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50 YEARS OF CLINICAL CARDIOLOGY a personal experience

50 YEARS OF CLINICAL CARDIOLOGY a personal experience. Prof. Dr. Fayez Fayek Botros National Heart Institute. Graduated in 1956 and now year 2006 My talk will cover 50 years of advancement in cardiology, but from personal and general experience.

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50 YEARS OF CLINICAL CARDIOLOGY a personal experience

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  1. 50 YEARS OF CLINICALCARDIOLOGYa personal experience Prof. Dr. Fayez Fayek Botros National Heart Institute

  2. 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.

  3. HEART FAILURE

  4. 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 .

  5. 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).

  6. 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.

  7. 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

  8. HYPERTENSION

  9. 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 .

  10. 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 . Drugs :

  11. 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

  12. 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 .

  13. 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 .

  14. Quality of life

  15. Development of Antihypertensive Therapies Effectiveness Tolerability 1940s 1950 1957 1960s 1970s 1980s 1990s 2004+ Directvasodilators Alphablockers ACEinhibitors ARBs Others? 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.

  16. Now with Diuretics , ACE , ARBS , B Blockers & C C Blockers LIVE LONGERWITH BETTERQUALITY OF LIFE ...

  17. ISCHEMIC HEART DISEASE

  18. 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 .

  19. -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 .

  20. 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 .

  21. 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 .

  22. 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 .

  23. *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.

  24. INVESTIGATIONS Mainly :-x-ray….. very important - ECG Rare for : -apexcardiography. -phonocardiography:understanding of hemodynamics,murmursandheartsounds. -ballistocardiograph:oflittlevalue,no moreinformation. Now : Echocardiography(1970)

  25. Phonocardiography

  26. Echocardiography

  27. 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 .

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

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

  30. 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

  31. CARDIAC PACING *Only external . *We made our own pace makers. *applied :-brachial root tied around the arm -external jugular root. *Mr. Shatz

  32. Perforation of the right ventricular wall by the electrode tip

  33. CARDIOLOGY IN OUR TIME WAS CLINICAL CARDIOLOGY . . . NOW INVESTIGATIONAL CARDIOLOGY

  34. 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.

  35. 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 .

  36. 60 YEARS OF ADVANCE

  37. 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

  38. 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

  39. 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)

  40. 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 .

  41. Thank you

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