John M. Stang

Provocation of ventricular tachycardia after consumption of alcohol

CARDIAC conduction abnormalities and dysrhythmias often occur in the presence of cardiomyopathy and a history of excessive alcohol consumption. Using the repetitive ventricular response, we provoke...

Mitral valve prolapse: cardiac arrest with long-term survival☆

Cardiac arrest has been reported in patients with mitral valve prolapse; however, clinical characteristics and survival information are limited since most of the cases reported include autopsy data. Nine patients (2 male, 7 female) with mitral valve prolapse were identified who had cardiac arrest; ventricular fibrillation was documented in 8 patients; resuscitation was unsuccessful in 2. Eight had a history of palpitations (months to 15 years duration) and ventricular arrhythmias, 3 had a history (5-15 years) of recurrent syncope, and 1 was totally asymptomatic. Cardiac catheterization-angiographic studies in 8 patients demonstrated normal coronary artery anatomy and mitral valve prolapse. All 9 patients had auscultatory and echocardiographic evidence of mitral valve prolapse. Seven survivors (6 still alive) were followed from 3 to 14 years after cardiac arrest. A subset of patients with mitral valve prolapse and cardiac arrest is described in whom past medical history is compatible with cardiac arrhythmias or syncope, and whose long-term prognosis appears better than patients with other causes of cardiac arrest.

Reduction of mortality from prehospital myocardial infarction by prudent patient activation of mobile coronary care system

Numerous recent studies have documented the fact that lives are saved by prehospital mobile coronary care units (MCCU).lm6 As a result, such units, of various designs and types, have proliferated in the United States and in Europe.7v8 In spite of this development in emergency medical services (EMS), there is still some uncertainty regarding its impact on death from acute myocardial infarction (AMI) and sudden death in patients with coronary artery disease (CAD). Furthermore, arguments have been raised that MCCU often serve patients at low risk of death, who could well be treated by other means? This presentation is concerned with our S-year experience with a mobile coronary care system in Columbus, Ohio. A single advanced life support (ALS) vehicle manned by a physician and paramedics (Heartmobile) was added to a long-standing and well-utilized EMS system in April, 1969. Over the next 8 years the ALS system as well as the entire EMS system grew dramatically.‘O With respect to cardiac emergencies, it had been our impression that persons served by the ALS units were predominantly those with high risk of death. This was clearly true of an original cohort of 214 consecutive cases analyzed in 1970 when the Heartmobile was in use. However, we had no data concerning those patients with AM1 not seen by the EMS system. As a result, factors influencing patient decisions to use the

Treatment of prehospital refractory ventricular fibrillation with bretylium tosylate

Among 218 patients treated for prehospital arrest during an eight-month baseline period prior to addition of bretylium tosylate to the paramedic protocol in Columbus, 16 (7.3%) were seen with refractory ventricular fibrillation (RVF). These patients failed to respond to multiple countershocks, lidocaine, bicarbonate and epinephrine, and either were transported in arrest during cardiopulmonary resuscitation (CPR)(14) or were pronounced dead at the scene (2). A single patient was eventually resuscitated in and discharged from the hospital. During the subsequent 16 1/2-month experience with bretylium used only for prehospital RVF, 421 patients with prehospital arrest were seen, 35 of whom (8.3%) had RVF. All but five patients were defibrillated successfully, and 14 (40%) were converted to a rhythm sufficient to obviate CPR during transportation. Eleven patients (31%) survived to be admitted to the hospital, and eight of 35 (23% vs 1/16 or 6.2% above, P less than .05) were discharged and remained well three to 17 months later. Bretylium tosylate may provide life-saving therapy for refractory prehospital ventricular fibrillation so that survival from an almost uniformly fatal condition is improved. While patients with persistent arrest generally should be transported to the hospital, such patients should not be subjected to the difficulties of CPR in transit unless they are first given bretylium if RVF is present.

The electrophysiologic effects of upright posture

In order to determine the effects of upright posture on the electrophysiologic properties of the human heart, 12 patients underwent electrophysiologic studies in the supine and upright positions. Compared to supine, the upright position significantly reduced basic cycle length from 818 +/- 111 to 680 +/- 141 msec, sinoatrial conduction time from 186 +/- 94 to 135 +/- 56 msec, corrected sinoatrial recovery time from 206 +/- 104 to 108 +/- 55 msec, interatrial conduction time from 76 +/- 17 to 70 +/- 16 msec, and the AV nodal conduction time (AH interval) from 88 +/- 19 to 78 +/- 14 msec (all p less than 0.05). Right intra-atrial and His-Purkinje (HV interval) conduction times were not altered. When the subjects assumed the upright position, the effective refractory periods of the right atrium, atrioventricular node, and right ventricle decreased significantly at basic and paced cycle lengths. For the group as a whole, the upright posture did not significantly augment repetitive responses to atrial and ventricular extrastimuli.

Early Exercise Tests After Myocardial Infarction

Excerpt The mortality from coronary artery disease is declining, but we still face the responsibility of trying to identify potential victims, especially when coronary artery disease has been annou...

The role of paramedics in resuscitation of patients with prehospital cardiac arrest from coronary artery disease

Columbus, Ohio added prehospital coronary care to its Emergency Medical Services System (EMS) in 1969. The EMS System, which is citizen activated and tax supported (+5 per citizen per year), currently sees 32,000 patients a year in a city with a population of 650,000. Ninety-six per cent of the population is aware of the system. Over two thirds of patients with ischemic sudden death or myocardial infarction are seen by advanced life support paramedic (EMT-P) units. The EMT-Ps operate by protocol without telemetry and carry all standard resuscitative drugs and devices. Serial evaluations have shown that within the limits of the protocol, the EMT-Ps perform as effectively as physicians in diagnosis and care of acute cardiovascular emergencies, including endotracheal intubation. One third of ischemic cardiac arrest patients in whom resuscitation is possible (60% of such patients seen) are discharged from the hospital alive (14.2/100,000 lives saved per year). Lives are also saved by treatment of other life-threatening prehospital complications. In Columbus, the estimated annual mortality from ischemic heart disease is only 19%. The EMS System contributes significantly to this low figure.

Samuel A. Levine and his World War I encounters with the brothers Regii, Allbutt and Osler

The broad, diverse World War I US medical experience produced changes in medical thought far out of proportion to the actual duration and extent of the US wartime military involvement. Volunteer US hospital units serving in Europe were organized early in the war and influenced the design and organization of military field hospitals when the United States entered the war.’ The massive wartime mobilization process involved large numbers of medical officers in the examination and classification of 4 million young men and required new physical standards for separating the “fit” from the “unfit.” * Less documented but quite important in retrospect was the US medical officers’ experience at the British military “Heart Hospital,” which brought a group of

Mobile Pre-Hospital Coronary Care — Columbus, Ohio

The City of Columbus, Ohio, USA has a population of approximately 565, 000 residing within an area of 184 square miles. It exceeds the population of Denver and Atlanta by at least 50 000 people, and over the past twenty years has grown faster than any other city in the northeastern industrial quadrant of the United States [1]. It is a city constructed on flat terrain with efficient surface transportation related to criss-crossing major arteries in the center of the city and a surrounding ‘outerbelt’. The most readily recognizable feature of the city is the Ohio State University, which contributes 54462 students to the overall population. The Ohio State University Hospital is but one of eight hospitals that are capable of taking care of the coronary patient.

The Way We Teach: Anatomy of the Coronary Artery System

A simple model to enhance understanding of the three-dimensional anatomy of the human epicardial coronary artery circulation is discussed and potential instructive applications reviewed. The chambers of the heart are visualized as being related to one another as in a pair of opposed hands, which can be rotated to demonstrate the various structures as viewed in different angles of obliquity.