palliative.

Thrombolytic therapy, the next major advance in cardiac care, dramatically changed the treatment of myocardial infarction to positive heart attack care. Opening coronary vessels within less than 6 h following acute thrombotic occlusion further reduced mortality to 6% and reduced infarct size significantly [4]. Further study revealed that earlier administration of thrombolytic therapy (within 70 min of symptom onset) could reduce mortality to 1.2%. Equally impressive, now progression to a full myocardial infarction often can be avoided [4]. This changed the basic treatment paradigm - by earlier intervention, physicians could mitigate or even prevent the progression of the acute coronary syndrome.

Coronary care units stimulated astonishing progress in the diagnosis and treatment of heart attacks, creating a 'high-tech' and extremely expensive environment. Unfortunately, coronary care units are often crowded with patients to rule out myocardial infarction. The next major improvement in cardiac care will be triage-oriented: insuring that appropriate medical therapy reaches the people who need it, while identifying low and moderate-risk patients to reduce unnecessary hospital admissions. Only 25% of heart attack patients actually receive thrombolytic therapy, and only 10% receive it within the 'golden first hour' when it achieves its greatest therapeutic effect [20]. Thus, only 2-3% of all heart attack patients receive optimal benefit from thrombolytic reperfusion. Further, it has been estimated that 5% of myocardial infarction patients are inadvertently released from emergency departments, and 16% of those subsequently die [7, 8].

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