Coronary Care Medicine: A Practical Approach PDF
Preview Coronary Care Medicine: A Practical Approach
CORONARY CARE MEDICINE CORONARY CARE MEDICINE A Practical Approach Elliott M. Antman and John D. Rutherford .. Martinus Nijhoff Publishing a member of the Kluwer Academic Publishers Group BOSTON DORDRECHT LANCASTER DISTRIBUTORS for the United States and Canada: Kluwer Academic Publishers, 101 Philip Drive, Assinippi Park, Norwell, MA 02061 USA for the UK and Ireland: Kluwer Academic Publishers, MTP Press Limited, Falcon House, Queen Square, Lancaster LA1 1RN, UK for all other countries: Kluwer Academic Publishers Group, Distribution Centre, P.O. Box 322, 3300 AH Dordrecht, The Netherlands Library of Congress Cataloging-in-Publication Data Antman, Elliott M. Coronary care medicine. Includes index. 1. Heart-Diseases-Treatment-Handbooks, manuals, etc. 2. Critical care medicine-Handbooks, manuals, etc. 3. Coronary care units-Handbooks, manuals, etc. I. Rutherford, John D. II. Title. [DNLM: 1. Coronary Disease-diagnosis. 2. Coronary Disease-therapy. WG 300 A633c] RC682.A58 1986 616.1'23 85-29824 ISBN-13: 978-1-4612-9418-4 e-ISBN-13: 978-1-4613-2303-7 001: 10.1007/978-1-4613-2303-7 Copyright © 1986 by Martinus Nijhoff Publishing, Boston. Softcover reprint of the hardcover 1s t edition 1986 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 the prior written permission of the publishers, Martinus Nijhoff Publishing, 101 Philip Drive, Assinippi Park, Norwell, MA 02061 USA To our families CONTENTS Authors' Affiliations Vlll Foreword by Eugene Braunwald IX Preface XI 1. Pathogenesis and Pathology of Ischemic 9. Temporary and Permanent Pacemaker Heart Disease Syndromes 1 Therapy 219 2. Clinical Presentation of Ischemic Heart 10. Cardiac Arrest and Resuscitation 249 Disease 19 11. Hemodynamic Monitoring 259 3. Routine Management of Myocardial Infarction 55 12. Complications of Acute Myocardial Infarction 275 4. Cardiac Arrhythmias During Acute Myocardial Infarction 77 13. Myocardial Infarct Size Reduction 295 5. Management of Cardiac Arrhythmias not 14. Coronary Artery Spasm 317 Associated with Acute Myocardial Infarction 93 15. Post-Hospital Management of Myocardial Infarction 335 6. Pharmacological Therapy of Cardiac Arrhythmias 147 16. Prognosis After Hospitalization with Chest Pain or Myocardial Infarction 353 7. Cardioversion and Defibrillation 179 Index 373 8. Atrioventricular and Intraventricular Conduction Defects 199 Vll AUTHORS' AFFILIATIONS ELLIOTT M. ANTMAN, M.D., F.A.C.C. Assistant Professor of Medicine Harvard Medical School Director, Samuel A. Levine Cardiac Unit Cardiovascular Division Brigham and Women's Hospital Boston, MA JOHN D. RUTHERFORD, M.B., F.R.A.C.P., F.A.C.C. Assistant Professor of Medicine Harvard Medical School Co-Director, Clinical Cardiology Service Cardiovascular Division Brigham and Women's Hospital Boston, MA formerly Cardiologist, Green Lane Hospital Auckland, New Zealand VlJI FOREWORD Attention to reducing the major risk factors Contemporary coronary care involves a associated with the development of arterio multitude of measures: efforts to prevent the sclerosis has been widespread and appears to acute event; thrombolytic therapy to abort have lowered the incidence of coronary artery infarction; pharmacological measures to delay disease. Nevertheless, acute myocardial and reduce ischemic cell death; monitoring of infarction and related ischemic syndromes the hemodynamic consequences of myocardial represent the most common causes of death as infarction; treatment of acute pump failure; use well as one of the principal reasons for of modern electrical devices as well as a large hospitalization in the industrialized world. In number of new drugs to prevent and treat light of this, care of the patient with acute cardiac arrhythmias; and finally, identification coronary disease remains a major medical prior to hospital discharge of patients who are at challenge. high risk for recurrent infarction or sudden The approach to managing patients with death and the choice of the appropriate acute myocardial infarction can be said to have management approach. evolved through three major phases. For the This fine book provides comprehensive first half-century after Herrick's landmark descriptions of these various aspects of paper describing this condition was published in contemporary coronary care. It is accurate, 1912, management consisted primarily of thorough, and easily readable. The authors have placing the patient at rest in order to allow the succeeded in weaving together both well myocardial scar to heal and to prevent cardiac established practice and the most up-to-date rupture. In the second phase, beginning in the information available in this rapidly changing early 1960s, the focus was on the coronary care field. Rather than offering a "cookbook" unit and on continuous monitoring of the approach, they have developed a sound strategy heart's electrical activity, which allowed for caring for patients with coronary disease. prophylaxis against and treatment of life For all those professionals responsible for the threatening cardiac arrhythmias. The third and care of patients with these serious and current phase in the therapy of acute myocardial important disorders-cardiologists, internists, infarction and related syndromes is the subject and coronary care nurses, both those in training of this book by Elliott Antman and John and those already practicing-Coronary Care Rutherford, my colleagues at the Harvard Medicine will be of enormous value. Medical School and the Brigham and Women's Hospital. Eugene Braunwald, M.D. IX PREFACE The proliferation of specialized cardiac inten In this manual, we have tried to offer as sive care units over the last two decades has concisely as possible a pragmatic approach to brought about significant advances in coronary diagnosis and the problems of management for care medicine. For patients suspected to be patients with severe heart disease. In addition, suffering from a serious cardiac disorder (usual we have endeavored to provide the reader with ly acute myocardial infarction), the need for practical information about differential diagno close monitoring and skilled nursing care is sis, drugs, arrhythmias, and means for interpret widely accepted. Staff members who care for ing hemodynamic data. It is our hope that this these critically ill patients are now expected to book will be useful not only for persons at become familiar with a multitude of new and various stages of training in this field but also potent cardiovascular pharmacotherapeutic for the practicing internist, cardiologist, and agents, specialized invasive hemodynamic intensive care unit physician who encounter monitoring techniques, and means of mechani patients in the coronary care unit. cally supporting the failing cardiovascular sys tem. Newcomers to the intensive care unit area Acknowledgments - such as medical students, interns, medical residents, and cardiovascular trainees during the The authors gratefully acknowledge the invalu early phases of their fellowship as well as nurs able editorial assistance of Diane Q. Forti. The ing students and recently graduated nurses - authors also acknowledge the leadership and feci understandably anxious when called upon continued support of Eugene Braunwald, M.D.; to implement life-saving therapeutic modalities Thomas W. Smith, M.D.; and John M. Neutze, in this setting and are often unfamiliar with the M.D. Finally, our thanks to others who contri appropriate use of the latest drugs and special buted to the completion of this project includ ized invasive techniques. ing Mary Gillan, Lisa McHale, and Kay Martin. Xl CORONARY CARE MEDICINE 1. PATHOGENESIS AND PATHOLOGY OF ISCHEMIC HEART DISEASE SYNDROMES 1. Atherosclerosis 1.2. PATHOGENESIS OF ATHEROSCLEROSIS 1.1. DEFINITIONS 1.2.1. Classic theories. Historical concepts The terms "arteriosclerosis" and "athero of the pathogenesis of atherosclerosis can be sclerosis" are often confused in descriptions of divided into two major schools of thought. experimental and clinical arterial lesions. Arter One is the encrustation theory (proposed by iosclerosis is a general term implying arterial Rokitansky), which states that small mural hardening without respect to a specific etiology, thrombi form in areas of endothelial injury. examples being atherosclerosis, Monckeberg's These become organized by smooth muscle medial calcification, and arteriolosclerosis cells, grow, and playa major role in the devel J. (small vessel disease) [1 Atherosclerosis refers opment of a mature plaque. The second theory to a specific disease process characterized by the is the imbibitionlinsudation theory (proposed development of yellow, lipid-laden plaques. by Virchow), which states that the infiltration There are three pathological stages in such of plasma constituents into the arterial intima plaque development: is the principal factor in the development of atherosclerotic plaques. As summarized by 1. The fatty streak, which is a yellow, Wissler [1], these two theories are now being generally flat patch on the intima made up of combined into a more unified concept (figure accumulated lipid-containing smooth muscle 1-1). Abundant evidence has accumulated cells. Commonly found in young individuals indicating that elevated serum cholesterol levels fatty streaks probably have no pathological are strongly associated with progressive significance in many cases. atherosclerosis. Although mural thrombi are not thought to play a major role in athero 2. The fibrous plaque, which is an intimal sclerotic plaque development, injury to the deposit of lipid-laden smooth muscle cells vascular endothelium (at least in part due to surrounded by collagen, elastic fibers, and insudation of hyperlipidemic serum) causes extracellular lipid. Fibrous plaques mayor may encrustation of platelets and monocytes. Smooth not arise from fatty streaks and can exist muscle cells in the intima and media are sub without causing significant obstruction of the sequently stimulated to proliferate and form an vascular lumen. advanced plaque. 3. The complex plaque, which is a fibrous plaque that has progressed to include calcifica 1.2.2. New concepts in atherosclerosis. The tion, hemorrhage, cell necrosis, an inflamma study of the pathogenesis of atherosclerosis tory reaction, and extension to the arterial is a complex, rapidly evolving field that com media. Adventitial fibrosis and inflammation bines many disciplines, including cellular and may be present. molecular biology, biochemistry, and genetics.
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