to Know how the treatment of important disease as myocardial infarction has been developed through time

1. The treatment of acute myocardial
infarction:
the Past & the Present
Dr. Ameel Toma

2. 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

3. 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).

4. 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

5. 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,

6. 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.

7. 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 quinidine
for 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.

8. 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.

9. 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.

10. • It was quite discouraging to young physicians,
because we felt so impotent;
• older physicians accepted this as ‘just the way
it was.’

11. 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’.

12. Phase 2: the coronary care unit:
• Cardiac arrest ?????

13. 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.

14. 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.

15. • 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’.

16. • 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

18. What is next???

19. • 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.

20. 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 transmural
myocardial 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.

21. 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.

22. • 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]

25. First catheterisation in a human
• In 1929, a German surgical
trainee, Werner Forssmann,
experimented on a human
cadaver and realized how easy it
was to guide a urological catheter
from an arm vein into the right
atrium
•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

26. • 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."

27. 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

28. Cut Down

29. Seldinger Technique

30. • 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).

31. 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, Gruentzig
performed 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,

32. • 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

33. THANK YOU