Showing papers by "Eugene Braunwald published in 1989"

Unstable angina : a classification

Abstract: The establishment of a prognosis and the approach to the treatment of many diseases is aided greatly by a logical classification. For example, classification of a wide variety of neoplasms by anatomic extent, microscopic appearance, and the presence of special markers now forms the basis for selecting appropriate therapy. In cardiology, the classification of patients with acute myocardial infarction and congestive heart failure has been of enormous value in following the progress and in selecting therapy of individual patients and in comparing the outcome of similar patients treated at different locations and at different times. The purpose of this article is to provide a classification of unstable angina. This classification is designed to facilitate communication about these patients, to aid in the decision regarding diagnostic measures and therapy of individual patients, and to provide a more precise basis for including patients in and for evaluating the outcome of clinical trials.

Myocardial reperfusion, limitation of infarct size, reduction of left ventricular dysfunction, and improved survival. Should the paradigm be expanded?

Abstract: For nearly a decade, it has been appreciated that 1) thrombotic occlusion of an epicardial coronary artery is usually the proximate cause of acute myocardial infarction; 2) after sudden and sustained total occlusion of such a vessel, the course of myocardial necrosis is generally rapid and relentless (in most cases, the process is completed within 3 or 4 hours of the coronary occlusion, in 6 hours at a maximum); 3) infarct size is a critical determinant of left ventricular function; and 4) left ventricular function, in turn, is the most important determinant of early (in-hospital) and long-term (postdischarge) survival. Major efforts have been devoted to the development of techniques designed to interfere with the sequence of events summarized above. Considerable attention has been directed to achieving timely reperfusion of occluded coronary arteries to interrupt the infarction with the hope that the resultant limitation of infarct size will improve ventricular function and thereby patient survival.1 Many techniques to achieve reperfusion have been used, including emergency coronary artery bypass surgery, emergency percutaneous transluminal coronary angioplasty (PTCA), and the intracoronary and intravenous administration of a variety of thrombolytic agents; the last of these approaches is particularly attractive because its simplicity makes it applicable to a large proportion of patients with acute myocardial infarction. In some instances, combinations of these techniques, such as intravenous thrombolytic therapy followed by PTCA, have been used. These efforts to treat acute myocardial infarction have been notably successful, as reflected in an improvement in survival noted in controlled randomized trials.2-6 Also, the absolute mortality rates achieved in some recent trials of reperfusion therapy (3-5%) are far lower than those noted previ-

Hypertrophic cardiomyopathy--continued progress.

Abstract: Students of medical history observe a familiar sequence in the growth of knowledge about many diseases. The initial description is often a pathologic one, involving patients with the most advanced, usually fatal, form of the disease. Clinical–pathological correlations are then carried out in living patients in whom the condition is recognized and in whom the pathologic findings are confirmed during operation or at autopsy. Detailed explorations of the clinical and laboratory manifestations then provide clues to the underlying pathophysiology and help in establishing diagnostic criteria. Often much later, the fundamental cellular defects are identified, and ultimately the molecular or even . . .

Variables predictive of good functional outcome following thrombolytic therapy in the Thrombolysis in Myocardial Infarction phase II (TIMI II) pilot study.

Abstract: Before commencing the randomized Thrombolysis in Myocardial Infarction phase II (TIMI II) study, 370 patients were administered intravenous recombinant tissue plasminogen activator (rt-PA) within 4 hours of onset of acute myocardial infarction (AMI) and assigned to 2-hour (immediate) percutaneous transluminal angioplasty (n = 33), 18- to 48-hour (delayed) angioplasty (n = 288) or no angioplasty (n = 49) in a nonrandomized, observational pilot study. Left ventricular ejection fraction at rest and during exercise was assessed by gated equilibrium radionuclide ventriculography at hospital discharge and again at 6 weeks. At hospital discharge, ejection fraction averaged 50% at rest and 56% at peak exercise. At 6-week follow-up, ejection fraction averaged 50% at rest and 53% at peak exercise. At 6-week follow-up, resting ejection fraction averaged 49% in the 2-hour angioplasty group, 49% in the 18- to 48-hour angioplasty group and 55% in the no-angioplasty group. Variables independently predicting “good functional outcome” at 6-week follow-up (survival with resting ejection fraction ≥50% and no decrease with exercise) in the 18- to 48-hour angioplasty group were fewer leads with ST-segment elevation ≥0.1 mV, younger age, rapid normalization during rt-PA infusion of ST segments or dramatic relief of chest pain, absence of arrhythmias within the first 24 hours of treatment initiation, no prior infarction and not a cigarette smoker at entry. Thus, the TIMI II pilot study demonstrates that most patients with AMI of ≤4-hour duration treated with rt-PA have good ventricular function after AMI. Although nonrandom group assignment prevented rigorous statistical comparison of the 3 treatment groups, no obvious disadvantage of the more conservative noangioplasty assignment was apparent.