The treatment of acute myocardial infarction:

the Past & the Present

Dr. Ameel Toma

Milestones in Cardiology:

• 1628 William Harvey, an English Physician, first describes blood circulation.

• 1706 Raymond de Vieussens, a French anatomy professor, first describes the structure of the heart's chambers and vessels.

• 1733 Stephen Hales, an English clergyman and scientist, first measures blood pressure.

• 1816 Rene T. H. Laennec, a French physician, invents the stethoscope.

• 1903 Willem Einthoven, a Dutch physiologist, develops the electrocardiograph

The treatment of acute myocardial infarction:

• Phase 1 (1912–1961), bed rest and ‘expectant’ treatment)

• Phase 2 (1961–1974, the coronary care unit);

• Phase 3 (1975–present, myocardial reperfusion).

Phase 1 (1912–1961),

-in the past century, skillful physicians observed that prodromal symptoms often precede acute myocardial infarction

• Symptoms (crescendo angina, status anginosus, accelerated angina), by presumed pathophysiology(coronary failure, acute coronary insufficiency),or by its prognostic significance (impending myocardial infarction, preinfarction angina

Phase 1 (1912–1961),

• 1912 James Herrick concluded that the slow, gradual narrowing of the coronary arteries could be a cause of angina. He’s credited with inventing the term “heart attack.”

• presents the classic signs and symptoms of myocardial infarction and recommends bed rest,

Phase 1 (1912–1961),

• In his 1912 paper, Herrick wrote: “The importance of absolute rest in bed for several days is clear.” At the time, pathologists considered myocardial infarctions to be ‘wounds’ of the heart and cardiac rupture was feared as a dreaded, invariably fatal complication. Soon, in most hospitals, Herrick’s ‘several days’ of bed rest became two or three weeks.

• The usual duration of hospitalization in uncomplicated cases was six weeks, followed by a prolonged recovery at home. Few patients were permitted to return to normal activity.

Phase 1 (1912–1961),

• By 1929, AMI was recognized as a relatively common medical emergency.

• Levine, emphasized the frequency and danger of cardiac arrhythmias and recommended quinidinefor ventricular tachycardia and intramuscular adrenaline for atrio-ventricular block.

• Electronic ECG monitoring was not yet available and he suggested that nurses be trained to detect arrhythmias by frequent auscultation.

Phase 1 (1912–1961),

• In the first edition of Harrison’s Principles of Internal Medicine, published in 1950, treatment of AMI included inhaled oxygen in patients with pulmonary rales and/or cyanosis, as well as subcutaneous atropine and papaverine and sublingual nitroglycerine to relieve coronary spasm. Perhaps most importantly, anticoagulants.

Phase 1 (1912–1961),

• As an intern in 1952, we admitted patients with AMI wherever a bed was available on the medical service, but always as far from the nurses’ station as possible, so that they would not be disturbed, especially the frequent telephone ringing. It was not uncommon for me, when arriving on the medical floor at 6 am to draw blood to be sent for testing, to discover that one of my AMI patients had died quietly during the night.

• It was quite discouraging to young physicians, because we felt so impotent;

• older physicians accepted this as ‘just the way it was.’

Phase 1 (1912–1961),

• so few of cardiologist considered the management of myocardial infarction to be a primary concern. They saw the diagnosis and treatment of congenital and rheumatic heart disease to be their main function.

• In 1956, when I was training under Paul Wood at the National Heart Hospital, I was advised by a Professor of Medicine in London not to become a cardiologist because ‘all the mitrals had been operated on’.

Phase 2: the coronary care unit:

•Cardiac arrest ?????

Phase 2: the coronary care unit:

• 1960, while poised with a scalpel in my hand about to do a venous cutdown as a preliminary to a cardiac catheterization, David Leak came into the laboratory and told me that a physician with a myocardial infarction had been admitted into an adjacent ward and had sustained a cardiac arrest.

• I had little choice but to go ahead, I opened his chest and started cardiac massage. Cardiac surgical colleagues arrived with a defibrillator shortly afterwards, and we were able to resuscitate the patient. He made an excellent cardiac but rather a slow mental recovery.

Phase 2: the coronary care unit:

began in 1961 with a paper by Desmond Julian, then a cardiology registrar at Edinburgh’s Royal Infirmary, which described 4 Four separate components came together in these units:

(1) the segregation of patients with AMI into specialized intensive care units – designated areas of a hospital in which trained staff, specialized equipment, including monitors, catheters, pacemakers, drugs, and frequently cardiologists were all at hand;

(2) continuous electrocardiographic monitoring of cardiac rhythm with audible alarms for serious arrhythmias;

(3) the training of medical and nursing staff in closed chest resuscitation; and perhaps most importantly

(4) providing trained nurses with the authority and responsibility to perform this procedure, including external defibrillation, in the absence of a physician.

• The paper was rejected by the British Medical Journal because ‘it was irresponsible to suggest that all patients with myocardial infarction should be admitted to wards in which they could receive intensive care’.

• 1960 CPR by closed chest cardiac massage.

• 1961 J. R. Jude, an American cardiologist, leads a team performing the first external cardiac massage to restart a heart

• 1961 Intensive central monitoring proposed.

• 1963 Coronary care unit

What is next???

• Constantinides described fissuring of atherosclerotic plaques leading to coronary artery thrombosis in 1966.

• Davies et al and Falk showed at postmortem studies that patients with unstable angina and myocardial infarction almost always have atherosclerotic plaque fissuring or ulceration.

Phase 3: myocardial reperfusion:

• in 1975 by Chazov et al. who lysed coronary thrombi by infusing streptokinase directly into the blocked coronary arteries of patients with AMI.

• FDA’s approval of streptokinase and urokinase for “intracoronary use in lysing thrombi obstructing coronary arteries in evolving transmuralmyocardial infarction” in 1984

• In 1986, the GISSI investigators, in one of the first cardiac mega-trials, demonstrated a reduction in mortality by streptokinase infused intravenously.

Phase 3 (1975–present, myocardial reperfusion).

• ISIS-2 trial, 1988 ,with the use of aspirin showed a .25% reduction in the risk of infarction, stroke, or vascular death.

• 1979 Percutaneous transluminal coronary angioplasty in man described.

• 1984 acute B-blockers is useful.

• 1988 Acute aspirin improves survival (ISIS-2)[38]

• 1992 ACE inhibitors improve survival[39]

• 1997 Primary angioplasty can be superior to thrombolysis [40]

First catheterisation in a human

• In 1929, a German surgicaltrainee, Werner Forssmann,experimented on a humancadaver and realized how easy itwas to guide a urological catheterfrom an arm vein into the rightatrium

•In the early 1940's, Cournand, working in New York,began utilizing

right heart catheterisation on a regular basis in the undertaking of a

comprehensive investigation of cardiac function in both normal and

diseased patients

• 1929 — First documented human cardiac catheterization is performed by Dr. Werner Forssmann in Eberswald, Germany.

• 1941 — Cournand and Richards employ the cardiac catheter as a diagnostic tool for the first time, utilizing catheter techniques to measure cardiac output.

• 1956 — Forssmann, Cournand and Richards share the Nobel Prize. Cournand states in his acceptance speech "the cardiac catheter was...the key in the lock."

Coronary Angiography

• 1958 Accidental discovery by Sones

• Involves injecting contrast agent into the coronary arteries

• Cine-angiography

– X-ray images taken in rapid succession to capture the dye’s progression

Cut Down

Seldinger Technique

• 1974 — Andreas Gruentzig performs first peripheral human balloon angioplasty

• 1976 — Gruentzig presents results of animal studies of coronary angioplasty at American Heart Association meeting

• 1977 — First human coronary balloon angioplasty performed intraoperatively by Gruentzig, Myler and Hanna in San Francisco

• 1977 — Andreas Gruentzig performs first cath lab PTCA on awake patient in Zurich;

• the first intracoronary stents were successfully deployed in coronary arteries in 1986(self-expanding Wallstents).

Andreas R. Gruentzig (1939-1985)

• He presented the results of animal studies with the balloon at the American Heart Association meeting in 1976 and was met with skepticism.

• Dr. Richard Myler of Saint Mary's Hospital in San Francisco suggested they collaborate and the two performed the first human coronary angioplasty intraoperatively during bypass surgery in San Francisco.

• In September 1977, in Zurich Switzerland, Gruentzigperformed the first coronary angioplasty on an awake human. Now, a year later, when he presented the results of his first four angioplasty cases to the 1977 AHA meeting, the audience burst into applause,

• in 1989 the Palmaz-Schatz balloon-expandable intracoronary stent was developed.

• 1994 — the Palmaz-Schatz stent is approved by the F.D.A. for use in the United States

• 2003 — the first drug-eluting stent, the Cypher, manufactured by Johnson & Johnson / Cordis, is approved by the F.D.A., marking a major advance in the battle to reduce restenosis to single digits

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