ACUTE CORONARY CARE 1986

Transcription

1 ACUTE CORONARY CARE 1986

2 To Lydia Califf for her many and varied contributions to the work in acute coronary care by both Drs. Califf and Wagner.

3 ACUTE CORONARY CARE 1986 edited by Robert M. Califf and Galen S. Wagner Duke University Medical Center Durham, North Carolina., UI Martinus Nijhoff Publishing a member oj the Kluwer Academic Publishers Group Boston/DordrechtiLancaster

4 Distributors for North America: Kluwer Academic Publishers 190 Old Derby Street Hingham, MA 02043, USA Distributors for the UK and Ireland: Kluwer Academic Publishers MTP Press Limited Falcon House, Queen Square Lancaster LAI IRN, UNITED KINGDOM Distributors for all other countries: Kluwer Academic Publishers Group Distribution Centre P.O. Box AH Dordrecht, THE NETHERLANDS ISBN-l3: DOl: / e-isbn-13: ISSN Copyright 1985 by Martinus Nijhoff Publishing, Boston Softcover reprint of the hardcover 1st edition 1985 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise, without written permission of the publisher, Martinus Nijhoff Publishing, 190 Old Derby Street, Hingham, Massachusetts

5 CONTRIBUTORS PREFACE CONTENTS I. CORONARY CARE: THE PRE-HOSPITAL PHASE 1. Autonomic Changes During the Acute Phase of Acute Myocardial Infarction and Ischemia (Ronald G. Victor) II. CORONARY CARE: THE POST-ADMISSION PHASE 2. Use of the Initial Electrocardiogram During Acute Myocardial Infarction to Estimate the Extent of the Jeopardized Myocardium and Guide the Determination of Therapy 21 (Tomoaki Hinohara) 3. Use of Antiplatelet Agents in Patients with Unstable Angina Pectoris 35 (Peer Grande and Anne-Marie Grauholt) 4. Thrombolytic Therapy in Patients with Acute Myocardial Infarction 43 (E. Passamani) 5. Novel Thrombolytic Drugs 55 (E. B. Grossbard) 6. Acute Interventional Cardiac Catheterization 63 (Richard S. Stack, Tomoaki Hinohara and Eric B. Carlson) 7. The Use of Beta-Blockers in the Acute Phase of Myocardial Infarction 73 (S. Yusuf) III. CORONARY CARE: THE CORONARY CARE UNIT PHASE 8. Post Thrombolytic Care 91 (David G. Harrison, Robert F. Wilson and Carl W. White) 9. Determining Reperfusion and Myocardial Infarct Size 103 Using Serum Enzymes (Robert Roberts and Peter R. Puleo) 10. The Measurement of Acute Myocardial Infarct Size by CT 133 (Bruce H. Brundage) vii ix 3

6 vi 11. Magnetic Resonance Imaging for Evaluation of Myocardial Ischemia and Infarction 145 (Richard D. White, Martin J. Lipton and Charles B. Higgins) 12. Positron Imaging in the Evaluation of Ischemia and Myocardial Infarction 163 (Richard A. Goldstein) 13. Hemodynamic Considerations in Acute Infarction 173 (Robert M. Lester and Raphael Bloomgarden) 14. Comparative Effects of Intravenous Nitroglycerin and Sodium Nitroprusside in Cardiac Intensive Care 193 (Jose C. Martin) 15. Acute Coronary Care and Diagnosis Related Groups 219 (Phyllis S. Ellenbogen and Andrew G. Wallace) IV. CORONARY CARE: THE PRE-DISCHARGE PHASE 16. The Use of Ultrasound to Detect Infarction Expansion and Mural Thrombi 235 (James Heinsimer) 17. Lessons from Predischarge Cardiac Catheterization 247 (Phillip J. Harris) 18. The Process of Selecting the Proper Antiarrhythmic Treatment for Patients at High Risk of Sudden Death Following Myocardial Infarction 253 (Seth J. Worley) 19. Lessons from the BHAT Study Regarding Selection of Patients Post Myocardial Infarction for Beta Blockade 279 (W. T. Friedewald and C. D. Furberg) V. CORONARY CARE: THE CONVALESCENT PHASE 20. The Prehospital Discharge Evaluation of the Patient with Acute Myocardial Infarction 295 (D. D. Waters) 21. New Inotropic Agents 305 (Charles A. Simonton and Kanu Chatterjee) 22. Common Problems in Patient Management During the Two Months Following Acute Myocardial Infarction 321 (Steven F. Roark) INDEX 333

7 CONTRIBUTORS RAPHAEL BLOOMGARDEN, M.D., The Graduate Hospital, One Graduate Plaza, Philadelphia, PA BRUCE H. BRUNDAGE, M.D., The Cardiology Section, Department of Medicine, University of Illinois at Chicago, Box 6998, Chicago, IL ERIC B. CARLSON, M.D., Interventional Cardiac Catheterization Program, Box 31119, Duke University Medical Center, Durham, NC KANU CHATTERJEE, M.B., Department of Medicine, Cardiovascular Division, University of California, San Francisco, CA PHYLLIS S. ELLENBOGEN, M.B.A., Duke University Hospital and the Department of Medicine, Box 3708, Duke University Medical Center, Durham, NC WILLIAM T. FRIEDEWALD, M.D., Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, NIH, Federal Building, Room 212, 7550 Wisconsin Avenue, Bethesda, MD C. D. FURBERG, M.D., Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, NIH, Federal Building, 7550 Wisconsin Avenue, Bethesda, MD RICHARD A. GOLDSTEIN, M.D., Division of Cardiology, University of Texas Medical School, 6431 Fannin, MSB 1.246, Houston, TX PEER GRANDE, M.D., Ph.D., Medical Department B (Cardiology), Rigshospitalet, University Hospital, 9 Blegdamsvej, DK-2100, Copenhagen 0, DENMARK ANNE-MARIE GRAUHOLT, B.S., Medical Department B (Cardiology), Rigshospitalet, University Hospital, 9 Blegdamsvej, DK-2100, Copenhagen 0, DENMARK ELLIOTT B. GROSSBARD, M.D., Clinical Research, Genentech, Inc., 460 Point San Bruno Boulevard, South San Francisco, CA PHILLIP J. HARRIS, M.B., Department of Cardiology, Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney, NSW 2050, AUSTRALIA DAVID G. HARRISON, M.D., Department of Internal Medicine and the Cardiovascular Center, The University of Iowa College of Medicine and Veterans Administration Hospital, Iowa City, IA JAMES HEINSIMER, M.D., Department of Medicine, Division of Cardiology, Box 31264, Duke University Medical Center, Durham, NC CHARLES B. HIGGINS, M.D., Department of Radiology, University of California, San Francisco, CA 94143

8 viii TOMOAKI HINOHARA, M.D., Department of Medicine, Box 3482, Duke University Medical Center, Durham, NC ROBERT M. LESTER, M.D., The Graduate Hospital, One Graduate Plaza, Philadelphia, PA MARTIN J. LIPTON, M.D., Department of Radiology, University of California, San Francisco, CA JOSE C. MARTIN, M.D., Department of Medicine, Box 3486, Duke University Medical Center, Durham, NC EUGENE R. PASSAMANI, M.D., Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, Federal Building, Room 320, Bethesda, MD PETER R. PULEO, M.D., Cardiology Section, Baylor College of Medicine, 6535 Fannin, Houston, TX STEVEN F. ROARK, M.D., Department of Medicine, Box 3022, Duke University Medical Center, Durham, NC ROBERT ROBERTS, M.D., Cardiology Section, Baylor College of Medicine, 6535 Fannin, MS F-905, Houston, TX CHARLES A. SIMONTON, M.D., Department of Medicine, Division of Cardiology, Box 3310, Duke University Medical Center, Durham, NC RICHARD S. STACK, M.D., Interventional Cardiac Catheterization Program, Box 3111, Duke University Medical Center, Durham, NC RONALD G. VICTOR, M.D., Department of Internal Medicine, Cardiovascular Division, University of Iowa College of Medicine, Iowa City, Iowa ANDREW G. WALLACE, M.D., Duke University Hospital and the Department of Medicine, Box 3708, Duke University Medical Center, Durham, NC DAVID D. WATERS, M.D., Department of Medicine, Montreal Heart Institute, 5000 East, Belanger Street, Montreal, Quebec H1T lc8, CANADA CARL W. WHITE, M.D., Department of Internal Medicine and the Cardiovascular Center, The University of Iowa College of Medicine and Veterans Administration Hospital, Iowa City, IA RICHARD D. WHITE, M.D., Department of Radiology, University of California, San Francisco, CA ROBERT F. WILSON, M.D., Department of Internal Medicine and the Cardiovascular Center, The University of Iowa College of Medicine and Veterans Administration Hospital, Iowa City, IA SETH J. WORLEY, M.D., Department of Medicine, Box 31271, Duke University Medical Center, Durham, NC SALIM YUSUF, M.B., Clinical Trials Branch, Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, Federal Building, Room 216, Wisconsin Avenue, Bethesda, MD 20205

9 PREFACE The concepts of acute coronary care are changing so rapidly that it is appropriate that the volume ACUTE CORONARY CARE: PRINCIPLES AND PRACTICE, published early in 1985, would have yearly updates. The process of rapid production of camera-ready manuscripts has added new capability to the exchange of information. ACUTE CORONARY CARE 1986 is the first of a series of yearly updates in this important area of cardiology. Materials published during the fall of 1984, including abstracts for the November American Heart Association meetings were reviewed by the editors to identify the areas of new information and the authors making important contributions. Manuscripts were completed and edited during the spring of 1985 and the final camera-ready versions were delivered to Martinus Nijhoff by mid-july. The broad area of coronary care is divided into its five time sectors: Pre-hospital, Post-admission, Coronary Care Unit, Pre-discharge, and Convalescent. As patients are more frequently encountered in the pre-hospital phase, it has become evident that alterations in the autonomic nervous system have a great impact on the clinical situation. The chapter by Ron Victor emphasizes the important interactions between the nervous system and the cardiovascular system in this critical situation. Immediately post-admission in a setting where acute coronary care is available, a most important decision regards initiation of aggressive attempts at coronary reperfusion. This places additional responsibility on optimal interpretation of the standard 12-lead electrocardiogram, which is the only universally available diagnostic technique with potential for indicating the presence and, possibly, extent of the ischemic myocardium. Tom Hinohara discusses our current level of understanding of quantitative changes in the admission electrocardiogram. He stresses the importance of careful electrocardiographic evaluation of patients receiving acute interventional therapy to improve understanding of the capabilities and limitations of this simple technique. There is a great deal of new information available about several interventions which might potentially have profound effects on the process of acute myocardial ischemia and infarction. Peer Grande and Anne-Marie Grauholt discuss the role of anti platelet agents for preventing an acute infarction in

10 x patients with unstable angina pectoris. Gene Passamani reviews the clinical trials of thrombolytic agents which have been completed and also indicates those still in progress. Newer thrombolytic agents are also on the horizon, as discussed in the chapter by Elliott Grossbard. Richard Stack presents the rationale for combining angioplasty with acute attempts at thrombolysis in the modern interventional cardiac catheterization laboratory. All of these interventions are aimed at restoration of coronary blood flow and thereby improving myocardial nutrient supply. The other aspect of the equation is decrease in myocardial metabolic demand. Salim Yusuf reviews the clinical trials which have evaluated acute use of intravenous betaadrenergic blocking agents in patients with acute myocardial infarction. Since many patients are treated with strategies designed to achieve reperfusion prior to arrival on the CCU, the early aspect of the CCU phase is often dominated by "post thrombolytic care" as is discussed by Oa.vid Harrison. With all of the attempts at limitation of infarct size, it is important to develop improved methods of accurate infarct size measurement. Four such methods are covered in detail: Bob Roberts and Peter Puleo review the status of enzymatic studies, Bruce Brundage discusses rapid computerized tomography, Rick White et al. present nuclear magnetic resonance, and Rick Goldstein reviews positron emission tomography. Since an important consequence of myocardial infarction is limitation of cardiac function, it is important to consider new diagnostic and therapeutic aspects of hemodynamics. Bob Lester points out the limitations of the bedside evaluation of cardiac function and indicates the importance of developing new non-invasive methods of estimating the status of peripheral perfusion. Both pharmacologic and mechanical methods have been available for several years which are capable of improving coronary and/or peripheral blood flow. Jose Martin compares the effects of the intravenous administration of nitroglycerin and nitroprusside. A discussion of acute coronary care in 1986 would not be complete without a consideration of the medical economics involved. Phyllis Ellenbogen and Andy Wallace review cost-benefit considerations in the chapter on acute coronary care and diagnosis related groups.

11 Optimal post-discharge management requires consideration of the complications which often are encountered by the individual patient. Jim Heinsimer reviews the use of ultrasound to detect infarct expansion and mural thrombi, findings which are associated with an adverse prognosis. It is important to evaluate the role of invasive as well as non-invasive studies immediately post infarction and Phil Harris presents lessons from an extensive experience with predischarge cardiac catheterization. Seth Worley considers the relationship between the processes of identifying the patients at high risk of sudden death and selection of the optimal antiarrhythmic therapy. Now that several large studies have documented decreased post infarct mortality in patients receiving beta adrenergic blockade, it is important to optimize the selection of patients as reviewed by Bill Friedewald. David Waters reviews the various techniques for characterizing the patient entering the convalescent phase following acute myocardial infarction. Many of these patients will have chronic cardiac failure and Chuck Simonton and Kanu Chatterjee summarize the current status of new inotropic agents. Since a smooth transition between the acute and convalescent phases is critical, Steve Roark discusses the common problems encountered in patient management during this period. Few areas of medical care are in so great a state of uncertainty as acute coronary care. The brief chapters in this book are designed to provide easy access to the literature available during 1985 in a relatively few areas of acute coronary care. Robert M. Califf, M.D. Galen S. Wagner, M.D.