50 YEARS OF 50 YEARS OF CLINICALCLINICAL

CARDIOLOGYCARDIOLOGYa personal a personal experienceexperience

Prof. Dr. Fayez Fayek BotrosProf. Dr. Fayez Fayek Botros

National Heart InstituteNational Heart Institute

Graduated in 1956 and now year 2006Graduated in 1956 and now year 2006 My talk will cover 50 years of My talk will cover 50 years of

advancement in cardiology, but from advancement in cardiology, but from personal and general experience.personal and general experience.

Compared with nowadays ,Cardiology Compared with nowadays ,Cardiology in our time was:in our time was:

**primitiveprimitive

**giving great care to history taking ,giving great care to history taking ,

observation & clinical examination.observation & clinical examination.

**less tools for investigations & less tools for investigations & treatmenttreatment..

HEART FAILUREHEART FAILURE1.1. Rest in a comfortable arm chair.Rest in a comfortable arm chair.2.2. Low salt diet . Low salt diet . 3.3. Oxygen.Oxygen.4.4. DigitalisDigitalis::( Paul Woods diseases of the heart &circulation ,1966)( Paul Woods diseases of the heart &circulation ,1966)

It is doubtful if there are any real contraindications to It is doubtful if there are any real contraindications to use Digitalis in therapeutic doses :use Digitalis in therapeutic doses :Initial doses of 0.5 mg six hourly or t.d.s. for tow days 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 followed by 0.25 mg t.d.s. until desired effect is achieved or early signs of intoxication , when the dose should be or early signs of intoxication , when the dose should be reduced to 0.25 mg once or twice daily .reduced to 0.25 mg once or twice daily .

5.5. OuabainOuabain :(Strophanthin) :(Strophanthin)is derived from strophanthus gratus .is derived from strophanthus gratus .used IV in acute cases .used IV in acute cases .

6.6. Mercurial DiureticsMercurial Diuretics : : **Discovered by accident at the Wenckebach clinic in Discovered by accident at the Wenckebach clinic in Vienna in 1919 , when noticed that a new syphilitic Vienna in 1919 , when noticed that a new syphilitic mercurial medicine (Novasurol ) ,when injected in a mercurial medicine (Novasurol ) ,when injected in a girl with syphilis produced diuresis , but was painful girl with syphilis produced diuresis , but was painful & toxic. & toxic. **Replaced by more benign Salyrgan that was Replaced by more benign Salyrgan that was combined with theophylline to produce (Mersalyl).combined with theophylline to produce (Mersalyl).

**Mersalyl given IM every 3Mersalyl given IM every 3rdrd or 4 or 4thth day with day with ammonium chloride 2gm t.d.s. to replace chloride ammonium chloride 2gm t.d.s. to replace chloride loss.loss.

**acts by decreasing tubular reabsorption of Na, K acts by decreasing tubular reabsorption of Na, K chloridechloride

**ToxicityToxicity: high fever , rigors ,vomiting, colic, : high fever , rigors ,vomiting, colic, diarrhea, fatigue, convulsion, toxic nephritis and diarrhea, fatigue, convulsion, toxic nephritis and sudden death (VF or asystole).sudden death (VF or asystole).

ACUTE HEART FAILUREACUTE HEART FAILUREPrice text book of Medicine 1967Price text book of Medicine 1967

VenesectionVenesection::**Acute LVF : Acute LVF : 600cc blood. 600cc blood.**Severe CHF : may break the vicious Severe CHF : may break the vicious circle of failure and lead to increasing circle of failure and lead to increasing response to diuretics .response to diuretics .

TourniquetTourniquet : :by applying the cuff to the four extremities by applying the cuff to the four extremities which may induce dramatic response. which may induce dramatic response.

RESISTANT HEART FAILURERESISTANT HEART FAILURE

AcupunctureAcupuncture : :-Put patient in an arm chair for 24 hours.-Put patient in an arm chair for 24 hours.

-A triangular cutting needle …. A dozen -A triangular cutting needle …. A dozen punctures in punctures in

each leg .each leg .

-Southeys tubes … large bore needles inserted -Southeys tubes … large bore needles inserted in s.c.in s.c.

tissues of the thighs or calves .tissues of the thighs or calves .

LeachesLeaches

HYPERTENSIONHYPERTENSIONPaul Wood text book 1966Paul Wood text book 1966

ConservativeConservative : :-Put patient to bed till symptoms disappear & BP-Put patient to bed till symptoms disappear & BP

reaches a static level .reaches a static level .

-Sedation for mental relaxation .-Sedation for mental relaxation .

-Obese patient needs weight reducing diet with -Obese patient needs weight reducing diet with one dayone day

per week of semi starvation .per week of semi starvation .

-Encephalopathy needs rest & vigorous -Encephalopathy needs rest & vigorous dehydration .dehydration .

-Low sodium diet .-Low sodium diet .

DrugsDrugs: :

Rauwolfia SerpentinaRauwolfia Serpentina : :-was used in India as a sedative .-was used in India as a sedative .

-centrally acting by depleting brain serotonin and -centrally acting by depleting brain serotonin and hypothalamic nor-hypothalamic nor-

adrenaline .adrenaline .

-side effects: sinus bradycardia, nasal congestion, depression,-side effects: sinus bradycardia, nasal congestion, depression,

weight gain, and diarrhea .weight gain, and diarrhea .

L-Hydrazinophthalazine (apresoline)L-Hydrazinophthalazine (apresoline) : :-central & peripheral action .-central & peripheral action .

-stopped for formidable side effects : severe headache, -stopped for formidable side effects : severe headache, tachycardia, anxiety, depression, rheumatoid like symptoms & tachycardia, anxiety, depression, rheumatoid like symptoms & SLE .SLE .

Lumbo -dorsal sympathectomyLumbo -dorsal sympathectomy::

-25% died within 3-5 years .-25% died within 3-5 years .

-bilateral resection of whole sympathetic -bilateral resection of whole sympathetic chain chain

from D8 to L2 .from D8 to L2 .

-relieve as much vasoconstrictor tone as-relieve as much vasoconstrictor tone as

possible .possible .

-side effect :.postural hypotension-side effect :.postural hypotension

.impotence.impotence

Medical SympathectomyMedical Sympathectomy: :

Ganglion blocking agentsGanglion blocking agents::-block both sympathetic and parasympathetic systems .-block both sympathetic and parasympathetic systems .-side effects: *constipation up to ilieus .-side effects: *constipation up to ilieus . *dry mouth .*dry mouth .

*urine retention .*urine retention . *impotence .*impotence .*orthostatic hypotension .*orthostatic hypotension . *syncope .*syncope .*disturbance of vision due to difficulty of *disturbance of vision due to difficulty of

accommodation .accommodation . Adrenergic blocking agentsAdrenergic blocking agents::

-best known was Guanethedine (Ismeline).-best known was Guanethedine (Ismeline).-prevents production and/or release of adrenergic catecholamines-prevents production and/or release of adrenergic catecholamines

from post ganglionic nerve endings . from post ganglionic nerve endings . -gave good results in 70% of patients .-gave good results in 70% of patients .-side effects : *orthostatic hypotension .-side effects : *orthostatic hypotension . *myalgia .*myalgia . *fluid retention .*fluid retention . *impotence .*impotence .

*frequency of micturition*frequency of micturition *tremors .*tremors .*nasal congestion .*nasal congestion .

Alpha Methyl DopaAlpha Methyl Dopa : :-block formation of both serotonin and dopamine .-block formation of both serotonin and dopamine .

-dose : 250 up to 1000mg t.d.s.-dose : 250 up to 1000mg t.d.s.

-side effects: *sedation .-side effects: *sedation . *somnolence .*somnolence .

*sleep disturbance .*sleep disturbance . *depression .*depression .

*dry mouth .*dry mouth . *nasal congestion .*nasal congestion .

*parkinsonism .*parkinsonism . *gyneacomastia .*gyneacomastia .

*not used in acute liver disease or hepatic *not used in acute liver disease or hepatic dysfunction dysfunction

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

Quality of lifeQuality of life

020406080

100

percentage

Physician's assment of the effect of antihypertensive therapy

improved

no change

no change

050

100percentage

Patient's assessment of the effects of antihypertensive therapy

improved

no change

worse

050

100percentage

Relatives' assessment of the effect of antihypertensive therapy

improved

no change

worse

Development of Development of Antihypertensive TherapiesAntihypertensive Therapies

Development of Development of Antihypertensive TherapiesAntihypertensive Therapies

DirectDirectvasodilatorsvasodilators

DirectDirectvasodilatorsvasodilators

AlphaAlphablockersblockers

AlphaAlphablockersblockers

Others?Others?Others?Others?

PeripheralPeripheralsympatholyticssympatholytics

Ganglion Ganglion blockersblockers

VeratrumVeratrumalkaloidsalkaloids

PeripheralPeripheralsympatholyticssympatholytics

Ganglion Ganglion blockersblockers

VeratrumVeratrumalkaloidsalkaloids

Central alphaCentral alpha22

agonistsagonists

Non-DHPNon-DHPCCBsCCBs

Beta blockersBeta blockers

Central alphaCentral alpha22

agonistsagonists

Non-DHPNon-DHPCCBsCCBs

Beta blockersBeta blockers

ThiazideThiazidediureticsdiureticsThiazideThiazidediureticsdiuretics

DHP CCBsDHP CCBsDHP CCBsDHP CCBs

ARBsARBsARBsARBsACEinhibitors

ACEinhibitors

EffectivenessEffectivenessEffectivenessEffectiveness

TolerabilityTolerabilityTolerabilityTolerability

1940s1940s 19501950 19571957 1960s1960s 1970s1970s 1980s1980s 1990s1990s 2004+2004+

DHP, dihydropyridine; CCB, calcium channel blocker; ARB, angiotensin II receptor blocker.DHP, dihydropyridine; CCB, calcium channel blocker; ARB, angiotensin II receptor blocker.DHP, dihydropyridine; CCB, calcium channel blocker; ARB, angiotensin II receptor blocker.DHP, dihydropyridine; CCB, calcium channel blocker; ARB, angiotensin II receptor blocker.

Now with Diuretics , ACE , ARBS , Now with Diuretics , ACE , ARBS ,

B Blockers & C C BlockersB Blockers & C C Blockers

LIVE LONGERLIVE LONGER WITH BETTERWITH BETTER QUALITY QUALITY OF LIFE ...OF LIFE ...

AnginaAngina

-light diet .-light diet .-reduce calorie intake .-reduce calorie intake .-10 – 15 cigarettes /day allowed or stopped if -10 – 15 cigarettes /day allowed or stopped if

persistent attacks .persistent attacks .-Amyl nitrite capsule broken in handkerchief -Amyl nitrite capsule broken in handkerchief & &

inhaled . Patient is embarrassed by noise ofinhaled . Patient is embarrassed by noise of capsule , pungent smell , vivid flush &capsule , pungent smell , vivid flush & tachycardia .tachycardia .

Then oral form of glyceryl trinitrate .Then oral form of glyceryl trinitrate .

-long term anticoagulant therapy .-long term anticoagulant therapy .-B Blocking agents play small but -B Blocking agents play small but important roleimportant role

in treatment of angina .in treatment of angina .-Clofibrate (Atromid S) seems to lower -Clofibrate (Atromid S) seems to lower serum serum

cholesterol & combat platelet stickiness .cholesterol & combat platelet stickiness . Not yet recommended . Not yet recommended . -artificial Myxoedema . -artificial Myxoedema . Now obsolete (1966) and only used in Now obsolete (1966) and only used in

intractable angina . intractable angina .

Paul Wood 1966Paul Wood 1966 : :

I have never myself been able to I have never myself been able to develop much enthusiasm for this form of develop much enthusiasm for this form of treatment , partially because of rise of treatment , partially because of rise of cholesterol ,and symptoms of cholesterol ,and symptoms of Myxoedema .Myxoedema .

I have only embarked anti-thyroid I have only embarked anti-thyroid treatment in advanced cases that have treatment in advanced cases that have been almost totally incapacitated .been almost totally incapacitated .

Angina treatment (cont.)Angina treatment (cont.)

--SurgicalSurgical : :

**bilateral thoracic sympathectomy ,gave bilateral thoracic sympathectomy ,gave partial relief.partial relief.

**production of coronary collateral production of coronary collateral circulation :circulation :-A flap of pectoral muscle or omentum sutured to the -A flap of pectoral muscle or omentum sutured to the heart .heart .

-apply bone dust , asbestos ,magnesium , talc ….-apply bone dust , asbestos ,magnesium , talc ….

-ligation of great cardiac veins arch of coronary -ligation of great cardiac veins arch of coronary sinus . sinus .

CARDIAC INFARCTIONCARDIAC INFARCTIONHOME OR IN HOSPITAL ICCUHOME OR IN HOSPITAL ICCU

ICCUICCU :-facilitates external cardiac massage, :-facilitates external cardiac massage, electric defibrillation ,electric pacing if electric defibrillation ,electric pacing if needed.needed.

Main aim was to reduce mortalityMain aim was to reduce mortality

But the present evidence does not justify on But the present evidence does not justify on insistence for need of admission .insistence for need of admission .

* * TreatmentTreatment::

-complete bed rest for 3 weeks.-complete bed rest for 3 weeks.-arm chair for 3 weeks.-arm chair for 3 weeks.-mild movements for 3 weeks.-mild movements for 3 weeks.-gradual rehabilitation for 3 weeks.-gradual rehabilitation for 3 weeks.

( No return to work before 12 weeks .)( No return to work before 12 weeks .) Anticoagulants to all cases.Anticoagulants to all cases. Diet :-semi starvation for 1Diet :-semi starvation for 1stst few days . few days .

-800 caloric diet (only fruit juice….soft -800 caloric diet (only fruit juice….soft food ,food ,

little milk is allowed ).little milk is allowed ).

**Prognosis:Prognosis:25% die during the 125% die during the 1stst month of cardiac month of cardiac infarction.infarction.

INVESTIGATIONSINVESTIGATIONS

Mainly :Mainly :-- x-rayx-ray ….. very important….. very important - - ECGECG

Rare for : Rare for : --apexapex cardiographycardiography.. --phonocardiographyphonocardiography ::understanding understanding

ofof hemodynamicshemodynamics ,murmurs,murmurs andand heartheart sounds.sounds.

--ballistocardiographballistocardiograph ::ofof littlelittle valuevalue ,, nono

moremore information.information.

Now : Now : EchocardiographyEchocardiography (1970)(1970)

BALLISTOCARDIOGRAPBALLISTOCARDIOGRAPGYGY

Based on : when a gun is fired , it recoils .Based on : when a gun is fired , it recoils .((Newton's 3Newton's 3rdrd low of motion : for every action on a body , there is low of motion : for every action on a body , there is

an equal opposite reaction )an equal opposite reaction )

**As early as 1877 Gordon recorded the As early as 1877 Gordon recorded the movements of a suspended platform on movements of a suspended platform on which a man is lying.which a man is lying.

**1939 ,Starr & his associates developed a 1939 ,Starr & his associates developed a couch.couch.

**1949 Dork and Taubman the body s allowed 1949 Dork and Taubman the body s allowed to move on its own cushion of fat ,the to move on its own cushion of fat ,the movements of a bar laid across the shins movements of a bar laid across the shins being amplified & recorded . being amplified & recorded .

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

CARDIAC CARDIAC CATHETERIZATIONCATHETERIZATION

1.1. Cath lab was primitive as compared Cath lab was primitive as compared with now …. No screens , No with now …. No screens , No computers , even No calculators .computers , even No calculators .

2.2. How we observe …….How we observe …….

3.3. Our own Kefa catheter in coils shaped Our own Kefa catheter in coils shaped by our selves with heated rod.by our selves with heated rod.

4. Rotating table, patient tied with belts .4. Rotating table, patient tied with belts .

table moves only forwards and table moves only forwards and backwards.backwards.

5. Cath. finding calculations with 5. Cath. finding calculations with calculating rulers . No automatic calculating rulers . No automatic calculations for valve area Gorlin’s calculations for valve area Gorlin’s formula , Co , PVR ….. etcformula , Co , PVR ….. etc

CARDIAC PACINGCARDIAC PACING

**Only external .Only external .

**We made our own pace makers.We made our own pace makers.**applied :-brachial root applied :-brachial root tied around the armtied around the arm

-external jugular root.-external jugular root.

**Mr. ShatzMr. Shatz

Perforation of the right ventricular wall by the electrode tip

CARDIOLOGY IN OUR TIME CARDIOLOGY IN OUR TIME WAS WAS

CLINICAL CARDIOLOGYCLINICAL CARDIOLOGY..

..

..

NOWNOWINVESTIGATIONAL INVESTIGATIONAL

CARDIOLOGYCARDIOLOGY

Good history ,good observation .Good history ,good observation . Full clinical examination for 20-30 minutes.Full clinical examination for 20-30 minutes. Few investigations : x-ray , ECG ..Few investigations : x-ray , ECG .. Few drugs .Few drugs . But : great But : great

sympathy ,understanding ,reassurance& sympathy ,understanding ,reassurance& friendship .friendship .

May or may not improve life span May or may not improve life span

But definitely improve Q.O.L.But definitely improve Q.O.L.

NowNow::

Fast era .Fast era . Short time :5-10 minutes.Short time :5-10 minutes. Many investigations.Many investigations. Many drugs & expensive treatment .Many drugs & expensive treatment .

Improve Q.O.L. , prolong life Improve Q.O.L. , prolong life spanspan

But no friendly relation .But no friendly relation .

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

1961The Framingham Heart Study finds

that cholesterol level ,blood pressure , and electrocardiogram abnormalities increase the risk of heart disease .

1968Rene’ Favaloro reports saphenous

vein coronary artery bypass graft surgery (CABG) for angina pectoris

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)

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 .