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Rapid Responses: Rapid Responses published:
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MAN WITH A HAMMER IN THE HAND
- BM Hegde (21 May 2004)
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Angioplasty versus thrombolysis for MI: patients are forgotten again!
- Dr. Naseem A. Qureshi, MD, IMAPA, LMIPS (26 May 2004)
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Angioplasters or thrombolysers? Our current proposal is “Lyser-plasters”!
- Gian Franco Gensini, Andrea A. Conti (31 May 2004)
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Re: MAN WITH A HAMMER IN THE HAND
- Nirmal K Bhattacharjee (1 June 2004)
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What will they all do?
- Nirmal K Bhattacharjee (1 June 2004)
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Full dose thrombolysis plus immediate coronary angioplasty for myocardial infarction rather than primary angioplasty versus thrombolysis
- Luis R Llerena, Lorenzo Llerena (1 June 2004)
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Re: MAN WITH A HAMMER IN THE HAND
- Jörg Grimm (10 May 2005)
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BM Hegde, Retd. Vice Chancellor Mangalore-575004. India
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Dear Sir, "For a man with a hammer in the hand and wanting to use it,
everything here looks like a nail needing hammering."
“Learn from history; otherwise you will have to relive history” wrote Cicero, the great Roman thinker, many years ago. I would like to take the reader through the history of managing myocardial infarctions in the last half a century that I have been a witness to since my medical school days in the 50s in Madras. When I was a student we practised the Hippocratic advice: “cure rarely, comfort mostly but, console always.” Pain relief was the main stay of management and bed rest was rigorous and prolonged. Many must have died not of their coronary blocks but due to pulmonary infarcts! Usually 60% of those that get an acute infarct die instantaneously long before they see their doctor, anyway. All our statistics are based on the hapless remaining 40% and that too the few that make it to the hospitals. The latter must be very small, indeed, in a large country like India where 80% live in villages that are well outside the “Golden Hour” of the cardiologist anyway. According to the Mather’s study published in the BMJ in the 80s the villagers must be the lucky ones. When President Eisenhower had an infarct in 1954 or so, his two cardiologists, Paul Dudley White and Sam Levine took a bold stand to mobilise him faster and allowed him to run for the second term of Presidency, which he did with great success. This paved the way for early mobilisation and the era of prolonged bed rest ended. Two years before that my erstwhile chief, Nobel Laureate Bernard Lown, did show the benefit of early “Chair treatment” of acute infarcts. Then came the era of the Coronary Care Units. Starting in Kansas City in 1962, CCUs mushroomed all over the globe. It was good business for anti- arrhythmic drug manufacturers. Controlled studies then showed that the mortality was brought down by the CCUs to a low level of 10%. Today people claim that the conventional CCUs did nothing to acute infarct patients. Thrombolysis came like a bang and it was sold with so much enthusiasm that some doctors even forgot the contraindications and a lot of unfortunate souls would have met their maker due to our missionary zeal in thrombolysing them. Pharmaceutical companies were the rulers in the field. It is noteworthy that the first European co-operative study showed the post-infarction mortality having been brought down to 13% after thrombolysis. I am sure they did not know about the claim of the CCU enthusiasts of 10% mentioned earlier. The story of tpa and the Oxford cardiologist’s feet (What a Feat in the BMJ) was a great revelation in this direction. Despite all that the drug company and the Washington cardiologist won at the end. I think the first six hundred patients discharged following thrombolysis from the London Chest Hospital did have more than expected mortality in the first year in society but I do not have the original reference now. This last sentence derives its strength from my memory. I could be wrong but, not far off the mark. The story of the rat poison (warfarin) is missing from the above narrative. Then came hirudin with all fanfare but did not become such a money spinner as the thrombolytics were. We started hearing the voices of the doubting Thomases in the area of thrombolysis. “Go with the Flow” was a good editorial in Chest years ago, which showed how in low output states, as also, in cardiogenic shock the diastolic filling of the coronaries could be so poor that the thrombolytics rarely ever got into the blocked coronary vessels! There were others that questioned the role of these drugs in acute infarcts other than the anterior and antero-septal ones. Some thought thrombolysis might even harm patients with inferior infarcts. All in the game. Divine interventionalists are on the prawl now. One of the meanings of the word intervene in the Webster’s dictionary is to go in between with malice! Large audits on the long term outcomes of angioplasties have not been encouraging so far although many of the smaller studies, funded by God knows who, have shown excellent results. My own experience with patients who have undergone immediate post- infarction angioplasties (primary angioplasties) has not been satisfactory, but the skeptics would quote Hippocrates again to say that “experience fallacious and judgment difficult”. Peer reviewers would be afraid to touch observational research. Immediate reperfusion would logically hinder normal ventricular remodeling, making the scar weaker and might precipitate heart failure faster in those ventricles. Fibroblastic proliferation and scar formation would be hampered. It could also result in reperfusion injury! Be that as it may, interventions have come to stay in medicine today. Any voice against that would be dubbed unscientific. What worries me, however, is the negative role that angioplasties could play in the real pathology. Angioplasties destroy the endothelium without any control by the operators. Angioplasty can do nothing for the basic problem in coronary artery disease: i.e.: reduced coronary reserve in the perforating vessels. The other worry is that majority of the acute infarct related epicardial coronary arteries are usually less than 40% blocked. Many times very early plaques only attract the clot to block a vessel. Crushing such an early block could expose larger areas of the endothelium to invite clotting. EDRF would also be depleted from the damaged endothelium. We also ignore the hemorrhagic potential of the blood thinners given after angioplasty in the acute phase. Future might be non-invasive laser directed repair of the blocked vessels and in difficult patients angioscopically modulated atherectomy or genetically modified angiogenesis. This might not be scientific fiction. One has to remember that in the area of vessel blocks many pieces are missing in the jigsaw puzzle. Our management strategies have been mostly palliative and not logical. We still do not know why a young man of thirty might drop down dead of an acute infarct while an octogenarian goes on and on with all the vessels almost totally blocked with angina for a full life span. When we get a new tool we act as if we have won the battle against coronary artery disease. I am reminded of what Khalil Gibran wrote in his book The Prophet:”Say not”, I have “got the truth”; rather say; “I have got a truth.” Newer techniques and newer drugs will, of course, come into the area where knowledge is patchy like that of the coronary disease, but we should learn from history to be careful before embracing any and every one of them indiscriminately. Yours ever,
Competing interests: None declared |
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Dr. Naseem A. Qureshi, MD, IMAPA, LMIPS, Medical Director [A], Director, CME&R Postcode 2292, Buraidah Mental Health Hospital, Saudi Arabia
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Sir: Richard Smith (1) opted for editorializing "angioplasters and thrombolysers" for the treatment of myocardial infarction (MI) evidenced by ST elevation. He suggested facilitated angioplasty as the treatment of choice for MI patients. However, four protagonists (2,3,4) in this topical drama extensively minutely discussed the pros and cons of each type of modality for the management of MI patients. All four are well qualified and experienced cardiologists. Dr. Smith supported angioplasty, which is expensive and relatively time taking procedure as the first line of treatment. On the contrary, Dr.Channer argued against angioplasty as the first line of treatment and strongly favoured for the continuation of thrombolysis as the first treatment option in MI patients. Drs Bogaty and Brophy discussed the historical trend of "CHANGE" of old by new one or vise versa if possible. I feel very strongly that the views of patients, their care givers and patients support organizations should also be taken into consideration regarding the use of angioplasty and thrombolysis. Patients have right to refuse treatment and they have right to select the treatment from given choices. If they are incapacitated, probably similar attitudes may emerge from their carers and patients support groups. Therefore, the views expressed by supporters of angioplasty and thrombolysis may not be applicable uniformly to the MI patient population. In next "Education and debate" don't forget patients whose views are the deciding factors in making final choice (s) regarding treatments offered to them. References: 1. Richard Smith. Angioplasters and thrombolysers. BMJ 2004; 328: 0- h. 2. David Smith. Primary angioplasty should be first line treatment for acute myocardial infarction: FOR. BMJ 2004; 328:1254-1256. 3. Kevin S Channer. Primary angioplasty should be first line treatment for acute myocardial infarction: AGAINST.BMJ 2004; 328:1256- 1257. 4. Peter Bogaty, James M Brophy. Primary angioplasty or thrombolysis? a topical parable. BMJ 2004; 328:1257-1258. Competing interests: None declared |
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Gian Franco Gensini, Full Professor of Internal Medicine Dip. Area Critica Med. Chir., Università di Firenze; Fondazione Don Carlo Gnocchi, Firenze, Italy., Andrea A. Conti
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Sir, We have read and really appreciated your editorial comment (1) in the May 22nd 2004 issue of The British Medical Journal, and we would like to add a some comments to it. We agree with you with regard to the high quality and vivacity of the two papers by D Smith and KS Channer (2,3) published in the “For and Against” section of the journal. A “For and Against” debate focussing on primary angioplasty in the treatment of acute myocardial infarction appears particularly stimulating and timely. With specific regard to your synthesis of Channer’s position, we agree with you and him that great attention must always be paid in extrapolating from the results of trials conducted in selective patients to the real world. However, with reference to “real world angioplasty”, we recall that data are already available with regard to its value. In our published experience performed on 135 patients, interhospital transfer for direct coronary angioplasty in unselected patients with acute myocardial infarction resulted feasible, safe and effective. In effect, the early return to the admission hospital was safe and did not negatively influence the in-hospital outcome, and the incidence of cardiac mortality at 6 months and at long-term follow-up was 3.4 and 5.1% respectively (4). Just to conclude on Richard Smith’s proposal of a “third” strategy, apart from angioplasty and thrombolysis, that is, “home thrombolysis followed by rescue angioplasty” (1), at present in our large volume centre (more than 1,500 angioplasty procedures performed a year) the technique of the so- called “facilitated angioplasty”, using a combination of thrombolysis, platelet glycoprotein IIb/IIIa antagonists and early intervention, is preferred (5). Therefore, the new figure of the “Lyser-plaster”, following the already well established ones of the angioplaster and of the thrombolyser, should from now on be considered! References 1) Smith R. Angioplasters and thrombolysers. BMJ 2004; 328. 2) Smith D. Primary angioplasty should be first line treatment for acute myocardial infarction. BMJ 2004; 328: 1254-5. 3) Channer KS. Primary angioplasty should be first line treatment for acute myocardial infarction. BMJ 2004; 328: 1255-7. 4) Margheri M, Meucci F, Falai M, Comeglio M, Giglioli C, Chechi T, et al. Transferring patients for direct coronary angioplasty: a retrospective analysis of 135 unselected patients with acute myocardial infarction. Ital Heart J 2001; 2: 921-6. 5) Katritsis D, Karvouni E, Webb-Peploe MM. Reperfusion in acute myocardial infarction: current concepts. Prog Cardiovasc Dis 2003; 45: 481 -92. Competing interests: None declared |
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Nirmal K Bhattacharjee, DGM (Medical) IOC Ltd. Digboi, Assam 786171
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Dear Sir, It was so nice to hear a sane voice giving us such a wonderful background of evolution of treatment of AMI, which unfortunately is loaded in favour of 'interventionists'- cutting,boring, drilling, stenting, blasting and by-passing - at the cost of logical rational thinking. I do not know whether the principle of 'watchful expectancy and masterly inactivity' that we learned in Obstetrics would be more appropriate than the flurry of invasive activities to which a hapless victim of AMI is subjected. You have wisely mentioned 'in the area of vessel blocks many pieces are missing in the jigsaw puzzle.' Again unfortunately people are trying to solve the puzzle, with the help of commercial enterprises, by changing the rules of the game and inporting the pieces which are not in the puzzle itself. It is difficult to go against the tide but then we are encouraged by your words of wisdom. With deep regards, N K Bhattacharjee Competing interests: None declared |
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Nirmal K Bhattacharjee, DGM(Medical), IOC Ltd. Digboi, Assam 786171
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Dear Sir, “What will they all do when, as predicted by our heart tsar, deaths from heart disease disappear?” The answer to your query is that they will be doing the plumber’s job in a highly effective but very expensive way. For even if the deaths from heart disease disappear, there will be enough blocked water pipes because of high water pollution especially in the developing countries. Regards. N K Bhattacharjee Competing interests: None declared |
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Luis R Llerena, Consultant Professor Institute of Cardiology, Havana Cuba 11100, Lorenzo Llerena
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EDITOR: Primary angioplasty and thrombolysis have changed the prognosis of acute myocardial infarction but in spite of numerous trials a debate remains about which of them should be the first line treatment 1- 3. It is clear that time is the main factor to be considered because early restoration of myocardial flow can limit necrosis and even abort infarction. Fresh thrombus is softer and easier to treat with lysis and also to squash with the balloon 4. Other factors must be taken into consideration as the coronary, clinical and haemodynamic characteristics of the patient and the available resources, including the skill of the operators, Both procedures have well known advantages and disadvantages and every patient must be analized and definite treatment decided accordingly with all factors present. If thrombolysis is decided it can be started almost immediately but the coronary characteristics before thrombolysis as the localization of thrombus and plaque, the status of all coronary arteries, the presence of collateral circulation and the angiographic results of the procedure will be unknown. Another disadvantage, fortunately not frequent, is that the aetiology of the coronary event might be for instance an arterial dissection, a myocardial bridge or other lesion in which thrombolysis is not indicated or dangerous. In our hospital we are performing the so called facilitated coronary angioplasty or pharmacoinvasive recanalization 5 with very good results including no bleeding complications in our first 25 patients (unpublished) though elder patients were excluded. We prefer this procedure though it has the same disadvantages of thrombolysis. Our strategy includes full- dose streptokinase with conjunctive antithrombotic and antiplatelet regimens, coronary angiography as soon as possible and if significant stenoses is present immediately coronary stent angioplasty is performed. So our choice is full dose thrombolysis plus angioplasty and not primary angioplasty versus thrombolysis. Luis R Llerena Consultant professor hemorx@infomed.sld.cu Lorenzo Llerena Professor, Chairman Haemodynamic Department Institute of Cardiology, Havana, Cuba 1 Smith R. Angioplasters and thrombolysers. BMJ 2004;328 (22 May). 2 Bogaty P, Brophy JM. Primary angioplasty or thrombolysis ? a topical parable.BMJ 2004;328:1257-8. 3 Smith D, Channer K. Education and debate. For and against. Primary angioplasty should be first line treatment for acute myocardial infarction. BMJ 2004;328:1254-7. 4 Giugliano RP, Braunwald E. Selecting the best reperfusion strategy in ST-elevation myocardial infarction. It is all a matter of time. Circulation 2003;108:2828-30 5 Dauerman HL, Sobel BE. Synergistic treatment of ST-segment elevation myocardial infarction with pharmacoinvasive recanalization. J Am Coll Cardiol 2003;46:646-51. Competing interests: None declared |
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Jörg Grimm, University IT Coordinator 8091 Zürich Switzerland
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When I read this: "For a man with a hammer in the hand and wanting to use it, everything here looks like a nail needing hammering." Mark Twain, I thought, my, that IS funny English ! An "exact" Google Search for "man with a hammer", reveals, that Twain had a better command of it: "To a man with a hammer, everything looks like a nail," wrote Mark Twain. Best regards Dr. sc. techn. ETH Jörg Grimm, IT Specialist, University Hospital Zürich, Switzerland. Competing interests: None declared |
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