Transcript 50 YEARS OF CLINICAL CARDIOLOGY a personal experience

50 YEARS OF CLINICAL
CARDIOLOGY
a personal experience
Prof. Dr. Fayez Fayek Botros
National Heart Institute
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Graduated in 1956 and now year 2006
My talk will cover 50 years of advancement in
cardiology, but from personal and general
experience.
Compared with nowadays ,Cardiology in our
time was:
*primitive
*giving great care to history taking ,
observation & clinical examination.
*less tools for investigations & treatment.
HEART FAILURE
1.
2.
3.
4.
Rest in a comfortable arm chair.
Low salt diet .
Oxygen.
Digitalis:( Paul Woods diseases of the heart &circulation ,1966)
It is doubtful if there are any real contraindications to use Digitalis in
therapeutic doses :
Initial doses of 0.5 mg six hourly or t.d.s. for tow days followed by 0.25 mg
t.d.s. until desired effect is achieved or early signs of intoxication , when
the dose should be reduced to 0.25 mg once or twice daily .
5.
Ouabain :(Strophanthin)
is derived from strophanthus gratus .
used IV in acute cases .
6. Mercurial Diuretics :
*Discovered by accident at the Wenckebach clinic in Vienna in
1919 , when noticed that a new syphilitic mercurial medicine
(Novasurol ) ,when injected in a girl with syphilis produced
diuresis , but was painful & toxic. *Replaced by more benign
Salyrgan that was combined with theophylline to produce
(Mersalyl).
*Mersalyl given IM every 3rd or 4th day with ammonium chloride
2gm t.d.s. to replace chloride loss.
*acts by decreasing tubular reabsorption of Na, K chloride
*Toxicity: high fever , rigors ,vomiting, colic, diarrhea, fatigue,
convulsion, toxic nephritis and sudden death (VF or asystole).
ACUTE HEART FAILURE
Price text book of Medicine 1967
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Venesection:
*Acute LVF :  600cc blood.
*Severe CHF : may break the vicious circle of failure
and lead to increasing response to diuretics .
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Tourniquet :
by applying the cuff to the four extremities which may
induce dramatic response.
RESISTANT HEART FAILURE
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Acupuncture :
-Put patient in an arm chair for 24 hours.
-A triangular cutting needle …. A dozen punctures in
each leg .
-Southeys tubes … large bore needles inserted in s.c.
tissues of the thighs or calves .
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Leaches
HYPERTENSION
Paul Wood text book 1966
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Conservative :
-Put patient to bed till symptoms disappear & BP
reaches a static level .
-Sedation for mental relaxation .
-Obese patient needs weight reducing diet with one day
per week of semi starvation .
-Encephalopathy needs rest & vigorous dehydration .
-Low sodium diet .
Drugs :
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Rauwolfia Serpentina :
-was used in India as a sedative .
-centrally acting by depleting brain serotonin and hypothalamic noradrenaline .
-side effects: sinus bradycardia, nasal congestion, depression,
weight gain, and diarrhea .
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L-Hydrazinophthalazine (apresoline) :
-central & peripheral action .
-stopped for formidable side effects : severe headache, tachycardia, anxiety,
depression, rheumatoid like symptoms & SLE .
Lumbo -dorsal sympathectomy:
-25% died within 3-5 years .
-bilateral resection of whole sympathetic chain
from D8 to L2 .
-relieve as much vasoconstrictor tone as
possible .
-side effect :.postural hypotension
.impotence
Medical Sympathectomy :
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Ganglion blocking agents:
-block both sympathetic and parasympathetic systems .
-side effects: *constipation up to ilieus .
*dry mouth .
*urine retention .
*impotence .
*orthostatic hypotension .
*syncope .
*disturbance of vision due to difficulty of
accommodation .
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Adrenergic blocking agents:
-best known was Guanethedine (Ismeline).
-prevents production and/or release of adrenergic catecholamines
from post ganglionic nerve endings .
-gave good results in 70% of patients .
-side effects : *orthostatic hypotension .
*myalgia .
*fluid retention .
*impotence .
*frequency of micturition
*tremors .
*nasal congestion .
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Alpha Methyl Dopa :
-block formation of both serotonin and dopamine .
-dose : 250 up to 1000mg t.d.s.
-side effects: *sedation .
*somnolence .
*sleep disturbance .
*depression .
*dry mouth .
*nasal congestion .
*parkinsonism .
*gyneacomastia .
*not used in acute liver disease or hepatic dysfunction
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B Blocker :
The place of propranolol in treatment of hypertension is not known .
Quality of life
Patient's assessment of the effects of
antihypertensive therapy
Physician's assment of the effect of
antihypertensive therapy
percentage
percentage
100
80
60
40
20
0
improved
no change
no change
100
50
0
improved
no change
worse
Relatives' assessment of the effect of
antihypertensive therapy
percentage
100
50
0
improved
no change
worse
Development of Antihypertensive
Therapies
Effectiveness
Tolerability
1940s
1950
1957
Direct
vasodilators
Peripheral
sympatholytics
Ganglion
blockers
Veratrum
alkaloids
1960s
1970s
1980s
1990s
ACE
Alpha
ARBs
blockers inhibitors
2004+
Others?
Thiazide
diuretics
Central alpha2 DHP CCBs
agonists
Non-DHP
CCBs
Beta blockers
DHP, dihydropyridine; CCB, calcium channel blocker; ARB, angiotensin II receptor blocker.
Now with Diuretics , ACE , ARBS ,
B Blockers & C C Blockers
LIVE LONGER WITH BETTER QUALITY
OF LIFE ...
Angina
-light diet .
-reduce calorie intake .
-10 – 15 cigarettes /day allowed or stopped if
persistent attacks .
-Amyl nitrite capsule broken in handkerchief &
inhaled . Patient is embarrassed by noise of
capsule , pungent smell , vivid flush &
tachycardia .
Then oral form of glyceryl trinitrate .
-long term anticoagulant therapy .
-B Blocking agents play small but important role
in treatment of angina .
-Clofibrate (Atromid S) seems to lower serum
cholesterol & combat platelet stickiness .
Not yet recommended .
-artificial Myxoedema .
Now obsolete (1966) and only used in
intractable angina .
Paul Wood 1966 :
I have never myself been able to develop much
enthusiasm for this form of treatment , partially
because of rise of cholesterol ,and symptoms of
Myxoedema .
I have only embarked anti-thyroid treatment in
advanced cases that have been almost totally
incapacitated .
Angina treatment (cont.)
-Surgical :
*bilateral thoracic sympathectomy ,gave partial
relief.
*production of coronary collateral circulation :
-A flap of pectoral muscle or omentum sutured to the heart .
-apply bone dust , asbestos ,magnesium , talc ….
-ligation of great cardiac veins
arch of coronary sinus .
CARDIAC INFARCTION
HOME OR IN HOSPITAL ICCU
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ICCU :-facilitates external cardiac massage, electric
defibrillation ,electric pacing if needed.
Main aim was to reduce mortality
But the present evidence does not justify on insistence
for need of admission .
*Treatment:
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-complete bed rest for 3 weeks.
-arm chair for 3 weeks.
-mild movements for 3 weeks.
-gradual rehabilitation for 3 weeks.
( No return to work before 12 weeks .)
Anticoagulants to all cases.
Diet :-semi starvation for 1st few days .
-800 caloric diet (only fruit juice….soft food ,
little milk is allowed ).
*Prognosis:
25% die during the 1st month of cardiac infarction.
INVESTIGATIONS
Mainly :- x-ray
- ECG
….. very important
Rare for : -apex cardiography.
-phonocardiography :understanding of
hemodynamics ,murmurs and heart sounds.
-ballistocardiograph :of little value , no
more information.
Now : Echocardiography (1970)
BALLISTOCARDIOGRAPGY
Based on : when a gun is fired , it recoils .
(Newton's 3rd low of motion : for every action on a body , there is an equal
opposite reaction )
*As early as 1877 Gordon recorded the movements of a
suspended platform on which a man is lying.
*1939 ,Starr & his associates developed a couch.
*1949 Dork and Taubman the body s allowed to move on
its own cushion of fat ,the movements of a bar laid
across the shins being amplified & recorded .
Diagram of a normal
ballistocardiogram to show
approximate time relationship to
the left ventricular pressure pulse
CARDIAC
CATHETERIZATION
1.
Cath lab was primitive as compared with now
…. No screens , No computers , even No
calculators .
2.
How we observe …….
3. Our own Kefa catheter in coils shaped by our
selves with heated rod.
4. Rotating table, patient tied with belts .
table moves only forwards and backwards.
5. Cath. finding calculations with calculating rulers
. No automatic calculations for valve area
Gorlin’s formula , Co , PVR ….. etc
CARDIAC PACING
*Only external .
*We made our own pace makers.
*applied :-brachial root tied around the arm
-external jugular root.
*Mr. Shatz
Perforation of the right ventricular wall by the electrode tip
CARDIOLOGY IN OUR TIME
WAS
CLINICAL CARDIOLOGY
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NOW
INVESTIGATIONAL CARDIOLOGY
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Good history ,good observation .
Full clinical examination for 20-30 minutes.
Few investigations : x-ray , ECG ..
Few drugs .
But : great sympathy ,understanding ,reassurance&
friendship .
May or may not improve life span
But definitely improve Q.O.L.
Now:
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Fast era .
Short time :5-10 minutes.
Many investigations.
Many drugs & expensive treatment .
Improve Q.O.L. , prolong life span
But no friendly relation .
1948
The Framingham Heart Study , the first major
effort to study the epidemiology of chronic
disease ,is lunched .
1954
Inge Edler and Carl Helmuth Hertz report
using ultrasound to image the beating heart
in humans (echocardiography)
1958
Mason Sones performs the first selective
coronary arteriogram
1960
Richard Lower and Norman Shumway report
the first successful orthotopic
homotransplantation of a canine heart
1961
The Framingham Heart Study finds that
cholesterol level ,blood pressure , and
electrocardiogram abnormalities increase the
risk of heart disease .
1968
Rene’ Favaloro reports saphenous vein coronary
artery bypass graft surgery (CABG) for angina
pectoris
1976
E.L.Chazov et al. report the successful
reperfusion of an infarct-related artery
with intracoronary streptokinase in a
patient with an acute myocardial
infarction.
1977
Andreas Gruntzig reports percutaneous
transluminal coronary angioplasty
(PTCA)
1980
Michael Mirowski reports treating malignant
ventricular arrhythmias in humans with an
implantable automatic defibrillator .
1982
William DeVries performs the first artificial
heart surgery.
1986
Jacques Puel and Ulrich Sigwart insert the
first stent in a human coronary artery.
1991
Warren M. Jackman publishes his article
showing that radio-frequency current is
highly effective in ablating atrioventricular
pathways in W.P.W. syndrome .