Historical Perspectives in Cardiology Resuscitating a Circulation Abstract to Celebrate the 50th Anniversary of the Coronary Care Unit Concept

of Day’s talk “An Intensive Coronary Care Area in Action.” His Los Angeles audience listened to the Kansas City cardiologist describe his unit and watched “a color motion picture of the area showing the equipment and its use.”24 The college’s journal published the text of his talk in October. Recalling the California meeting, Day explained that Corday “saw the possibilities of the idea and became one of the outstanding leaders in the field of training.”25 Corday became president of the American College of Cardiology (ACC) in 1965 and used his position to promote the CCU model. He created and chaired the college’s Special Committee for Liaison with Congress, the Surgeon General, and the National Institutes of Health the same year that President Lyndon Johnson signed the Heart Disease, Cancer, and Stroke Amendments of 1965 into law. Known as the Regional Medical Programs Act, the law would accelerate the diffusion of the CCU model.26 It authorized grants to “assist in the establishment of regional cooperative arrangements among medical schools, research institutions, and hospitals for research and training (including continuing education) and for related demonstrations of patient care in the fields of heart disease, cancer, stroke, and related diseases ... to afford to the medical profession and the medical institutions ... the opportunity of making available to their patients the latest advances in the diagnosis and treatment of these diseases.”27 Corday also created the ACC’s Bethesda Conference, a theme-based meeting model that united a small number of cardiologists considered topic experts with government representatives and other interested parties to discuss a specific subject and to publish a report. He invited Day to chair a conference on “Training Technics for the Coronary Care Unit” and suggested a dozen doctors and 4 nurses who should participate. In addition to Corday and Day, 23 individuals attended the December 1965 conference. They included the cardiologist–head nurse teams who launched America’s earliest CCUs at the Presbyterian Hospital in Philadelphia, PA (Lawrence Meltzer, Roderick Kitchell, and Rose Pinneo); the New York Hospital in Manhattan, NY (Thomas Killip and Mary Fordham); the Miami (FL) Heart Institute (Paul Unger and Adeline Jenkins); and the Peter Bent Brigham Hospital in Boston, MA (Bernard Lown). Their report contained recommendations on CCU design, cardiac resuscitation, and coronary care nursing.28 The following year, Corday wrote to Senator Lister Hill, coauthor of the Hill-Burton Act, which supported hospital construction, and a champion of National Institutes of Health funding. Hill thanked Corday for writing “with respect to the need for coronary care units in hospitals” and said that he would give the Bethesda Conference Report his “careful attention” (Lister Hill to Eliot Corday; June 27, 1966; ACC Archives; Washington, DC; quoted with permission). With 1 exception, the participants in the Bethesda Conference were pioneers of the CCU movement or in positions of influence at the Public Health Service or the National Heart Institute (as it was then known). Jeremy Swan, an Irish-American physiologist who had been at the Mayo Clinic since 1951, had never worked in a CCU, but he had extensive experience in cardiac catheterization. Most important, Corday had just recruited him as the first chief of cardiology at Cedars-Sinai Medical Center. This new name reflected the recent affiliation of Cedars of Lebanon Hospital with Mount Sinai Hospital, located 6 miles away. When Corday heard Day speak in Los Angeles in 1962, the Kansas City unit was the only CCU in the United States. Not for long. Four years later, Howard Burchell, a Mayo Clinic cardiologist and the editor of Circulation, marveled over the “mushrooming of coronary units” across the country. More than 200 were already in operation.29 The time lag between the first descriptions of the CCU concept in Circulation and the Lancet in 1961 and the widespread implementation of the model in the United States was incredibly short, considering its implications for staff, space, equipment, and patient care. This rapid diffusion was the antithesis of the phenomenon of resistance to innovation written about recently by Ernest Hook30: “Scientists and historians can cite many cases of scientific and technological claims, hypotheses, and proposals that, viewed in retrospect, have apparently taken a long time to be recognized, endorsed, or integrated into accepted knowledge and practice.” Ironically, this was the case with the recognition of AMI. British physician William Heberden published his classic description of angina pectoris in 1772, and Chicago internist James Herrick published the first English-language description of the clinical syndrome of AMI in 1912.31,32 Fye 50th Anniversary of the Coronary Care Unit Concept 1889 by gest on N ovem er 1, 2017 http://ciajournals.org/ D ow nladed from Evidence-Based Medicine and the Rise and Fall of Lidocaine The life-saving potential of the CCU seemed self-evident to doctors, nurses, hospital administrators, and patients in the mid-1960s, but 2 Harvard Medical School faculty members challenged the model in 1973: “The use of coronary-care units for the treatment of patients with myocardial infarction has increased explosively with little attention to efficacy, need, or cost.”33 In their opening paragraph, they cited articles by Bernard Lown, who established a CCU at the Harvardaffiliated Peter Bent Brigham Hospital in 1965, 3 years after Hughes Day opened his unit in Kansas City. Referring to Lown’s articles and 2 others from Britain, they declared, “Clinicians justify this intensive and expensive therapy by a definitely reduced in-hospital case fatality rate. Research on the units has centered mainly on end results of clinical experience ‘before and after’ institution of a unit within a hospital or on preventive and therapeutic advances.”33 Lown’s legacy in terms of the CCU relates to his development of the direct-current defibrillator and to his role in promoting the prophylactic use of lidocaine as a strategy to reduce the likelihood of cardiac arrest in patients with AMI. In 1981, he published an insider’s perspective on the nearly negligible time lag between the use of lidocaine in dogs with experimental infarction, it first clinical application, and its diffusion into practice: We discovered the remarkable efficacy of lidocaine in the animal laboratory in December 1964. When given as a bolus IV, it consistently abolished the ever-present ventricular arrhythmias in dogs recovering from AMI after coronary artery ligation. One month later, the first patient admitted to the CCU at the Peter Bent Brigham Hospital, Boston, received lidocaine IV. The policy was to control ventricular premature beats (VPBs), considered the putative harbingers of VF. Adhering to this policy, not a single episode of VF was encountered in 130 consecutive patients with proved AMI. Mortality among patients with myocardial infarction at the Peter Bent Brigham Hospital, which had ranged from 29% to 33% over the preceding five years, declined to 11.5%. These findings led to the promulgation of the view that the proper objective of CCU care was to prevent the need for resuscitation by treating VPBs with lidocaine.34 In a 1968 debate about the CCU with San Francisco cardiologist Arthur Selzer, Lown promoted 3 “policies that almost completely abolish the need of resuscitation for primary derangements in heart rhythm ... 1) abolition of ventricular beats during the first 48 to 72 hours after onset of acute myocardial infarction; (2) acceleration of the ventricular rate in the presence of bradyarrhythmias that are associated with ectopic beats or with hemodynamic disturbance; and (3) early detection of left ventricular failure and prompt digitalization. When these policies are adhered to, it is possible to reduce the incidence of ventricular fibrillation to less than 1%.”35,36 Selzer closed his rebuttal with a warning: “My presentation has shown in detail why statistics mentioned by Dr. Lown are unreliable and should not be accepted at face value. What we need is a properly designed alternate case study with good controls. However, this may be morally impossible, and we may be left permanently with conflicting statistics and no real answer.”37 For a generation, lidocaine was central to the strategy of preventing life-threatening ventricular arrhythmias in patients with AMI. Its meteoric rise and subsequent fall is a compelling example of the impact of controlled clinical trials on cardiovascular practice during the past quarter century. Evidence-based medicine, the organizing principle of what has been called the “trial-guideline-education process,” revolutionized the care of patients with AMI.38,39 Between 1990 and 1996, the recommendations regarding prophylactic lidocaine in the ACC/AHA guidelines for the management of patients with AMI changed dramatically—from a Class I to a Class III indication.40,41 The various factors contributing to this complete reversal are beyond the scope of this historical essay, which focuses on the origin of the CCU concept and its rapid diffusion into practice. The introduction of reperfusion therapy with thrombolytic agents or catheter-based interventions and the routine use of -blocking drugs transformed the natural history of AMI and reduced its early and late complications.1 Meanwhile, evidence-based medicine also contributed to a dramatic decline in the use of the Swan-Ganz catheter, a technology designed to help manage the most frequent nonarrhythmic causes of death in AMI patients: cardiogenic shock and refractory pulmonary edema. Cedars of Lebanon Hospital and the Swan-Ganz Catheter Cedars of Lebanon Hospital, where Wilburne and Corday admitted patients, was the largest private hospital in Los Angeles. It opened a CCU in January 1966, 6 months after Jeremy Swan arrived from the Mayo Clinic to be chief of cardiology at the new Cedars-Sinai Medical Center. The name implied a physical merger of the 2 hospitals, but that would not occur for another decade. Swan’s office was at the Cedars of Lebanon Hospital, and he later recalled that the institution’s CCU was established there “largely through the efforts of Eliot Corday.”42 Wilburne, the private practitioner who had described the concept, was not involved in its implementation or operation. Swan’s sophistication in hemodynamics was critical for his hospital’s participation in a new federally funded program. The National Heart Institute’s Myocardial Infarction Research Program, launched in 1966, was designed to study (among other things) the pathophysiology of AMI and to identify more effective treatments for complications such as shock and heart failure. Nine myocardial infarction research units were created, including 1 at Cedars of Lebanon.43 By this time, Swan was an acknowledged world leader in clinical cardiovascular physiology as a result of 15 years of experience in Mayo’s high-volume catheterization laboratory. He now had the resources to assemble a team of clinical investigators who would evaluate hemodynamic responses to various interventions in AMI patients to “develop therapeutic guidelines” for their “optimal management.”44 Swan coauthored a 1970 article describing a technology (the Swan-Ganz catheter) that would be used widely to evaluate intracardiac 1890 Circulation October 25, 2011 by gest on N ovem er 1, 2017 http://ciajournals.org/ D ow nladed from pressures and cardiac output in patients with AMI and other critical illnesses. The bedside technique provided a wealth of insight into the hemodynamic consequences of AMI and their treatment. As with lidocaine, evidence-based medicine resulted in a much more limited role for the Swan-Ganz catheter by the close of the century.45,46 Nurse Empowerment: A Crucial Component of the Coronary Care Unit Model The widespread implementation of the CCU model in the mid-1960s triggered a major shift in the traditional relationship between doctors and nurses.47 New monitoring technology alerted staff to the sudden onset of VF and to the possibility of reversing death by prompt defibrillation. There was no time to wait for a doctor to deliver the shock because irreversible brain damage occurred 4 minutes after cardiac arrest. Physicians, seeking ways to save patients’ lives without having to position themselves minutes away from the bedside at all times, trained and empowered specific nurses to defibrillate patients. The founders of America’s second CCU (at Philadelphia’s Presbyterian Hospital) championed the concept that specific nurses should be trained to play a very active role in the treatment of cardiac arrest. Lawrence Meltzer and Roderick Kitchell opened their unit in November 1962. Meltzer explained 2 years later, “It was apparent to us, even before we began, that the entire success of the undertaking would depend on nurses. We envisioned that they would constantly attend the patients, be taught to recognize arrhythmias, know the therapy for each catastrophe and, in effect, be in charge of the unit.”48 Meltzer, Kitchell, and their unit’s head nurse, Rose Pinneo, coauthored Intensive Coronary Care: A Manual for Nurses in 1965. The opening sentence set the tone: “It may seem curious that the first book dedicated to a new concept of treatment for acute myocardial infarction has been directed primarily to nurses rather than physicians.” They emphasized that the new treatment technologies had to be used immediately to save lives. To achieve this goal, doctors had to abandon traditional notions of a nurse’s limited role in clinical decision making. The authors declared, “Intensive coronary care is essentially an advanced system of nursing. It is not an advanced system of medical practice based on electronics.” Their prescription for saving lives was explicit: “A CCU nurse must be able to perform ... therapeutic measures by herself without specific orders.” This included the definitive treatment for VF: “If the physician has not arrived within two minutes of the onset of this fatal arrhythmia, she defibrillates the patient by herself.”49 Support for giving specially trained nurses the authority to defibrillate patients grew quickly in the late 1960s as concerns about the legal implications of the practice declined. The CCU-inspired empowerment of nurses represented a critical first step in the evolution of team-based care that is such a conspicuous part of current-day cardiology practice. The Challenge of Assigning Priority to Innovators and Pioneers The original descriptions of the CCU concept by Wilburne and Julian in 1961 are compelling examples of simultaneous innovation. Working in very different contexts, they recognized an opportunity to reverse sudden death in patients with AMI by implementing an innovative care model that united vulnerable patients with new technologies and specially trained staff in a specific hospital space. Thomas Kuhn, who has written about simultaneous innovation and the challenge of assigning priority, explains, “To the historian discovery is seldom a unit event attributable to some particular man, time, and place.”50,51 In the case of the CCU, the new care model proposed by Wilburne and Julian was the result of decades of discoveries, inventions, and innovations that, in turn, represented the contributions of thousands of individuals working in countless contexts. William Grace, who opened one of the nation’s first CCUs at St. Vincent’s Hospital in New York City in 1964, wrote 6 years later, “It is clear that the Coronary Care Unit concept in this country was pioneered by Hughes Day and Lawrence E. Meltzer.”52 In fact, there were 2 types of CCU pioneers: individuals who proposed the concept and those who implemented and promoted it in presentations and publications. Cardiologists from the US Public Health Service’s Heart Disease Control Branch made this point in 1966 when they emphasized that the CCU was “really a concept and not necessarily a specific structure. The service to be provided must be stressed, rather than a rigid pattern of bricks and mortar.”53 The concept that Wilburne and Julian outlined in 1961 was fleshed out during the next decade as doctors, nurses, and administrators collaborated in establishing special units for AMI patients in hundreds of hospitals. Wilburne, a private practitioner, never directed a CCU and faded from view. Julian actually implemented the model and became a leading academic cardiologist. British scientist Francis Darwin, Charles Darwin’s son, wrote a century ago, “In science the credit goes to the man who convinces the world, not to the man to whom the idea first occurs. Not the man who finds a grain of new and precious quality but to him who sows it, reaps it, grinds it and feeds the world on it.”54 In this sense, Eliot Corday also deserves credit. When he was organizing the ACC-sponsored Bethesda Conference on CCUs in 1965, he invited AHA President Helen Taussig to attend. The Johns Hopkins pediatric cardiologist responded, “I greatly appreciate your advising me of the [conference] and shall be extremely happy if the American Heart Association can work closely with the American College on various problems of mutual interest” (Helen B. Taussig to Eliot Corday; November 12, 1965; ACC Archives; Washington, DC; quoted with permission). Her statement was very significant because it signaled a new chapter in the tense relationship that had existed between the organizations since the college was founded 15 years earlier.55 Seeking to encourage collaboration to catalyze the diffusion of the CCU model, Corday played a key role in organizing the 1967 National Conference on Coronary Care Units sponsored by the ACC, the AHA, and the federal government’s Heart Disease Control Program. When that conference was held in June, 650 individuals attended and 350 CCUs were operating in the United States.56 Fye 50th Anniversary of the Coronary Care Unit Concept 1891 by gest on N ovem er 1, 2017 http://ciajournals.org/ D ow nladed from The American Heart Association Publishes Wilburne’s Abstract The content of Wilburne’s Circulation abstract proves that he deserves credit along with Julian for describing the CCU concept whereas Day was the first American to implement it. Although Wilburne’s abstract was published on paper in 1961, it became invisible because it was not included in Index Medicus or PubMed. The authors of an article on the use of citation data to study discoveries and the evolution of science argue that “the development of citation indexes and elaborate methodologies for the use of citation data make it possible to trace discoveries and to assess the credit publishing scientists assign to individual scientists for particular discoveries.” They acknowledge, however, that “citation counts and the use of cluster maps cannot replace the study of original sources.”57 Today, decades of the true original sources— bound journal volumes—are endangered as libraries discard print runs when their contents become available electronically. There is another problem. With the passage of time, credit for discoveries and innovations becomes focused on a few leading actors while the supporting cast and other contributors disappear into the recesses of history. The contemporary emphasis, indeed obsession, on the most recent publications does a disservice to past researchers, clinical investigators, and innovators whose significant (sometimes critical) contributions are devalued. This phenomenon raises the interesting philosophical question, “Where does a review of the literature end and medical history begin?”58,59 One of the more intriguing aspects of the Wilburne story relates to why his rejected abstract was published at all. This was the result of a short-lived AHA policy in place a half-century ago. The association announced in the January 1961 issue of Circulation that application forms were available for those interested in submitting an abstract for the annual fall meeting. The wording suggests why Wilburne’s was turned down: “Papers intended for presentation must be based on original investigation in, or related to, the cardiovascular field .... All applications will be screened by the Committee on Scientific Sessions Program.”60 Rather than reporting research results, the theme of the Scientific Sessions, Wilburne described a new patient care model. When the 10-person program committee chaired by catheterization pioneer James Warren met that January, they debated the policy of publishing all submitted abstracts in Circulation versus only those accepted for presentation. Open heart surgeon William Glenn did not support publishing abstracts that were not presented: “He felt that the literature was full of such material which he classified as ‘junk.’” Electrocardiographer Elliot Newman “voiced the opinion that publication of the abstracts served good purposes. It provides a survey of investigation in progress, what people are doing or think they are doing, and encouraged investigators to submit abstracts. He felt that if abstracts were not selected for presentation ended up in the waste basket, fewer and poorer abstracts would be submitted.” After further discussion, the committee agreed to continue publishing all abstracts. That is why Wilburne’s abstract exists (minutes, AHA Committee on Scientific Sessions Program; January 13, 1961; AHA Archives; Dallas, TX; quoted with permission). James Warren wrote in 1965, 4 years after his committee rejected Wilburne’s abstract describing the CCU concept, “Vigorous therapy following acute myocardial infarction might effect a saving of 40,000 lives a year. Among the features of such therapy are placement of patients in special ‘coronary care units’ in hospitals, institution of measures to combat shock and congestive heart failure, and use of anticoagulants and vasopressor drugs.”61 That year, the AHA published a 2-part article on the CCU in Modern Concepts of Cardiovascular Disease, a monthly educational leaflet mailed to 100 000 doctors. On the basis of early reports from Day’s unit in Kansas City and Meltzer’s in Philadelphia, the authors concluded, “Although the number of treated cases in these two units was small, the clinical data nevertheless suggest that a significant reduction in the mortality rate in acute myocardial infarction can be expected when the patients are observed and treated in a Coronary Care Unit for an initial period of three to seven days.”62 Wilburne’s Circulation abstract faded from view, but the model he described in it became a very visible part of most American hospitals and had profound consequences for patient care, cardiology practice, and the nursing profession.