The Patient with Heart Disease and the Cardiovascular Physician and Surgeon: 1958-1983

6 J AM COLL CARDIOL 1983:1:6-12

The Patient With Heart Disease and the Cardiovascular Physician and Surgeon: 1958-1983

SYLVAN LEE WEINBERG, MD, FAce Dayton. Ohio

The patient with heart disease and the physician pro• cardial revascularization and open heart surgery have viding cardiovascular health care have experienced dra• become commonplace and percutaneous angioplasty an matic change since the American College of Cardiology option. As custodians of cardiology's historic advances, first published its journal 25 years ago. During the dec• the cardiologist and cardiovascular surgeon are cast in ade before 1958, cardiology and cardiovascular surgery a role of decision maker and problem solver. Today's emerged as specialties. Surgery by closed techniques diagnostic and therapeutic cardiology, used appropri• flourished and open heart surgery began. Since 1958, ately, has great potential for good-used inappro• spectacular progress has occurred. Closedchest massage priately, for great harm. The patient has the right to and defibrillation, electronic monitoring, advances in expect the physician to act objectively and appropriately electrophysiology and a new pharmacology have changed in dealing with problems that may threaten his or her cardiology. The coronary care unit has evolved into a livelihood or life. The physician who does less is an un• comprehensive coronary care system. Pacemakers, myo- worthy heir to cardiology's great legacy of 1983.

The patient with heart disease and the physician live in a There is a striking increase in papers devoted to basic. different world from that of 25 years ago when the American applied and clinical research. Moving quickly from Volume College of Cardiology introduced its official journal. The 1 to Volume 49 create s a kind of Rip Van Winkle effect. College now begins its second quarter century of publication. It is as if the reader has awakened in a world where every• The year 1958 was a watershed in the history of car• thing is strange and new . diology. It had been a little more than a decade since the end of World War II. During that interim, cardiology had become a specialty in its own right. Department s of car• Cardiology in 1958 diovascular surgery emerged. There was unparalleled ex• In 1958, closed chest cardiac massage to maintain the cir• pansion in training and research in cardiovascular medicine culation and external defibrillation to restore the heartbeat and surgery, financed and stimulated largely by the new were not yet in clinical use (1-4) . While catheterization of National Heart Institute. It was a period of ferment and the right and left chambers of the heart was well known, change. The prospect of prodigious progre ss lay ahead. techniques were primitive compared with those of today One way to comprehend the change experienced by both (5,6). Transseptal catheterization of the left heart chambers, patient and physician during this quarter century is to browse now used rarely, had not been introduc ed (7). Contrast through Volume I of 1958 and then through Volume 49 angiography and ventriculography had very limited clinical which began the 25th year of publication by the American application. Coronary arteriography had not yet demon• College of Cardiology. The number of articles has tripled. strated the feasibilit y of myocardial revascularization by internal mammary artery implantation into the left ventricl e (8,9). When the College journal first went to press, car• From the Coronary Care Unit, Good Samaritan Hospital and Heallh diologists had not yet recognized the vast clinical impli• Center , and the Wright State University School of Medicine, Dayton , Ohio. Addre ss for reprints: Sylvan Lee Weinberg. MD. Good Samaritan cation s of visualizing coronary circulation and the potent ial Hospital and Health Center, 2222 Philadelphia Drive. Dayton, Ohio 45406. for surgical revascularization. Intracardiac pacemaking and

permanent tran svenous pacemakers, commonplace toda y. artery disease. Today. the Master test has been replaced by were not in use (10). Indeed. external pacemakers were the multilevel bicycle ergometer and treadm ill. The decline relatively new and not yet cast aside ( I I ). of the Master test was dramati cally illustrated at a recent Cardiac surgery. The year 1958 marked perhaps the presentation to a group of our fourth year medical students zenith of progress in the closed surgical treatment of con• and junior house officers. The vast majority had never heard genital and acquired valvular heart disease (12). The pre• of the Master test. Whil e stress in relation to coronary dis• vious decade had seen surgical relief of stenotic mitral. ease was discussed in 1958 (32), the term type A behavior aortic and pulmonary valves as well as some successful pattern to describe the coronary-prone personality had not recon stru ctive efforts (13-16). Congenital lesions. such as yet becom e a part of the common language (33). Since that atrial and ventricular septal defects. were yielding to the time. interest in stress and the genesis and management of surgeon's hand (17). Open heart surgery was done by hy• coronary disease has continued to increase (34). The entire pothermia ( 18). The pump oxygenator and open heart tech• field of myocardial imaging is new since 1958. Echocar• niques were coming into vogue ( 19.20) . Some 40 articles diograph y and radionuclides have revolutionized the non• on the subject were publi shed in the English language in invasive approach to valvul ar. myocardial and indirectly to 1957. Titles still appeared in 1958 on internal mammary coronary heart disease (35,36). artery ligation (21). implantation of the internal mammary artery into the left ventricle and poudrage to treat coronary Progress in Cardiology Since 1958 artery disease (22. 23 ). Diagnostic tests. Balli stocardiography was popular in Although its literature did not anticipate many subsequent the literature of 1958 and the subject of seve ral symposia spectacular advances . cardiology in 1958 was poised for in the College journal. High technology meant electroky• progress. By 1960, the surgical treatment of angina pectori s mography and intracardiac phonocard iography. The only was already being assessed (37). In that same year. there mention of radio isotopes in the College journal of 1958 was a report of segmental perfusion of coronary arteries described treatment of angina pectoris with radioactive io• with fibrinolysin in acute myocardial infarction (38). A spe• dine to produce a hypothyroid state (24). How could the cial unit was proposed for the treatment of patients undergo• physician of 1958 anticipate that 25 years later , Volume 49 ing open cardiotomy (39). Surgical appro aches to diseases would print a spectrum of articles on imaging the myocar• of the great vessels became well establi shed (40). Progress dium to define anatomy and function using radionu clides? began to accelerate exponentially. Pharmacologic therapy. Compared with today. the pharmacology of 1958 was limited in scope and effective• The Coronary Care Unit ness. Mercurials were the leading diuretics. The thiaz ides, After World War II. there was a great proliferation of elec• furosemide and ethacrynic acid were still in the clinical tronic equ ipment. The ability to monitor the electrocardio• future (25.26). There were , indeed. many article s on the gram introduced an entirely new dimen sion to the under• treatment of hypertension. They reported such agents as standing of acute coronary heart disease. Closed cardi ac rauwolfia, cryptenamine and protoveratrine . Beta-receptor massage and external defibrillation heralded a new era of blocking agents. calcium antagonists and angiotensin-con• cardiac resuscitation. This triad of monitoring. external de• verting enzyme inhibitors were unknown. ln a single sup• fibrillati on and closed che st massage made possible the cor• plement to the College journ al of [982. there were more ona ry care unit which was introdu ced in 1962 (4 1-43). The article s on dru g treatment than in the entire first volume of coronary care unit was a major development of the past 25 1958. years . Its impact on cardi ology was monumental. From a Although the electrocardiographic diagnosis of arrhyth• mode st beginning in a community hospital. the coron ary mias was sophisticated in 1958. electrophysiologic studies care unit proved that progress and innovation were not en• since then have enhanced our understanding of mechani sms tirely the province of the great centers. The recognition and (27). The phy sician of today is startled to see intravenous treatment of cardiac arrhythmias changed from a somewhat quinidine advocated in the management of ventricular tachy• esoteric pursuit to a practical requirement for every physi• cardia (28) . Therapeutic choices were limited . Procainamide cian and nurse who treated patients with acute coronary was a relatively recent alternative. A quarter of a centu ry disease. later. if the galaxy of antiarrh ythmic agents. including li• The coronary care unit Triggered 0 virtual revolution, docaine. beta-receptor blockin g agent s and calcium antag• not limited 10 coronary disease . The nursing profession onists failed. the cardiologist could resort to sophisticated rapidly ass umed a major role in the care of the acutely ill electrophysiologic mapping and surgery (29. 30) . patient. The respon sibility of the nurse . and consequently Stress testing and diagnosis of coronary artery dis• nursing educational requirements. changed dramatically. The ease. In 1958, the Master two- step test (31) was the stan• effectiveness of the coronary care concept was not lost on dard provo cative exercise test to diagnose ischemic coron ary those intere sted in other areas of acute care. Medical and 8 J AM CaLL CARDIOL WEI\JBER ( j 1983:1:6-12

surgical inten sive care units. pulmonary care units. burn Care of the Patient: 1983 Versus 1958 units and many others were develop ed . Succe ss in the cor• onary care unit was realized from the control of arrhythmias. Office Diagnosis and Procedures which cau sed many deaths early in the course of acute The magnitude of chan ge in the past quarter centu ry in myocardial infarction. Recognition and treatment of life• cardiology has been so great that a few pages can offer only threatenin g arrhythmias with lidocaine and prompt defi• the barest outline. One way to view this change is to compare brillation and cardioversion reduced postmyocardial infarc• the experience of the patient with heart disease in 1958 with tion arrhythmic deaths to a minimum. that of todays patient. The process in the physician 's office The problem oflate postcoronary care unit mortality was begins today much as it did then . The history. the physical challenged by the intermediate coronary care unit (44.45 ). examination. the electrocardiogra m and the chest X-ray film Surveillance was continued throughout the later phases of remain fundamental. There the similarity ends. For the pa• the postmyocardial infarction hospital stay. These units are tient with a heart murmur or an abnormal cardiac silhouette . still in use today. although their life-saving value has not the echocardiogram and radionucl ide imaging and dynami c been established with certainty (46). studies provide information not imagined in 1958. Pericar• Interest then turned to the point ofentry into the coronary dial effusion. mitral valve prolapse and stenosis. other val• care system . Vast public educational programs created a vular abnormalities. septal and free wall hypertrophy. car• popul ation able to recognize the signs and symptoms of diac dilatation. ventricular dysfuncti on and a spectrum of acute coronary heart disease and to assist in life support and congenital anomalies may often be diag nosed noninvasively resuscitation before arrival of professional help. Ambu• in a matter of minute s in the ambulatory patient. lances evolved into mobile coronary care units staffed by The limited surgical alternatives in 1958 made accurate well trained paramedics. Electrocard iographic monitoring diagnosis much less urgent than today. Although some sur• and a coronary care unit approach began in the hospital gical procedures were ava ilable. the first prosthetic valve emergency room immediately on arrival of the patient with had yet to be implanted (54) . Open heart surgery was limited chest pain. and not in general use because risks and results were pro• Bedside hemodynamic monitoring and therapy. The hibitive. For the patient with otherwise nonremedial valvular coronary care unit did not stand long on the laurels it achieved or myocardial disease. the option of cardiac transplantation through the control of arrhythmias. In the early 1970s. the was in the realm of science fiction both techni cally and Swan-Ganz catheter made possible bedside hemodynami c immunologically. Tod ay. there are few valvular and con• appraisal (47) . A new approach to diagnosis and treatment genital lesions for which some surgical treatment is not of acute myocardial infarction followed . It was the era of avai lable. Even cardi ac transplantation under certain cir• hemodynamic monitoring and management. Such terms as cumstances is a practical option (55). preload and afterioad introduced a new language to coron ary care . As often happens. effective therapy followed accurate Coronary Heart Disea se diagnosis. Hemodynamic monit oring and a new pharma• Angina pectoris. Although progress has been dramatic cology of potent diuretic drugs. vasodilators, beta-receptor in all phases of cardiovascular disease. it is the patient with blocking drugs, pressor agents and calcium antagonists helped coronary heart disease who occ upies the center stage of to transform the coronary care unit into a physiologic lab• cardiology in 1983. Whether measured in terms of numbers. oratory. Concurrently, surgery became bolder and more suc• procedures. results . doll ars or impact on medicine and so• cess ful (48) . Complications of acute myocardial infarction . ciety. it is the diagnosis and treatment of coronary disease such as septal perforation and mitral apparatus injury. sud• that dom inates cardiology . In 1958. the patient presenting denly were treated surgicall y (49) . Events moved rapidly. with chest pain and suspected of having ischemic coro nary Some patients with acute myocardial infarction were taken disease required a relatively simple investigation. Thi s in• directly to the catheterization laboratory. On occasion. med• clud ed a history. physical exa mination, resting electrocar• ical revascularization was attempted with thrombolytic en• diogram and perhaps a Master two-step test. Except for zymes (50, 5 1). Other pati ents had emergency coronary ar• nitroglycerin , therapy was not specific. The approach was teriography and , after definiti on of anatomy, surgical indirect and supportive and emphasized control of pain . revascularization (52) . Transluminal angioplasty . un• congestive heart failure and arrhythmias. Related syndro mes dreamed of in 1958 , added a nonsurgical alternative to the such as hypertension . hyperthyroidism , diabetes and obesity treatment of occlusive coronary disease (53) . Angiopl asty were treated . evo lved so rapidly that present techn iques are probably tran• As is still the case, caveats included smoking. emotional sitional. During the 1970s, coronary arteriography and sur• and physical stress and fatigue. In 1958 . there prob ably was gical treatment of occlu sive coronary disease became com• less emph asis on physical exerc ise and behavior modifica• monpl ace , even before con sensus could be established for tion to control stress . Some controversies such as anticoag• indic ations and long-term effects. ulation and diet remain. A commentary on coronary artery PATIENT WITH HEART DISEASE: 1958-1983 J AM cou, CARDIOl 9 1983:1:6-12

disease (56). published in 1958, quoted an American Med• term prognosis. Relatively unfavorable factors include an• ical Association Council on Food and Nutrition opinion. terior location of infarction, cardiac enlargement. intra• " ... quite a bit more study concerning dietary fads will ventricular conduction defects, recurrent infarction. persis• have to be done before the average American eating habits tent tachycardia. severe and protracted pain (61.62) and an are to be drastically altered." The author also recommended inordinately high rise in serum enzyme levels (63). From a a low cholesterol diet despite the incomplete evidence. These hemodynamic point of view, hypotension not due to hy• statements could have been written today. povolemia, pulmonary congestion. elevated left ventricular With the exception of nitroglycerin. drug therapy for filling pressure or reduced ejection fraction suggests a more symptomatic ischemic coronary disease is totally different ominous short-term prognosis (64). Recognition of right from that of 1958. The long dormant concept of coronary ventricular infarction and the requirement for specific ther• artery spasm has been restored to clinical importance (57). apy are new since 1958 (65). The severity of the myocardial Long-acting nitrates, orally and transcutaneously, beta-re• insult may be defined further by echocardiography (66) and ceptor blocking drugs. calcium antagonists. more effective by radionuclide techniques (67). Other ways of categorizing diuretic drugs. peripheral vasodilators and psychoactive agents the acute infarction include the designations complete or contribute today to better control of angina. incomplete. transmural or nontransmural and complicated Unstable angina. For the patient with chest pain hos• or uncomplicated (60). Each of these categories is significant pitalized in 1983 because of unstable angina. the experience in defining treatment and prognosis. For example, in 1958 is entirely different from that of 1958. Today. he or she a nontransmural infarction was considered relatively benign. will be placed in a cardiac care facility where electrocar• Today it is known that the future of patients with this con• diographic monitoring is constant and hemodynamic sur• dition may be even more uncertain than that of patients with veillance available. The immediate therapeutic objective is a completed transmural lesion (68). The patient with un• the control of symptoms and signs of clinical instability. In complicated myocardial infarction may be hospitalized for addition to the pharmacologic regimen already described for less than 2 weeks and the patient with complicated infarction the ambulatory patient with angina. anticoagulant agents. rarely for more than 3. intravenous nitroglycerin and narcotic drugs may be used. Postinfarction management. After myocardial infarc• When the patient's condition has been controlled medically. tion, the ultimate prognosis depends on three factors-elec• elective coronary arteriography and ventriculography will trical stability. the integrity of the myocardium and the be performed. A decision can then be made for definitive character of coronary artery stenosis. Long-term evaluation medical or surgical management. Ifthe patient's condition begins before discharge from the hospital. It is at this point cannot be stabilized medically. coronary arteriography will that the decision-making process for patients with unstable be carried out as a relative emergency. angina and patients with a recent myocardial infarction con• Acute myocardial infarction. For the patient with acute verges. Here controversy remains. How important is the myocardial infarction, the program is also dramatically dif• presence of symptoms in patients who have had unstable ferent from that of 1958. The coronary care unit. with its angina or recent myocardial infarction? What happens to electrocardiographic and hemodynamic monitoring. capa• the patient depends on the philosophy of his or her phy• bility for resuscitation, defibrillation. cardioversion and sician and how the physician interprets the published data transvenous pacing and intraaortic balloon assistance. was and his or her own experience. Some physicians may select unknown in 1958. In 1958 the hallmark of treatment for a high risk postmyocardial infarction group by the response acute myocardial infarction was protracted bed rest. perhaps to an exercise stress test (69). A 24 hour ambulatory 6 weeks. At that time. a radical innovation was to lift the electrocardiogram may suggest a high risk category because patient out of bed in a chair (58). While papers were be• of electrical stability or an ischemic response to activity ginning to advocate a shorter stay for patients designated (0). Other physicians may consider that all patients without as "mild," (59) it was not until the middle 1970s that bed specific contraindications should have coronary anteriog• rest and length of stay were reduced materially (60). raphy after recovery from acute myocardial infarction 01. 72). Virtually every aspect of management of acute myo• Still others may proceed with a medical regimen without cardial infarction in /983 is different from that of /958. even considering coronary arteriography. One of the most important changes is philosophic. Today's Surgical therapy. One of cardiology's great dilemmas approach to the patient with acute myocardial infarction today is in the surgical management of coronary disease. looks beyond the acute phase. This attitude evolved after Absolutes are few. Consensus currently favors surgical re• the development of significant medical and surgical means vascularization for patients with obstructive left main dis• of improving long-term prognosis. From the moment the ease or symptomatic multivessel occlusive coronary disease. patient enters the coronary care unit. prognostic evaluation For patients with limited symptoms and less compelling begins simultaneously with treatment. Clinical, electrocar• combinations of obstructive disease and left ventricular dys• diographic and hemodynamic evaluation helps to define short- function there is no consensus. The selection of a medical 10 J AM cou, CARDIOl WEIt' HER(; 1983;1:6-12

regimen from available medications, exercise rehabilitation medic al program. The decision for medical treatment when (73) and behavior modification programs is no less perplexing. surgery is needed is no less inappropriate than unnece ssary surgery. The practice of medicine and cardiology is both art and science: neither is exac t. Effective decision makin g Cardiology: Present Status is as important to the patient and soc iety as the development This first issue of the Journal of the American College of of the test and the procedure. The ingenuity. talent and Cardiology reviews and interprets the evolution of cardiol• energy that created coronary arteriography and open heart ogy during the past 25 years. Topics vary from epidemiology surgery are wasted if these procedures are applied inappro• to echocardiography. from enzymes to electrophysiology. priately. The quality of the decision-making proce ss must from revascularization to rehabilitation and from arrhyth• be comparable to that of the intervention it select s. mias to arteriography. Almo st everything written is new Evaluation of clinical trials . Since World War II. clin• since 1958. These advances are not confined to the great ical studies have become standard for evaluating diagnostic centers. Relatively remote hospitals throughout the country and therapeutic procedures. Prospect ive, randomized. dou• are staffed with highly trained cardiologists and offer so• ble-blind trials have been used to document drug safety and phisticated facilities. efficacy. However well intentioned. these studies are rarely Although it may seem that progress has made the work perfect. Although it is attractive to think that a protocol can of the physician easier now than in 1958. this impression be designed to prove whether a drug or a procedure is is misleading. Today. diagnosis is more accurate and in• effective, in practice, unequivocal answers are rare. Several tervention more decisive. The physician's responsibility is searching commentaries on therapeutic trials have described much greater. Failure to diagnose bacteri al endocarditis, a their limitations (74-76). Stati stical analysis may suggest a dissect ing aneurysm or an ulcerated carotid lesion. or to good result erroneously or may not recognize a favorable recognize a subtle anginal equivalent. may deny the patient trend . The reasons for these errors are complex. The y may a chance for a cure . As never before . the physician has the be inherent in the design of the trial. in the execution or in opportunity to do good and the possibility to do harm. the interpretation. There are many instances in cardiology Decision-making process. In every stage of the diag• where clin ical trial s are not definitive. Well known examples nostic and therapeutic process, the cardiologist will make are the use of anticoagulant and antiplatelet agents. Iipid• decision s and perform or advise procedures that will affect lowering diets and agent s and . indeed. the role of myocardial the quality of life and perhaps even patient survival. The revascularization. The evaluation of a diagno stic or surgical deci sion-making process is the very essence of the practice technique may be more difficult than that of a medication. of medicine. This is especially true for the cardiology of The composition of a medication is constant. The result of 1983. a surgical procedure varies with the operator's skill. In the practice of cardiology, the setting for a vital de• Measures to improve decision-making process. cision is not necessarily dramatic. It is more likely to be Because definitive answers are few. how can the decision• mundane and innocent. A 45 year old woman presents for making process be improved? Perhaps the first step is to physical examination. She may describe a typical chest recognize that few tests provide absolute answers. The elec• pain . Her physician elects to perform a multilevel treadmill trocardiographic evolution of acute myocardial infarction, stress test. ST-T segment depression occurs.A pivotal de• an elevated blood sugar level or a positive pathologic biopsy cision must be made. Is the result of the exercise test de• may be unequivocal. Many clinical tests on which decisions finitive ? Does it really suggest the probability of life-threat• are made are not. The significance of an exercise stress test , ening occlusive coronary disease ? Does it warrant a coronary arteriogram or radionuclide imaging may be un• arteriography? Is it a false positive result or a normal vari• certain. The significance of a test must be evaluated in the ation ? Does it reall y correlate with the patient's history. clini cal context. The incidence of the disease in the popu• symptoms and other finding s? The phy sician 's deci sion may lation which the patient repre sents. the medications. phys• subject the patient to an expensive invasive procedure with ical finding s and symptoms are vitally important in inter• potential, though limited, risk of a major complication or pretation of a test. The phy sician must consider sensitivity. even death. Failure to perform the test may cause the di• specificity and the positive and negative predictive value of agnosis of life-threatening coronary disease to be missed . each test. The se usuall y cann ot be expressed in finite num• A negati ve result may reas sure the patient, but at a cost bers. Becau se deci sion makin g is generally not based on difficult to bear and which society is increasingl y reluctant absolutes. the physician must have special qualities. These to absorb . This is true particularly if astute judgment could are knowledge, experience, empathy, judgment and char• avoid the procedure. The arteriogram may show some de• acter. They are vital to the decision-making process. With• gree of arterial narrowing. Again. a fateful decision must out knowledge and experience. the physician lacks the in• be made . One judgment may lead the patient to the expense. tellectual and practical balance to decide . Without empathy morbidity and danger of surgery. Another may choose a he will not understand the patient's symptoms. expectations PATIENT WITH HEART DISEASE: 19S9-19g3 J AM COLI. CARDIOL II 1993:1:6-J2

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