Controversies in Cardiology

415 Pages·2015·9.73 MB·English

by  John A. Ambrose

Controversies
in Cardiology
John A. Ambrose
Alfredo E. Rodríguez
Editors
123
Controversies in Cardiology

John A. Ambrose (cid:129) Alfredo E. Rodríguez
Editors
Controversies in Cardiology
Editors
John A. Ambrose Alfredo E. Rodríguez
UCSF Fresno Department of Interventional Cardiology
Fresno , CA Otamendi Hospital
USA Buenos Aires
Argentina
ISBN 978-3-319-20414-7 ISBN 978-3-319-20415-4 (eBook)
DOI 10.1007/978-3-319-20415-4
Library of Congress Control Number: 2015949472
Springer Cham Heidelberg New York Dordrecht London
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“To our wives, Avis and Marta”

Foreword
As a clinician, I have always been attracted to the problem-oriented method not only
for patient care but also for education. My mentor at Emory, Dr. J. Willis Hurst, was
a great advocate of the problem-oriented approach to patient care, and 30 or more
years ago my university, Mercer University, established a medical school with the
problem-oriented method of education as a centerpiece. The idea of identifying
problems and then addressing all aspects of those problems in order to answer spe-
cifi c questions is attractive to many clinicians. In medical education, this approach
certainly keeps the attention of the student better than the traditional digesting of all
the basic sciences and ultimately applying them to clinical problems. So raising
questions is important but it is also important to raise the questions about the sub-
jects that do not have a universally-agreed upon answer. That seems to be the objec-
tive of Drs. John Ambrose and Alfredo Rodríguez in crafting this volume on
Controversies in Cardiology. Certainly there are controversies, and in this era, we
are easily convinced that things are happening so fast that the controversies are mul-
tiplying exponentially. But are these questions as pertinent as they were in the 1950s,
1960s, 1970s or 1980s? One might refl ect on open heart surgery, cardiac electrical
pacing, defi brillation, percutaneous intervention for coronary artery disease, man-
agement of acute myocardial infarction, and a revolution of effective drugs for
hypertension, congestive heart failure and atherosclerosis. Many of these issues of
the prior decades may seem non-controversial now. For the patient whose heart
beats too slowly to support the circulation, a pacemaker is the answer, and a 10,000
patient randomized controlled trial is clearly not necessary. Some that are not con-
troversial now were very controversial then. In the late 1960s, coronary bypass sur-
gery for severely symptomatic angina was an example of a highly- controversial
subject that, at present, has evolved into the question of which form of revascular-
ization should be performed. Drs. Ambrose and Rodríguez have picked 25 of their
favorite controversies to explore and have recruited leading experts to probe the
existing evidence, as well as current opinion, about these issues. In addition, sugges-
tions are made for further investigations needed to bring more clarity. The editors’
bias is clearly toward coronary artery disease and its diagnosis and therapy. Twenty-
one chapters deal in some manner with coronary disease and its complications and
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viii Foreword
treatment, while only three address the controversies surrounding structural heart
disease and only one addresses a rhythm disturbance. A different look reveals that
there are two chapters that address risk and prevention. Nine address coronary inter-
ventions. Another six address other issues of coronary artery disease, and three deal
with access and cost benefi t issues. Others might select different issues to discuss
but these favorites of Ambrose and Rodríguez are ones that many of us with a focus
on coronary artery disease deal with daily in our own practices. Many of these con-
troversies will be settled within the next few years, but many of them will remain
and be challenges for the judgment of physicians for years to come. Framing com-
mon clinical problems and attempting to answer them is a great contribution because
that, in fact, is how we think. My former mentor, Dr. Hurst, and Dr. Eugene Stead
often spoke about writing a book which would include the ten things that every
cardiologist should know. That book did not materialize, but if it had it would require
revisions on a frequent basis because not only the answers to our questions but the
questions themselves continue to change. The controversies of today addressed in
this book may not be the controversies of tomorrow but we only live in today. Drs.
Ambrose and Rodríguez have helped us understand where we live today and what is
needed to gain further understanding of what is needed tomorrow.
Piedmont Hospital, Atlanta, Georgia Spencer B. King, III, M.D.
Pref ace
It is quite amazing to have been witnesses to the spectacular evolution of cardiology
over the last 30–35 years. Just consider two achievements – the management of
acute myocardial infarction and the entire discipline of interventional cardiology. In
the 1970s, patients presenting with an acute myocardial infarction with ST elevation
and/or pathologic Q waves on ECG (then designated as transmural infarctions) were
put to bed rest for about 3 weeks to “recover.” Medications were crude and morbid-
ity and mortality were high. Now, the average length of stay for a patient with a
STEMI is about 2 days, and in most we aggressively insert metal tubes in their
thrombosed arteries that remain open with the appropriate technique and medica-
tions. Complications have been drastically reduced and long-term survival and qual-
ity of life have improved. Likewise, the entire fi eld of interventional cardiology was
no more than a dream in the early 1970s until the pioneering work of Gruntzig and
others made it a reality. We have evolved from crude balloons to atherectomy, then
to scaffolds, followed by medicated scaffolds and now disappearing scaffolds.
Obviously, over these decades, there have been several other examples of these
paradigm shifts in how our patients are now managed.
What has been responsible for these changes? In some, it has been in the devel-
opment of new uses for old medications such as aspirin in ACS, streptokinase for
STEMI and colchicine in pericarditis. However, the driving force behind most of
these changes that have revolutionized our approaches has been discovery, inven-
tion and innovation with the development of new medications and technologies.
And the testing ground for these innovations has been, for the most part, random-
ized clinical trials. Furthermore, 35 years ago there were few standardized
approaches to management and national guidelines were non-existent. Clearly, sev-
eral organizations, based on various trial data and expert opinion, now provide
direction and options for therapy in several different patient scenarios.
However, with such rapid change comes controversy, and not all situations that a
cardiologist encounters in caring for patients can always be resolved based on the
conventional wisdom of the day. Furthermore, the enthusiasm for a new drug or
procedure frequently leads initially to much “off-label” overuse when the new ther-
apy is introduced to the general patient population. Additional studies in the form of
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