Cardiac Critical Care in 2025 and in 2035

Cardiac critical care has been in evolution for more than 6 decades, yet the modern cardiac intensive care unit (CICU) remains relatively young.1, 2, 3 Initially established as coronary care units for patients with acute coronary syndromes (ACSs) to receive dedicated monitoring for ventricular arrhythmias, early units were largely reactive. As ACS treatments and outcomes improved, their role expanded.

Over time, many of these units and their teams evolved to become the modern-day CICU. This shift coincided with improving survival rates among patients with heart failure, cardiac transplantation, durable left ventricular assist devices, and congenital heart disease—conditions requiring not only cardiovascular expertise, but also general critical care knowledge and skills in the CICU. CICU clinicians now routinely manage both cardiac and noncardiac critical illnesses.⁴

As patient demographics skew older and the demand for critical care increases, the CICU is increasingly essential. Supported by advances in hemodynamic support, structural heart and electrophysiology interventions, complex coronary procedures, surgery, and multimodality imaging, treatment strategies have broadened. In many CICUs, patient complexity and acuity are among the highest in the hospital.

Reimagining the CICU: training, workforce, research, and future opportunities

With CICU evolution comes structural questions: What are optimal staffing models? How should training be standardized? What critical care training should core cardiology fellows receive? What training should CICU physicians, nurses, and allied health professionals have? How should disciplines, including medical and surgical cardiac critical care, integrate? What triage strategies are best?

Research has shifted from narrow, syndrome-focused studies to broader questions relevant to the critically ill cardiac patient. Historically focused on ACS, shock, and cardiac arrest, current CICU research now addresses ventilatory strategies, resuscitation, sedation, complication prevention, temporary mechanical circulatory support, and long-term post-CICU outcomes. Although much can be learned from general critical care, dedicated CICU research in these areas is needed.

Patient physiology, management, and prognosis in the CICU often differ from general ICU populations, requiring dedicated study. The long delay between widespread percutaneous hemodynamic support device use and robust trial evidence evaluating these interventions underscores the need for better evidence-generation models. Cardiology’s strengths in randomized controlled trials are only now being borne out in CICU research outside ACS. More evidence-based clinical practice guidelines are needed, particularly related to adapting general ICU data to the CICU.

Building a home for cardiac critical care research

To address these needs, the American College of Cardiology launched JACC: Advances in 2022 to elevate cardiac critical care research. The journal provides a dedicated home for studies once scattered across multiple cardiology and critical care publications, making it easier for CICU practitioners to stay current.

This issue of JACC: Advances offers a snapshot of this progress. In a state-of-the-art review, Rebecca Mathew et al⁵ examined management of severe hypoxemic respiratory failure in the CICU—a challenge increasingly seen today. Ventilation in CICUs once focused on short-term support for pulmonary decongestion; now, acute respiratory distress syndrome, severe pneumonia, pulmonary hypertension, and pulmonary embolism require advanced knowledge and practice. Prior reviews have addressed these topics as well as readiness testing and liberation from mechanical ventilation.⁶ Skills such as bronchoscopy, pleural drainage, high-risk airway management, and tracheostomy care are increasingly relevant.

Patrick Deschênes et al⁷ discuss the expanding role of pharmacists in managing complex medication regimens complicated by organ dysfunction, drug–drug interactions, antimicrobials, and immunosuppression. Other articles address workforce and training models, extracorporeal membrane oxygenation and extracorporeal life support care, postcardiac arrest care, and management of shock in pregnancy and congenital heart disease. Original research spans bedside and systemic challenges: mechanical ventilation, physiological monitoring, transfers, triage, and long-term outcomes. Collectively, these works highlight the field’s rapid evolution.

The CICU in 2035

Patient acuity and complexity will likely continue to increase. Consensus is needed on unresolved systems issues. Staffing model and training debates have persisted for years; now is the time for standardization and reduced interinstitutional variability. Not all CICUs will aim to provide the same level of care, and classification systems can help to define and standardize approaches.¹

From a research perspective, the CICU needs more high-quality trials beyond ACS. Encouragingly, recent cardiogenic shock and cardiac arrest trials demonstrate feasibility, and an increasing number of trials are underway. Systematic research frameworks can accelerate discovery and translation.^2,8, 9, 10

Adaptive platform trials—increasingly used in general ICU populations—offer promise for evaluating multiple interventions efficiently in heterogeneous CICU patients.^11,12 Collaboration with general ICU researchers will be pivotal. Challenges such as selecting trial endpoints,¹³ accounting for patient heterogeneity,14, 15, 16, 17 and identifying treatment beneficiaries (heterogeneity of treatment effect)¹⁸ also apply here. Advanced statistical methods may help identify heterogeneity of treatment effect and personalize care.¹⁸

Patient involvement in research priority setting is essential. Models like the James Lind Alliance demonstrate the value of patient perspectives in priority setting.

Long-term survivorship after cardiac critical illness remains understudied. Emerging post-CICU follow-up clinics could serve as platforms for research and care improvement.

A future built on collaboration

The CICU’s future will depend on stronger evidence, organized infrastructure, and interdisciplinary collaboration—emphasizing collective scientific rigor, proactive care, systems thinking, protocols, and trial design. Together, these strengths can elevate cardiac critical care into a high-functioning, evidence-generating, patient-centered subspecialty.

We are in one of the most exciting periods in CICU history. Cardiac intensive care is now central to managing the sickest cardiac patients, and it is increasingly proactive and capable. By 2035, we envision a structured, evidence-based, and innovative field.

We invite colleagues to shape this future, and enjoy the articles in this JACC: Advances special issue—all steps along the road to the CICU of 2035, undoubtedly an even more dynamic environment for patient care and discovery.

Funding support and author disclosures

Dr Proudfoot has received institutional funding from Getinge and J&J MedTech Heart Recovery and is funded by the Barts Charity and the Medical Research Council (MR/W03011X/1). Dr Metkus has received consultant/honorarium fees from TelaDoc-BestDoctors, Becton Dickinson, and Company and Oakstone-EBIX, and textbook royalties from McGraw-Hill. Dr Lawlor is supported by the Fonds de recherche du Quebec. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.