Burton L. Zohman

An evaluation of anticoagulant therapy in the treatment of acute myocardial infarction

T HE possibility that anticoagulants may be of value in the prevention and treatment of acute myocardial infarction was suggested by a series of animal experiments in which the incidence of artifically induced intravascular clots was observed to be dramatically reduced by the use of heparin.‘e4 In 1941 and 1942, heparin or Dicumarol was first used clinically in individual cases or in small series of cases of acute myocardial infarction. The first American report concerned exclusively with the use of Dicumarol in acute coronary occiusion appeared in December, 1945, when Wright5 described his experience with seventy-six cases. Between the time of that report and 1949, over twenty individual series of cases were published in the American literature. As reflected in these reports, the greatest experience with this means of therapy was obtained by Peters, Guyther, and Brambe16s7 in Baltimore, by Nichol8-1a in Miami, by Parker and Barker 11~12 at the Mayo Clinic, and by Wright and his associates13-l7 in New York. Although the early reports seemed consistently favorable, the results were in no instance based upon a sufficiently large series of properly controlled cases to warrant statistical analysis. These initial observations did, however, lead to the more extensive study carried out by the American Heart Association’s committee for the evaluation of anticoagulants in the treatment of coronary occlusion with myocardial infarction. This large-scale investigation1GJ8Jg at sixteen leading hospital centers provided data for statistical analysis of 1,031 cases of acute myocardial infarction. Of this number, 442 received conventional treatment for coronary thrombosis while 589 received heparin or Dicumarol or both. Of those patients not receiving anticoagulant therapy, 23.4 per cent died as compared to a mortality of 16.0 per cent in the group receiving this form of treatment. It appeared from these findings that approximately one-third of the expected deaths was prevented by the administration of anticoagulant drugs. Similarly, when the percentage of cases developing thrombo-embolic complications was examined, it was found that in the control group 26.0 per cent developed one or more of these complications as compared with 10.9 per cent in the treated group. The greatest benefits in the reduction of mortality were in patients 60 years of age or over. The crude death rates for patients less than 60 years in both the treated and control

Cortisone in the immediate therapy of apoplectic stroke.

In recent years considerable progress has been made in the rehabilitation of the hemiplegic patient. The brilliant work of Rusk and associates (1) and others has clearly demonstrated that modern methods of rehabilitation and retraining can successfully restore such patients to lives of independence and productivity. The advances in the therapy of residual defects, however, have far exceeded the questionable gains in the treatment of the acute phase of the cerebrovascular accident. The immediate treatment of “stroke” is mainly devoted to measures for saving life and restoring physiologic balance. All authorities stress the importance of skillful nursing care, maintenance of hydration, attention to bladder and bowels and the prevention of hypostatic pneumonia. The current attitude toward therapy has been summarized by Alvarez (2) in a recent editorial as follows: “The best treatment for cerebral thrombosis is an expectant one. We all know that in many of these cases a weakness of the arm or leg clears up, and often aphasia disappears almost entirely. This recovery may be due to subsidence of edema of the brain or it‘may be due to rerouting of impulses around the destroyed area of the brain tissue.” Nevertheless, despite the recognition that return of function often occurs spontaneously due to a clearing of cerebral edema and improvement in cerebral blood flow, there is impatience with the necessity for awaiting “expectantly” the final and unalterable decree of nature. The hope of decreasing the degree of neurologic residua has stimulated interest in a more active treatment of cerebrovascular occlusions. Thus, attempts have been made to improve the cerebral circulation in such patients by the administration of vasodilator drugs, by the injection of procaine into the stellate ganglion, and by the administration of anticoagulants. Drugs of the vasodilator group have been found of little value for treatment of organic occlusion of the cerebral vessels: on theoretical grounds alone, there is little to suggest that any lasting benefit could result from a short period of vasodilation. When neurologic signs and symptoms are the result of transient cerebral vasospasm, however, large doses of papaverine (3 to 8 gtains, three or four times a day) do have great value in the prevention of recurrences (3). There is a divergence of opinion in the literature as to the efficacy of blocking the stellate ganglion. The difficulty in differentiating between clinical improvement resulting from therapy and that occurring spontaneously, indicated the need for carefully controlled studies. It has been argued that no logical basis exists for blockage of the stellate ganglion, since most observations on the circu-

Risk of thromboembolic complications from cortisone therapy

Abstract An increased coagulability of the blood has been reported in the hyperadrenal state induced by the therapeutic administration of corticotropin (ACTH) and cortisone. This finding, as well as a seemingly high incidence of thromboembolism in patients receiving such treatment, has led some authors to consider the use of anticoagulants when serious vascular disease or thrombophilic tendencies are present in patients requiring hormonal therapy. Without clear knowledge of the actual risk involved in the use of ACTH or cortisone, however, clinical judgement as to the selection of cases for treatment and the need for preventive measures must remain clouded. The present communication has recorded observations in eighty-six patients with advanced cardiovascular and/or cerebrovascular disease who received large dosages of cortisone in a course of therapy generally extending over a period of three weeks. In these patients no thromboembolic phenomena or other vascular complications were encountered during the administration of the drug or following its withdrawal. This experience seems to indicate that the theoretical danger of thrombotic complications from the use of cortisone is not clinically significant and that underlying disease of the heart or blood vessels need not preclude such therapy when proper supervision and simple precautions are instituted.

The Syndrome of Bernheim as a Clinical Entity

Can the right ventricle become partially obliterated by a bulging and hypertrophied interventricular septum so as to produce the clinical picture of isolated right heart failure? If so, the syndrome of Bernheim must be accepted as a distinct clinico-pathologic entity. The authors have previously reported 3 cases of right ventricular stenosis which appeared to originate in this manner. More recently, this evidence has been challenged and theoretic objections have been raised as to the possible existence of the syndrome. The present report attempts to answer these contrary assertions and records another instance in which the syndrome was diagnosed clinically and confirmed at autopsy.

The influence of insulin shock therapy on the electrocardiogram

Abstract A study before and after a series of insulin shock treatments in 259 patients with schizophrenia was undertaken to determine the incidence of significant electrocardiographic alterations. It was concluded that this form of therapy is not associated with any cumulative injury to the myocardium which could be detected in the electrocardiogram.

SUBACUTE BACTERIAL ENDOCARDITIS COMPLICATED BY AGRANULOCYTOSIS; REPORT OF CASE WITH RECOVERY

Excerpt The superiority of penicillin over all other agents thus far employed in the treatment of subacute bacterial endocarditis appears to be established.1, 2, 3, 4, 5, 6That penicillin may simil...

Prognosis in Severe Angina Pectoris with Medical Versus Surgical Therapy.

Excerpt The response of 100 patients with severe angina pectoris under long-term treatment with propranolol and isosorbide dinitrate has been determined by controlled objective evaluation and compa...