The patient population cared for in the modern cardiovascular intensive care unit (CICU) has changed dramatically over the past few decades. Gone are the days when the CICU was primarily a coronary care unit (CCU). With acute coronary syndromes accounting for <10% of current admissions, heart failure and cardiogenic shock are now the bread and butter of the modern CICU.^1,2,3

Moreover, according to data from the Cardiology Critical Care Trials Network, the most common current indication for admission to a CICU is respiratory failure, followed by shock (21%).⁴ Cardiologists practicing in contemporary CICUs must not only have a broad cardiac knowledge base, but also expertise in the management of noncardiac ailments, from sepsis to renal failure.^3,5 Enter the evolving field of critical care cardiology (CCC).

The Landscape of CICU Staffing

Though interest in CCC is on the rise, the actual number of trainees who have completed both cardiology and critical care medicine (CCM) lags far behind what would be necessary to staff all CICUs with cardiac intensivists alone. However, with the growing complexity of CICU patients and data suggesting that ICU patient outcomes improve with intensivist staffing, there is a general recognition that a transformation in CICU staffing is warranted.^2,3,6-9

While some hospitals have moved towards utilizing general intensivists to staff the CICU, there is minimal exposure to cardiovascular critical care during general CCM fellowship.¹⁰ In the absence of a dual-trained cardiac intensivist, CICUs employ a variety of models to adequately care for patients with cardiac and noncardiac critical illnesses. This ranges from cardiologist staffing with an ICU consult on select patients to formal co-staffing by cardiologists and intensivists.

While Leapfrog standards do not currently mandate intensivist involvement for all critically ill patients, it is anticipated that this may change.^3,11,12 One of the largest barriers to increasing the availability of cardiac intensivists lies in the lack of integrated cardiovascular critical care training pathways.^13,14

Statements have been published by the ACC, American Heart Association (AHA) and the European Society of Cardiology that not only recommend incorporation of critical care training in general cardiology fellowship curricula, but also a rise in formal CCM-trained cardiologists.^2,6,9,15,16 The following are considerations for those interested in pursuing dual training in cardiology and critical care.

Should I Pursue Dual-Training in Cardiology and Critical Care?

Ultimately, it is most important to determine what you are looking for in your career. If you're planning on working mostly in CICUs (especially at academic or tertiary care centers), leading a CICU, working in multiple types of ICUs (cardiothoracic [CTICU], medical [MICU], etc.) or conducting CCC-based research, it is wise to pursue an additional year of CCM training.

In addition, while it is currently not a requirement to have formal intensivist training to staff a CICU of any kind, nor be an intensivist to bill for critical care, it is likely that staffing models will undergo major changes over the next decade or two. Thus, if your primary career goal is to work in a CICU, it is worthwhile to complete a CCM fellowship.

What Training Pathways Are Available For Dual-Boards?

Unlike pulmonary critical care (PCC), there are currently no specific combined programs for CCC that trainees can apply to straight out of residency. Instead, one must separately complete cardiology and CCM training. There are multiple ways to achieve this, which can cause confusion for CCC-bound trainees.

From internal medicine-based training, there are two paths to be eligible to sit for CCM boards outside of a PCC fellowship: 1) a two-year ACGME standalone CCM fellowship that can be completed without additional fellowship training, or 2) a one-year CCM fellowship after an internal medicine subspecialty fellowship (such as cardiology). All CCM programs require a minimum of 12 months of clinical training, six months of which must be in ICUs.

Most programs have more than six months of critical care time, and two-year programs do allow for more elective and research time. For the two-year option, a fellow can choose to do their critical care training before or after cardiology, each of which has its own pros and cons, as outlined by Miller, et al.¹³

While the ACGME website has a list of accredited two-year CCM fellowships, a list of one-year fellowship programs is not readily available. Most CCC-bound trainees utilizing the one-year pathway choose to do so at their home institution. If a program does not have a CCM fellowship outside of PCC, a trainee can work with the PCC leadership to try to arrange a specific track to fit their needs, which can be submitted to the ACGME for approval (this discussion would also need to include consideration of funding for the year).¹¹

Regardless of whether you participate in a formal two-year CCM fellowship, a preexisting one-year CCM fellowship after general cardiology training or a self-arranged one-year fellowship, it is prudent to speak with program leadership to determine whether your year can be tailored towards your career goals.

For example, if you wish to work in both a CTICU and CCU, it can be important to ask the CCM program director about the ability to prioritize additional CTICU time. It would also be important to inquire about the case mix of cardiac surgeries performed at the program to ensure adequate broad exposure.

Similarly, if you are interested in mechanical support and your general training did not have opportunities to directly care for patients with balloon pumps, Impellas and extracorporeal membrane oxygenation (ECMO), you may want to ensure your program has more of this time built into a critical care year.

This article was authored by Allison Levin, MD, MSc, a second-year cardiology fellow at Duke University. She earned her Bachelor of Arts in neuroscience from Columbia University, where she earned a MSc in biostatistics and her medical degree. Levin completed her internship at the University of Pennsylvania and her residency at Massachusetts General Hospital in Boston.

Do you have an idea for an article for this section? Want to write an article? Reach out to Levin on Twitter @Dr_ALevin or email cardiologyeditor@acc.org.

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