50 YEARS OF CLINICAL CARDIOLOGY a personal experience

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50 YEARS OF CLINICAL CARDIOLOGYa 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.

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HEART FAILURE
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HEART FAILURE

• 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 .
• Ouabain (Strophanthin)
• is derived from strophanthus gratus .
• used IV in acute cases .

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• 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).

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ACUTE HEART FAILUREPrice text book of Medicine
1967

• Venesection
• Acute LVF ? 600cc blood.
• Severe CHF may break the vicious circle of
  failure and lead to increasing response to
  diuretics .
• Tourniquet
• by applying the cuff to the four extremities
  which may induce dramatic response.

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RESISTANT HEART FAILURE

• 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 .
• Leaches

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HYPERTENSION
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HYPERTENSIONPaul Wood text book 1966

• 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 .

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Drugs

• Rauwolfia Serpentina
• -was used in India as a sedative .
• -centrally acting by depleting brain serotonin
  and hypothalamic nor-
• adrenaline .
• -side effects sinus bradycardia, nasal
  congestion, depression,
• weight gain, and diarrhea .
• L-Hydrazinophthalazine (apresoline)
• -central peripheral action .
• -stopped for formidable side effects severe
  headache, tachycardia, anxiety, depression,
  rheumatoid like symptoms SLE .

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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

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Medical Sympathectomy

• 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 .
• 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
• B Blocker
• The place of propranolol in treatment of
  hypertension is not known .

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Quality of life
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Development of Antihypertensive Therapies
Effectiveness
Tolerability
1940s
1950
1957
1960s
1970s
1980s
1990s
2004
Directvasodilators
Alphablockers
Others?
ARBs
ACEinhibitors
Thiazidediuretics
Peripheralsympatholytics Ganglion
blockers Veratrumalkaloids
Central alpha2 agonists Non-DHPCCBs Beta blockers
DHP CCBs
DHP, dihydropyridine CCB, calcium channel
blocker ARB, angiotensin II receptor blocker.
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• Now with Diuretics , ACE , ARBS ,
• B Blockers C C Blockers
• LIVE LONGER WITH BETTER QUALITY OF LIFE ...

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ISCHEMIC HEART DISEASE
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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 .

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• -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 .

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• 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 .

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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 .

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CARDIAC INFARCTIONHOME OR IN HOSPITAL ICCU

• 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 .

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Treatment

• -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.

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INVESTIGATIONS

• Mainly - x-ray .. very important
• - ECG
• Rare for -apex cardiography.
• -phonocardiography understanding of
• hemodynamics ,murmurs and
  heart sounds.
• -ballistocardiograph of little value ,
  no
• more information.
• Now Echocardiography (1970)

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Phonocardiography
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Echocardiography
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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 .

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Ballistocadiogram
Diagram of a normal ballistocardiogram to
show approximate time relationship to the left
ventricular pressure pulse
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CARDIAC CATHETERIZATION

• Cath lab was primitive as compared with now .
  No screens , No computers , even No calculators .
• How we observe .

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• 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
  Gorlins formula , Co , PVR .. etc

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CARDIAC PACING

• Only external .
• We made our own pace makers.
• applied -brachial root tied around the arm
• -external jugular root.
• Mr. Shatz

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Perforation of the right ventricular wall by the
electrode tip
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• CARDIOLOGY IN OUR TIME WAS
• CLINICAL CARDIOLOGY
• .
• .
• .
• 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.

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Now

• Fast era .
• Short time 5-10 minutes.
• Many investigations.
• Many drugs expensive treatment .
• Improve Q.O.L. , prolong life span
• But no friendly relation .

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60 YEARS OF ADVANCE
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• 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

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• 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

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• 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)

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• 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 .

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Thank you