Elliot Rapaport

1999 Update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction)

Executive Summary andListing of Recommendations nnThese guidelines are intended for physicians, nurses, and allied healthcare personnel who care for patients with suspected or established acute myocardial infarction (MI).nnThese guidelines have been officially endorsed by the American Society of Echocardiography, the American College of Emergency Physicians, and the American Association of Critical-Care Nurses.nnThis executive summary and listing of recommendations appears in the November 1, 1996, issue of Circulation. The guidelines in their entirety, including the ACC/AHA Class I, II, and III recommendations, are published in the November 1996 issue of the Journal of the American College of Cardiology. Beginning with these guidelines, the full text of ACC/AHA guidelines will be published in one journal and the executive summary and listing of recommendations in the other . Reprints of both the full text and the executive summary with its listing of recommendations are available from both organizations.nnEach year 900u2009000 people in the United States experience acute MI. Of these, roughly 225u2009000 die, including 125u2009000 who die “in the field” before obtaining medical care. Most of these deaths are arrhythmic in etiology. Because early reperfusion treatment of patients with acute MI improves left ventricular (LV) systolic function and survival, every effort must be made to minimize prehospital delay. Indeed, efforts are ongoing to promote rapid identification and treatment of patients with acute MI, including (1) patient education about the symptoms of acute MI and appropriate actions to take and (2) prompt initial care of the patient by the community emergency medical system. In treating the patient with chest pain, emergency medical system personnel must act with a sense of urgency.nnWhen the patient with suspected acute MI reaches the emergency department (ED), evaluation and initial management should take place promptly, because the benefit of reperfusion therapy is greatest if therapy …

1999 Update: ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction: Executive Summary and Recommendations A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction)

The American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the Management of Patients With Acute Myocardial Infarction have been reviewed over the past 2.5 years since their initial publication in the Journal of the American College of Cardiology (1996;28:1328–1428) to ensure their continued relevancy. The guidelines have been updated to include the most significant advances that have occurred in the management of patients with acute myocardial infarction (AMI) during that time frame. This update was developed to keep the guidelines current without republishing the entire document. This effort represents a new procedure of the ACC/AHA Task Force on Practice Guidelines. These guidelines will be reviewed and updated as necessary until it is deemed appropriate to revise and republish the entire document.nnThe guidelines, incorporating the update, are available on the Web sites of both the American College of Cardiology (www.acc.org) and the American Heart Association (www.americanheart.org). In the Web site version, deleted text is indicated by strikeout, and new/revised text is presented as double-underlined type. Reprints of the original document with the revised sections appended are available from both organizations (see information below).nnThe following is a listing of the recommendations made by the ACC/AHA Task Force on Practice Guidelines in the ACC/AHA Task Force Report “ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction.” More detailed information regarding the evidence and the rationale for these recommendations can be found in the full text of the guidelines themselves, which appears in the November 1996 and September 1999 (update) issues of the Journal of the American College of Cardiology. nnAs in previous guidelines, the American College of Cardiology and the American Heart Association have used the following classification system in which indications for a diagnostic procedure, a particular therapy, or intervention are designated as:nnClass I: Conditions for …

ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction:Executive Summary

Executive Summary andListing of Recommendations nnThese guidelines are intended for physicians, nurses, and allied healthcare personnel who care for patients with suspected or established acute myocardial infarction (MI).nnThese guidelines have been officially endorsed by the American Society of Echocardiography, the American College of Emergency Physicians, and the American Association of Critical-Care Nurses.nnThis executive summary and listing of recommendations appears in the November 1, 1996, issue of Circulation. The guidelines in their entirety, including the ACC/AHA Class I, II, and III recommendations, are published in the November 1996 issue of the Journal of the American College of Cardiology. Beginning with these guidelines, the full text of ACC/AHA guidelines will be published in one journal and the executive summary and listing of recommendations in the other . Reprints of both the full text and the executive summary with its listing of recommendations are available from both organizations.nnEach year 900u2009000 people in the United States experience acute MI. Of these, roughly 225u2009000 die, including 125u2009000 who die “in the field” before obtaining medical care. Most of these deaths are arrhythmic in etiology. Because early reperfusion treatment of patients with acute MI improves left ventricular (LV) systolic function and survival, every effort must be made to minimize prehospital delay. Indeed, efforts are ongoing to promote rapid identification and treatment of patients with acute MI, including (1) patient education about the symptoms of acute MI and appropriate actions to take and (2) prompt initial care of the patient by the community emergency medical system. In treating the patient with chest pain, emergency medical system personnel must act with a sense of urgency.nnWhen the patient with suspected acute MI reaches the emergency department (ED), evaluation and initial management should take place promptly, because the benefit of reperfusion therapy is greatest if therapy …

Early Versus Delayed Angiotensin-Converting Enzyme Inhibition Therapy in Acute Myocardial Infarction The Healing and Early Afterload Reducing Therapy Trial

BACKGROUNDnAlthough ACE inhibitor therapy has been shown to reduce mortality in patients with acute myocardial infarction (MI), the optimal dose and the timing of its initiation have not been determined.nnnMETHODS AND RESULTSnIn a double-blind trial of 352 patients with anterior MI, we compared the safety and effectiveness of early (day 1) versus delayed (day 14) initiation of the ACE inhibitor ramipril (10 mg) on echocardiographic measures of left ventricular (LV) area and ejection fraction (EF). An early, low-dose ramipril (0.625 mg) arm was also evaluated. Clinical events did not differ. During the first 14 days, the risk of manifesting a systolic arterial pressure of < or = 90 mm Hg was increased in both ramipril groups. LVEF increased in all groups during this period, but the early, full-dose ramipril group had the greatest improvement in EF (increase: full, 4.9 +/- 10.0; low, 3.9 +/- 8.2%; delayed, 2.4 +/- 8.8%; P for trend < .05) and was the only group that did not demonstrate a significant increase in LV diastolic area.nnnCONCLUSIONSnThe results of the present study demonstrated that in patients with anterior MI, the early use of ramipril (titrated to 10 mg) attenuated LV remodeling and was associated with a prompter recovery of LVEF. The use of low-dose regimen did not prevent hypotension and had only intermediate benefits on LV size and function. The more favorable effects on LV topography of the early use of full-dose ramipril support the results of the major clinical trials, which have demonstrated an early survival benefit of ACE inhibition.

Management of primary hyperlipidemia

Epidemiologic, clinical, genetic, experimental, and pathological studies have clearly established the primary role of lipoproteins in atherogenesis.1,2 Lowering plasma cholesterol concentrations reduces the availability of atherogenic lipoproteins and also, presumably, the accumulation of cholesterol in the intima of arteries. Measures to lower plasma cholesterol have become fundamental to the practice of preventive cardiology, and their use in both patients who already have coronary disease and healthy people has materially contributed to the 50 percent reduction in mortality from coronary heart disease in the United States in the past two decades.3,4 Lowering the plasma cholesterol concentration by a variety .xa0.xa0.

Echocardiography of left ventricular masses.

SUMMARY The M-mode and two-dimensional real-time echocardiographic findings in 10 patients with left ventricular masses are discussed. Two patients had left ventricular tumors and eight had left ventricular thrombi. In all cases the diagnosis was confirmed by angiography or surgery. The intracavitary and intramural left ventricular tumors were detected both bv M-mode and two-dimensional echocardiography. M-mode echocardiography, however, did not detect the left ventricular thrombus in all instances. Two-dimensional echocardiography was able to identify the four large and inhomogeneous left *entricular thrombi but did not clearly identify four cases of smaller mural thrombi. Echocardiographic techniques useful in detection of left ventricular masses are discussed.

ESC Textbook of Cardiovascular Medicine

John Camm, Thomas F. Luscher, Patrick W. Serruys, eds 1136 pages. Oxford, UK: Blackwell Publishing; 2006.

Incidence and Natural History of Left Ventricular Thrombus Following Anterior Wall Acute Myocardial Infarction

295. ISBN 1-4051-2695-7nnEditor’s Note: In our effort to provide an insightful, balanced, and constructively critical review of the new first edition of the ESC Textbook of Cardiovascular Medicine edited by Drs A. John Camm, Thomas F. Luscher, and Patrick W. Serruys that was published under the auspices of the European Society of Cardiology by Blackwell Publishing Ltd (2006), we have obtained the opinions of 3 distinguished senior cardiologists, Drs Gottlieb Friesinger, Desmond Julian, and Elliot Rapaport, to serve as a Select Panel for Review. To ensure the book was read in its entirety, the text was divided into thirds and apportioned equally to each reviewer; all 3 reviewers were assigned 4 chapters in common to read as well. nnThis summary review by 3 individuals, each of whom is internationally recognized for expertise in the broad field of general cardiology, is offered in the spirit of helping the ESC achieve its stated objective of providing a textbook that is successful in covering the knowledge that should be required of all general cardiologists. nn### General CommentsnnThis textbook is primarily targeted at the specific audience of those wishing to be accredited with the European Board for Accreditation in Cardiology (EBAC). It is not intended to be a work of reference, but, as stated in the foreword, of producing “a clinically focused resource for general cardiologists and trainees.” It presents 36 chapters within 1092 pages, each authored by anywhere from 2 to 6 multinational collaborating members of the European Society of Cardiology. One of its remarkable achievements in addition to the high standard of writing is its superb illustrations, figures, and tables that appear on virtually every page. They are well placed within the text and contribute in making …

Duration of hospitalization in "uncomplicated completed acute myocardial infarction". An Ad Hoc Committee review.

Previous studies have reported left ventricular (LV) thrombus in 20% to 56% of patients after anterior wall acute myocardial infarction (AMI). The Healing and Early Afterload Reducing Therapy (HEART) study was a prospective study comparing effects of early (24 hours) or delayed (14 days) initiation of ramipril, an angiotensin-converting enzyme inhibitor, on LV function after anterior wall AMI. This ancillary study assessed prevalence of LV thrombus. Two-dimensional echocardiography was performed on days 1, 14, and 90 after myocardial infarction. The cohort consisted of 309 patients. Q-wave anterior wall AMI occurred in 78%; 87% received reperfusion therapy. The prevalence of LV thrombus was 2 of 309 (0.6%) at day 1, 11 of 295 (3.7%) at day 14, and 7 of 283 (2.5%) at day 90. One patient had thrombus at 2 examinations. The day 1 echocardiogram was not correlated with thrombus development. LV size increased more in patients with thrombus than in those without thrombus. Patients with thrombus had more wall motion abnormality after day 1 than patients without thrombus (p = 0.03). Thus, the current prevalence of LV thrombus in anterior wall AMI is lower than previously reported, possibly due to changes in AMI management. Preservation of LV function is likely to be an important mechanism. Most thrombi are seen by 2 weeks after AMI. Resolution documented by echocardiography is frequent.

Duration of hospitalization in 'uncomplicated completed acute myocardial infarction'. An ad hoc committee review

The clinical and laboratory findings diagnostic of acute myocardial infarction include at least two of the following: (1) a history of pain consistent with myocardial ischemia, (2) electorcardiographic findings consistent with infarction, and (3) a rise in the serum level of specific cardiac enzymes. By the 4th or 5th day of illness, specific criteria can be applied to assign certain patients to a subset with uncomplicated completed acute myocardial infarction. These criteria include the absence of evidence of (1) continuing cardiac ischemia, (2) left ventricular failure, (3) shock, (4) important cardiac arrhythmias, (5) conduction disturbances, and (6) other serious illnesses in patients with an established acute myocardial infarction. In terms of prognosis and management, patients in this subset should be regarded as substantively different from patients in other subsets. They should respond favorably to short periods of immobilization and hospitalization than those generally used. They may remain at bed rest (modified in regard to sitting and the use of a commode) for 4 days. Subsequently, mobilization with a program of progressive activity over the ensuing 5 to 10 days should reduce the duration of hospitalization to less than the current average of 17.5 to 20.8 days for patients with acute myocardial infarction. Nine to 14 days should suffice in most instances. Current and future trials may indicate that still earlier mobilization and shorter hospitalization periods can be applied to certain patient groups, but the evidence on this point is incomplete. For the individual patient, many factors will determine the optimal duration of bed rest and hospital stay. The patients physician must consider the therapeutic benefits that may attend earlier mobilization and shorter hospitalization while weighing potential disadvantages. When the responsible physician does not regularly care for the patient, consultation with an experienced cardiologist is desirable. Patients whose condition is classified as uncomplicated may manifest deterioration during their illness and require assignment to a subset with a different prognosis and requiring different forms of treatment. For patients with uncomplicated acute myocardial infarction, as well as those in other subsets, absolute rules for therapy are unwise and application of broader principles by the alert physician is more likely to be beneficial.