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Of pre-infarct syndrome and bed rest
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recovery, however, should enable us confidently to use advances in medicine for blessings, whereas now sometimes they appear to be millstones round our necks. In order to recreate t h a t trust we need deeper and wider thinking a b o u t our work than generally we have shown. We need candor and simple good will. Above all, we need to prove t h a t science in medicine is but the handmaid of compassion; t h a t personal
fortune and the esteem of our peers is entirely secondary to the trust and care t h a t must lie between m a n and man.
Keith Norcross Consultant Orthopaedic Surgeon Dudley Road Hospital, P.O.-Box 293 Dudley Road, Birmingham B18 7QH England
Of pre-infarct syndrome and bed rest
The emphasis in the management of ischemic heart disease and myocardial infarction i s directed mainly toward the treatment of myocardial infarction and its many serious complications after the infarct and its complications develop. Mobile CCU, hospital CCU, medica ! management, and coronary bypass surgery command most a t t e n t i o n and space in medical literature today concerning the management of myocardial infarction. Prevention of infarction is not adequately emphasized. The greatest advancements in all fields of medicine have been in the field of prevention. It is well known t h a t "pre-infarction angina" is likely to lead to myocardial infarction; therefore, why not t r e a t the "preinfarction angina" vigorously with the objective of preventing infarction rather t h a n wait for the infarct to develop and then treat it? T r e a t m e n t to prevent infarction should begin promptly after the first signs of pre-infarction angina are manifested if infarction is to be prevented. It is always better to treat ischemic heart disease before any heart muscle is lost, in an a t t e m p t to prevent infarction with the loss of myocardium, than to treat an infarct after heart muscle has been lost. Heart muscle cannot regenerate and, therefore, an infarct of the myocardium represents an area of h e a r t muscle lost forever. Thus, the heart of a patient with an infarct must pump a sufficient amount of blood t o meet the demands of all
organ s of the body despite less h e a r t muscle. And, when the loss of muscle is g]'eat, the work capacity of the heart is certainly greatiy reduced. Therefore, the physician should treat ali patients with "preinfarction angina" in the same m a n n e r in which he would treat a patient with an acute myocardial infarct, but before myocardial infarction occurs. T h e patients should be placed at complete be d rest at home or in hospital for at least 30 days, with controlled diet, sedatives, avoidance of psychic and physical stress, oxygen, and other measures as needed. Remember also that, if the patient is hospitalized and develops an infarct soon after admission to hospital, he is already in a CCU or a private room where emergency therapeutic measures are immediately available with trained experts in attendance. This sittiation is certainly better for the patient t h a n his having to call a n d wait for a mobile CCU or to be transported by ambulance or automobile to the hospital. Furthermore, very few patients with pre-infarcti0n or crescendo angina will develop an infarct, anyway, if proper therapeutic measures are employed promptly in advance.
G. E. Burch, M.D. Tulane University School of Medicine and Charity Hospital New Orleans, Louisiana
Effects of cardiopulmonary bypass on the jugular venous pulse
The volume of the jugular venous pulse reflects changes in the right atrial pressure contour. The technique of cardiopulmonary bypass commonly includes cannulation of the right atrium and left ventricle, and amputation of the right atrial appendage, and thus might be expected to alter the jugular venous pulse. H a r t m a n ' noted reductions in t h e A wave and X descent following operation for artriaI septat defect. This reduction even occurred in one patient in whom the atrium was entered but the defect not repaired, suggesting t h a t closure of the defect was not responsible for the changes in the jugular pulse. We have noted attenuation of the jugular A wave and X
262
descent in a n u m b e r of patients undergoing cardiopulmonary bypass for a wide variety of cardiac lesions, and have been prompted to review the jugular pulse recordings in 34 of our patients who underwent cardiac surgery. Jugular pulses were recorded by the method of Tavel. ~ Tracings were obtained within one m o n t h prior to surgery in 29 patients, and from one week to ten years postoperatively in 34 patients. Preoperative tracings were not available for five patients, all of whom had undergone cardiopulmonary bypass. Twenty-five of these patients (13 males, 12 females, mean age 39) underwent surgery which utilized cardiopulmonary bypass for the following diseases: mitral stenosis (7), aortic stenosis
August, 1977, Vol. 94, No. 2
recovery, however, should enable us confidently to use advances in medicine for blessings, whereas now sometimes they appear to be millstones round our necks. In order to recreate t h a t trust we need deeper and wider thinking a b o u t our work than generally we have shown. We need candor and simple good will. Above all, we need to prove t h a t science in medicine is but the handmaid of compassion; t h a t personal
fortune and the esteem of our peers is entirely secondary to the trust and care t h a t must lie between m a n and man.
Keith Norcross Consultant Orthopaedic Surgeon Dudley Road Hospital, P.O.-Box 293 Dudley Road, Birmingham B18 7QH England
Of pre-infarct syndrome and bed rest
The emphasis in the management of ischemic heart disease and myocardial infarction i s directed mainly toward the treatment of myocardial infarction and its many serious complications after the infarct and its complications develop. Mobile CCU, hospital CCU, medica ! management, and coronary bypass surgery command most a t t e n t i o n and space in medical literature today concerning the management of myocardial infarction. Prevention of infarction is not adequately emphasized. The greatest advancements in all fields of medicine have been in the field of prevention. It is well known t h a t "pre-infarction angina" is likely to lead to myocardial infarction; therefore, why not t r e a t the "preinfarction angina" vigorously with the objective of preventing infarction rather t h a n wait for the infarct to develop and then treat it? T r e a t m e n t to prevent infarction should begin promptly after the first signs of pre-infarction angina are manifested if infarction is to be prevented. It is always better to treat ischemic heart disease before any heart muscle is lost, in an a t t e m p t to prevent infarction with the loss of myocardium, than to treat an infarct after heart muscle has been lost. Heart muscle cannot regenerate and, therefore, an infarct of the myocardium represents an area of h e a r t muscle lost forever. Thus, the heart of a patient with an infarct must pump a sufficient amount of blood t o meet the demands of all
organ s of the body despite less h e a r t muscle. And, when the loss of muscle is g]'eat, the work capacity of the heart is certainly greatiy reduced. Therefore, the physician should treat ali patients with "preinfarction angina" in the same m a n n e r in which he would treat a patient with an acute myocardial infarct, but before myocardial infarction occurs. T h e patients should be placed at complete be d rest at home or in hospital for at least 30 days, with controlled diet, sedatives, avoidance of psychic and physical stress, oxygen, and other measures as needed. Remember also that, if the patient is hospitalized and develops an infarct soon after admission to hospital, he is already in a CCU or a private room where emergency therapeutic measures are immediately available with trained experts in attendance. This sittiation is certainly better for the patient t h a n his having to call a n d wait for a mobile CCU or to be transported by ambulance or automobile to the hospital. Furthermore, very few patients with pre-infarcti0n or crescendo angina will develop an infarct, anyway, if proper therapeutic measures are employed promptly in advance.
G. E. Burch, M.D. Tulane University School of Medicine and Charity Hospital New Orleans, Louisiana
Effects of cardiopulmonary bypass on the jugular venous pulse
The volume of the jugular venous pulse reflects changes in the right atrial pressure contour. The technique of cardiopulmonary bypass commonly includes cannulation of the right atrium and left ventricle, and amputation of the right atrial appendage, and thus might be expected to alter the jugular venous pulse. H a r t m a n ' noted reductions in t h e A wave and X descent following operation for artriaI septat defect. This reduction even occurred in one patient in whom the atrium was entered but the defect not repaired, suggesting t h a t closure of the defect was not responsible for the changes in the jugular pulse. We have noted attenuation of the jugular A wave and X
262
descent in a n u m b e r of patients undergoing cardiopulmonary bypass for a wide variety of cardiac lesions, and have been prompted to review the jugular pulse recordings in 34 of our patients who underwent cardiac surgery. Jugular pulses were recorded by the method of Tavel. ~ Tracings were obtained within one m o n t h prior to surgery in 29 patients, and from one week to ten years postoperatively in 34 patients. Preoperative tracings were not available for five patients, all of whom had undergone cardiopulmonary bypass. Twenty-five of these patients (13 males, 12 females, mean age 39) underwent surgery which utilized cardiopulmonary bypass for the following diseases: mitral stenosis (7), aortic stenosis
August, 1977, Vol. 94, No. 2