V 61 no 2 march 1992 by Joanne Paterson

TAY ::•e ri od~::al

Wl.ME34 4D

Guideline to Authors The purpose of the UWO Medical Journal is to provide a single forum for original articles based on clinical or research medicine of topical or historic relevance. Since the readership of the Journal is interdi sci plinary, articles published will attempt to reflect the wide range of medical disci plines. The Journal will consider empirical, theoretical , and research reviews. Book reviews will al so be considered. The Journal reserves the right to refuse articles that do not comply with the Journal's publication criteria. Manuscript Submission: Each submi ssion should include two copies of the full manuscript a minimum of 20 days before the proposed Journal publication date. Authors are ex pected to submi t the final revised version of the manuscript (usuall y with the two copies) on computer diskette. The preferred program is WordPerfect 5 . 1. All figures must be camera-ready and artwork must be black and white. Manuscript Organi:t..ation: Manuscripts submitted should be set with one inch margins and typed single-spaced . If necessary , the Journal will accept manuscripts not submitted on di skette that are typed with one inch margins, double-spaced , ami singlesided on (8.5 x I I ") paper. Original research articles should have an abstract that clearly states the relevance of the article to the medical di cipline hei ng reported on . Thi s dimension should be THE

WO MEDICAL JOURNAL STAFF

EdiiOrs-ln-Chief Shirley Lee, Meds 92 J~ ffn:y Politsky,Meds 94

Marketing &: Advertising Consr1ltant Jcffn:y Politksy,Meds 94

Deparrment of Arrwork K.:n Alanen . Meds 94 (director) David F isma n, Meds 94 Dr. Michael Reider (cartoon art) Caroline Lo.:ri sch , M.:ds 94 (photog raphy)

Class Represeniatives Andrew Caru so. Meds 95 David Fisman , Meds 94 L:s Wright , M.:ds 93 Will Marcoux , Meds 92

Accounts Co-ordina10r Anne Silas. Mcd s 94 Faculty liason Dr. Martin Inwood

elaborated upon in the introduction. Experimental methods, results, ami discussion section follow the introducti on. Results and discussion sections may be combined if appropriate. Authors should rely on articles or information publi shed in recognized journals and sources. References should be listed in the following formal :

Perry T .L. , Berry K ., Hansen S. , Diamond S. , & Mo k C . Reg ional distribution o f amino acids in human brain obtained at autopsy. J. Neurochem. 18:51 3-19 ( 197 1) . Kadar D. Anti-inflammatory analgesics. In : Princip les of Medical Pham1aco logy, 4th Ed . (Kalant H .. Roschlau W .H .E. , & Se llers E .M ., Eds .). Toronto: Uniwrsity of Toronto Press. pp 383-98 ( 1985) .

Editorial changes in manuscripts will be undertaken to correct either grammatical or stylistic errors. Authorship: All members of the Faculty of Medicine of UWO are invited to submit manuscripts for publication. Medical students are certainl y encouraged to collaborate with medical staff who specialize in the medical sub-discipline being reported on . Manuscripts will also be considered from medical faculty (including interns and residents) from universi ties other than UWO. Modes of communication: Authors should submit with thei r manuscripts a cover letter inbluding a return address, telephone number, and fax number (where available) . Two copies of the manuscript (as well as the final revised version on d iskette) should be sent to: n re Editors VIVO Medical Joumal Health Sciences Building Faculty of Medicine Uni versity of IVestem Ontario London , Omario N6A 5CJ N.B. All material publi sh~d in the UWO Medical Journal reflects soldy the v i~w s and op inions o f the authors o f the mah:rial publi shed and not n~ c ~ssarily the editorial staff of the

Case Swdy Awhor C as.: D r. L.J. Md.:ndcz

Journal. 10 All mat erial published in the UWO Medical Journal is copy right protected--no part of the U\ VO M edical Journal may be reproduced iu whole or in part without the expressed written penuission of the editorial board of the Jounml.

Printing Company Selby Young Printe rs , Inc.

Next Deadline: April 30, I 992.

The UNIVERSITY of WESTERN ONrARIO

MEDICAL JOURNAL Volume 61

Number 2

March 1992

Guideline to Authors

Editorial Notes

Readers' Views

Class Reports

Event Reports Tachycardia! • by Harsh Hundal, Meds 95

The High Cost to Cure • AttemJJtiol to Solve the • by Dave Hackam, Meds 92

Problems in Ontario's Healtb Care System

The Learning Resource Centre • by Dr. David Lloyd & Beth Thornstein Trying to Understand the Puzzle of Licensure and Post-Grad Training • Craig Markle, Meds 93

Cardiology: Current Concepts and Treatment 49

Newer Approaches to lnterventional Cardiology • by Dr. /an M. Penn The Current Status of Cardiac Transplantation • by Dr. Stuart 1. Smith

Limited Myocardial Reperfusion Injury - Current Concepts and Future Directions • by Morris Kannazyn , Ph .D.

The Preoperative Assessment and Postoperative Management of Cardiac Patients Undergoing Noncardiac Surgery • by Kevin M. Deitel, Medical College of Wisconsin

Thinking on Your Feet - a test of your clinical skills and medical vocabulary

Health Care page 44

Licensure page 48

Cardiology page 49

On the Co~er: 7he March /992 edition of the U. W.O. Medical Joumalfeawres a special section 0 11 Cardiology. 7he cover depicts (clockwise from bortom right-hand com er) Dr. O tristiaan Bam ard, one of the pioneers in the field of cardiac transplantation; one of the firs t designs of an artificial ball-valve; a11 adaptation of the he an from a drawing by Leonardo Da Vinci from the book "Classics i11 Cardiology "; and an electrocardiogram depicting 2nd degree hean block. At1ist: Kin Alanen, Meds 94.

Editorial Notes M.o. -to be or not to be? In these times of present confusion over licensure, it is difficult to know what to believe anymore. For this year's class of graduating medical students, their fate has been sealed with the deliverance of the CIMS match, destinating them to locations all over Canada . This year's graduating class is somewhat fortunate in that they have been g ranted a one year licensun:. A stroke of luck -if one plans to practice for the rest of their medical career only in Ontario. For many, however, this is a dangerous assumption to make as it does not allow for flexibility to practice where one desires; thus necessitating writing P.drt II of the Medical Council of Canada Qualifying Examination (MCCQE) to ensure general license portability in provinces other than Ontario. For the upcoming graduating class of 1993 , certification will only be granted in approved programs accredited by the Royal College of Physicians and Surgeons or by the College of Family Physicians . The third route of Rotating Internships will eventually no longer exist, as 1 years will be required for licensure. This brings up a number of questions . For the graduating class this year, the biggest concern lies with those who chose a rotating internship, in order to subsequently apply to specialties such as Surgery, Obstetrics & Gynaccology, and Pediatrics . What if one docs not get accepted into the specialty of their choice on completing a rotator internship? As well, students graduating in 1993 will also be applying for the same specialty spots as straight residencies, as rotator spots will be virtually nil. This will result in an increased numbt:r of applicants . Considering the dec reasing number of residency spots and the increasing number of applicants for these positions , it is obvious that students should form alternative plans if lhey do not get into their specialty program of choice. As well , there is the problem of being locked into a program. As an undergraduate medical student, most do not know enough about any one specialty to choose it as a career for the rest of their life. Even amongst residents today, there are many who change career paths half-way through their residency. This inability to switch programs is especially an important factor for those graduating in 1993, as they may not get a practicing licence until the completion o f their residency program . The idea of not having a license after 4 years of residency training is an unsellling prospect, especially considering the number of years one studies in order to practice medicine, and the amount of student loans the typical medical student carries! One must also question the value of the MCCQE Part II . The purpose of this exam is to test basic clinical skills and expose students to difficult issues

in medicine cg. telling a patient he is HIV-positive, critical appraisal, etc. As it stands, medical students arc constantly ev-dluated on their clinical skills throughout medical school. It is questionable that one extra year of post-graduate training will make a large difference in rounding out these skills . As well, the degree of compassion and tact with which a physician interacts with a patient is often an inborn trail, and not one that can be taught or examined . Secondly, as medical students go on to subspecialize, they will have had fewer opportunities to practice clinical skills outside of their specialty -would it not be bcllcr to write MCC Part II in conjunction with MCC Part I? Lastly, although MCC Part II will be required for licensure, certification in lhe program an individual is in must be completed before being granted a license, thus weakening the necessity of MCC Part II for licensure. On a broader prospective, the present changes occurring in licensure will most definitely decrease the number of practicing physicians in Ontario. Many of the smaller hospitals outside of teaching centres rely on residents to work their emergency wards on weekends, as these emergency wards are run mainly by Family physicians running busy practices and emerg throughout the week . Some argue that residents are not trained in emergency medicine and therefore should not be allowed to work emergency rooms . This seems somewhat ridiculous considering that most residents are exposed to the same amount of cmcrg during their residency as Family residents , and have probably been exposed to more codes , intubations, etc. during their residency. Physician burnout to provide 24-hr emergency room access may be a likely occurrence, with smaller hospital emergency wards closing, resulting in more transfers to teaching centre emergency rooms. These smaller community hospitals, however, are the very hospitals that arc suppose to stay open, with the influx of Family physicians that will be graduating over the next five years . So what does this all mean? A number of different medical committees are still in the process of trying to come to some level of agreement regarding licensure both within Ontario and between the other provinces . Without a doubt, they have a difficult task, which has resulted in much frustration from medical students who are caught in lhis present state of flux . We can only hope that logical decisions will be reached which will benefit our health care system and the practicing physicians of tomorrow, and not result in poorer medical care for the public. â&#x20AC;˘ Shirley Lee, Mt'ds 92 Editor

ith the arrival of the 1992 Olympic Games , the

fcvor of the Games' fierce competition has spread rapidly. Olympic competition consists of highly focussed athletes who aspire to perform the best they can either for an Olympic medal or for personal satisfaction. The interest and excitement that the Olympics generates is astounding . The Olympics is competition. Unlike the Olympics , however, competition is not something that comes about every four years; competition is omnipresent. Examples of competition a re endless . Human life is initiated through competition between spcnnatozoa to fertilize an ovum. Everyday human life abounds with competiton. Animals, microo rganisms, and other life forms compete with each other for food, space, and light. Competition appears to be an inbred. inexorab le aspect of existence -competition is a key to survival. Medical school and the health care system a re certainly good examples of a renas in which competition is prevalent. A recent trend in certain medica l schools (including UWO) has been to attempt to "reduce" competition amongst medical students. The reduction of competition should allow students to funnel their efforts on karning material in a thorough manner rather than on the rotc memorization of facts (a study technique often cmployed to ensurc high test scores). On method to reduce competition is through the application of ccrtain curriculum changes. Onc such change is thc convcrsion from a number gradc systcm to an honours-pass-fail (HPF) grading system . In light of the potential usc of an HPF grading system, thc co ncerned indiviJual should wdnt to know if this curriculum change is effective and worthwhile. The usc of an HPF grading system to reduce the foc us o f students o n marks appea rs worthwhilc . Aftcr all. a grade of 80 % on a test docsn't mean a studcnt knows 80 % of the material in a given ticld of study, but only 80% of the answers of a particular exam as judged by a particular instructor. Howeve r, thcrc is no reliable mcthod to assess whether this objectivc of thc HPF system is achieved. Do students really focus lcss on mcmorizing and more on developing an understanding of principles? If this changc in focus cannot bc rcliably asscsscd, then one must consider whcthcr thc HPF system is in actuality an approp riate implement.

supply or decrcasing demand . Since an evaluation is based on a previously detincd scale with an upper and lower limit, thc likelihood of an increased supply of marks is remote . Furthermore, since there must always bc a way to evaluate students, the occurrence of a dccreascd dcmand of evaluations is also improbable . Post-g raduate positions, for example, depend on the evaluation of students' performances both on exams and in the hospitals. Moreover. with the activation of government-induced restrictio ns in funds for post-graduate residencies, the competition for such positions is apt to become even mo rc intense. At UWO , thc preoccupation with the rcduction of co mpetition has even led to a restriction of the publication in the UWO Medical Jou rnal of departmental award winners . Dcspitc this censorship, the awards still exist and so do the winncrs . Imagine the Olympics with an unpublicizcd medal award ceremonies. Censorship neither removes nor reduces competition. Rathcr than attempting to reduce compelltwn among students, which in reality isn't being achieved, schools should focus on instructing students on how to effectively cope with the challenge of competition. As well. students should be rco ricntcd as to the true value of such curriculum changcs as an HPF grading system . Furthcrmorc . futurc curriculum changes should be utilized only if thcy havc a clea r objective, and one whose ach icvcmcnt can bc reliably assessed. In short, thc reality is that competition exists and it shall not disappear any tim;; soon . Louis Pasteur once said that "chancc favours the prepared mind. " The notion of being prcparcd should bc synonymous with the concept of bcing aware. Indeed, an individual who is aware of as many circumstantial variables as possible is likely to be onc who will bc most satisfied by and understanding of a given outcome. Insofa r as competition is an impo rtant variable in a variety of scenarios, including thosc linked to health care, an individual should be skilled at confronting the challenge of competition rathcr than avoiding it altogether. Opposition is, aftcr all. a good thing for mankind; kites rise against, not with the wind . â&#x20AC;˘

Jeffrey Jâ&#x20AC;˘oiitsky, Mt'ds 94 The othcr potential usc o f the HPF grading system IS the reduction of competition . This usc of the HPF systcm, however, is fallacy . Thcrc arc two primary mcans by which competition may be reduced; increasing

Editor

Readers' Views Dear Editors:

have foreseen. •

I would like to provide an allernate view on anending lectures to lhat given by Jeffrey Politsky in the Winter 1992 (sic( issue of lhe UWO Medical Journal.

G. Michael A. Solylo UWO Class of Medicine 1994

Why I allend lectures : I) I benefit from lhe experience of lhe lecturer, who is able to provide me wilh imponant basic data I may not recognize as imponant on my own. Good lecturers do no overwhelm students with information, as textbooks often do. With a basic database acquired lhrough lectures, I can fill out my knowledge through independent study. 2) Allending lectures allows me to pick up points and concepts emphasized by lhe lecturer -information likely to be on an exam. There is much debate on how useful exams are in assessing our knowledge . No one disp utes, however, that we must pass the exams to remain in medical school and to progress to subsequent stages in our training . 3) Many lecturers try to incorporate their own clinical experience in !heir lectures. By presenting actual cas.:s, slides , or vid.:os . I am given material in an interesting way, and may gain insight into lhe subject maller unattainable from a te xtbook. 4) I can interact wilh a lecturer--h.: or she can answ.:r questions, elaborate on a concept , tell a joke . Th.: human element is an imponant pan of th.: learning process . 5) Allending classes allows for social interaction with classmate s, facully, and the rest of lhe campus commu nity. A common criticism dir.:cted at lhe medical prof.:ssion is an inability to deal with people . I believe that isolating yourself by studying textbooks at home will not develop or even maintain your abilities to interact wilh olher human beings. All medica l students know the feeling of social isolation lhat occurs during exam time -1 do not want that sensation for the duration of the school y.:ar. None of my reasons for allending lcctur.:s arc striki ng ly original. but I fell lhat they should be e xpress.:d in this forum. I have tried not to allack Mr. Politsky's views on a personal level. but ralher allempted to provide an alternative viewpoint. I am, however, compelled to address several of his points. I feel that his comments were unfair to lhe Facully. Yes, !here are some poor lecturers here at Western , but !here are al o some .:xc.:llent lecturers, and I b.:lieve lhe general quality of instruction is bener than Mr. Politsky impli.:s. I am sure that. as lh.: editor of a publication, Mr. Politsky knows that dangers of making swe.:ping generalizations -yet he does not refrain from making lhem . Funh.:nno re , in orde r to assess the quality of a lecturer, you must anend th.: lecture! Mr. Politsky's self-admission that h.: does not allend lectures makes him unqualified to render judgment. Finally, I do not agree lhat Mr. Pol itsky has been "relegat.:d" to learning medicine on his own. Rather, he has made a personal choice to learn independently. As a stude nt with a graduate degree. Mr. Politsky should have some awareness of his own learning style. as it was likely well developed long before he entered medicine. Mr. Po litsky must have been awar.: of Western' s approach to medica l education when applying to medical sc hool. In sha n , Mr. Polit sky should not blame the curric ulum or the faculty for a situation that he should

I am pleased that my editotial in the December 1991 iss11e oj1he Medical Jo11mal has prompted some tho11ght. By all means, lhe foremost point 10 stress with regard to the alternate views that Mr. Solylo and I have expressed is that distinct opinions regarding a given s11bject matter~ acceptable. There is not necessarily a CO/Teet or incorrect view. Mr. Solylo cenainly raises some importam concepts. His first Jour points are valid and adequately stated. Hisf'.fth point and final two paragraphs, howevt:r, are nor as well conceived, and I should like to address these stau:meniS in the following ways: First, I am 11naware of the "common ctilicism" /hat physicians are 11nable to "deal" with people. F11nher, Mr. Solylo 's implicacion that smdying 1exrs at home will resull in deficits in social imeractive skills is ded11ctively unsound. On the one hand, the two concepiS are not directly linked. On the other hand, to suggest that social skills deteriorate consequemto lack of daily illleraction wilh classmates is, at the very least, a hig!J/y resrticlive notion . I cannot speak on behalf of "all" medical s/lldenJS: I, however, do nor feel socially isolated during exams. Second, being editor of a p11blication and "knowing the dangers (whatever they may be) of making sweeping generalizations • are not logically connected entities. Despite this non seq11illlr, I will address Mr. Solylo 's commem. In my editotial. I was q11i1e ca11ti011S 10 assen that the opinions I expressed were strictly mine. Th ese opinions were based on the lec/llres I did auend and nor on tire lect11res I did not a/lend. Reasonable j11dgemem on a mauer may be rendered through che application of carefill observation and analysis. ntird, having a graduate degree does nor email having an awareness of one's leaming sryle (11nless this was the dissertation topic) . Nonellreless, my me/hod of leaming did have a fomwt prior to entering medicine--a/lending lecmres and subseq11ently reviewing relevam material. More imponant lhan my •teaming sryle • prior to emeting medicine is whatlleamed: 10 maimain a jle.rible and adaptable posmre in the face of novel or adverse conditions. Since I haven't gained much from lecmres , I ha ve jo11nd an alternate way to learn effectively. Indeed, I was aware not only that medical instruction at UWO was by lecmre, bm of the courses ta11ght as well. A more complete awareness of Westem 's approach to medicine, as Mr. Solylo deems necessary, wo111d likely involve a thorough investigation of tire strengths and weaknesses of each lecmrer--a ltulicro11s notion for an applicam. Fin ally, the primaty iss11es of this discussion are 1he val11e of lee/tires and the usefi<lness of the cwTent curriculum. Clearly these mailers have no relation to the medical school applicant. Equally clearly, these mailers are direclly relau:d to 1he Faculry {both leaching and curricul11m commillee divisions). Smdents should no/ consider that challenge and ctiticism offaculry policy is unfair or unacceptable. Challenge and ctiticism are obligate steps in tire develapment and advancement of theories and philosophies. • Jeffrey PoliJsky, Meds 9-1 • Edilor, UWO Medical Jnumal

Class Reports More Fooloscopy by Will Marcoux, Meds 92

1 is late February. Snow flurries fall outside, and that same branch at my window still knocks into my consciousness . But this time it' s night. the glowing red embers o f Tachycardia arc dying down , the witch's spell is broken, the class of '92 has leaped o ut of the fairy talc donning white coats. Instead of foolosophizing, I want to sleep, yet I toss and turn . At least my desk isn't cluttered with internship letters and CIMS papers . Instead , like all Mcds-Four desks before it, it sits silently waiting . For the Might Match is about to occur and a computer in Ottawa is about to tell Meds '92 what is best. The thinking and weighing and compa ring and deciding is over -just all our hopes and fantasies for the future remain . The wind and window tapping continue. I awake from a restless dream . It seemed that my classmates and I were climbing wooden staircases that kept going up and up and never went anywhere. Much like the Winchester Mystery House in San Jose, California, these gold-leaf embellished stairs changed directions and spiralled , but lead to wood panelled dead ends a Ia Collip Reading Roo m, or narrow hallways and mo re stairs. Suddenly, we found ourselves capped and gowned in a inner-city slum just like I remember in Fez, Morocco. Each of us near-graduates may propose an individual interpretation, especially if we have a predilection for the psychoanalytic couch .

Western's Schoo l of Medicine has empowered us with access to the tools o f medical knowledge (i .e . nimbleness in sta irway climbing) to hopefully lessen physical plights ; but what about the ability to love in the agape sense of the word , the ability to help in places where no sun shines? In all our preparations for the licensing exam, in all our haste and stress of this event, may we all also seek the ability to both receive and give this health-giving essence . May we always seck an everincreasing capacity and competence to lovingly ca re, so mething no amount o f studying or exams will provide . One thin g fo r certain, once we are at last out of this fairy talc a nd if that computer in Ottawa tells me that London is best for me, I'm cutting down some bean stalk branches nca r my window .... at last then I could get some sleep. â&#x20AC;˘

regarding their professional futures . Hopefully more info rmation will be revealed to us as more decisions arc, if any, made .

From the Trenches Les Wright, Meds 93 Greetings from the wo rld o f clerkship'

Yet, I can't help but think of the last four yea rs and the co llective effo rt and cost, body, mind and spirit that we have all sustained. But , like the MCCQE practice exam, the meaning, the purpose and results of the various educational manoeuvers may have been obscu rred or nonexistent. What was the last four years really all about and for what? Now slums may depict medical economics in shambles , however, for graduating medical students perhaps they can also represent the lack of the most basic of w-ants: shelter, food, warmth and love . By simply being who and where we are, we shall soon be surro unded with the reality of life -human need .

Much has

happened since my last report fro m the trenches -the most important being Tachycardia. Yes. once again , Meds '93 wowed 'em with a display of musical and theatrical excellence that will surely become legenda ry. Many. many thanks and kudos to everybody who sac rific.ed most of their off-call (and some of their oncall ) time to achieving , once more, the nearly impossible in so little time . A class meeting with Dr. Barr, postgraduate dean, at the end o f February regarding changing licensure requirements left many frust rated , anxious. and at loose ends

In the meantime , some folks are preparing themselves psychologically fo r the upcoming Meds Formal--the swankiest shmoozfcst o f the year. Thirty bucks a head gets yo u dinne r and dancing at the new Century Club on April I Oth with two or three hundred of your closest friends. Make plans to get off call NOW. Till then , cle rk happily , get lots of sleep, plan exciting electives in locales south of the Tropic of Cancer, read a good book (it's good fo r the soul) and enjoy! After a ll. clerkship is a once in a lifetime deal -certainly something to share with the grandkids. It's been a great yea r. Take care , all! â&#x20AC;˘

The JJ Report by Jeffrey PoliJSky & Justin Amann, Meds 94 Jt>ff: Hi Justin . Justin: Hey J. What kind of trouble can we make today. Jt>ff: Frankly Justin, I'd rather have a nice quiet report - unassuming, unprovoking , and non-inflammato ry. No strong opinions or lewd, carnal, or lacivious co mments. I just want a nice report . Justin (with a "what-you-talkin'-bout-Willis" look on his fact>): What-you-talkin'-bout Jeff? .Jt>ff: Easy J . I WdS just kidding. .Justin (relit>ved): Okay . You had me worried for a bit l'il buddy. .Jt>ff (set>ing Trevor approaching): Hi Trev. How's things? Trt-veor: Enh! Same shit, different day! Jt>ff: My Trevo r, you ' rc quite the cunning linguist. Trt-vor: Hey, no gi rl 's ever complained. Justin (cringing): Yes, well, uh, Trevor, why don 't you tell us what you thought of this year's Tachycardia . Trt-vor: It would be my pleasure. I was intrigued by the parallelism between this yea r's plays and last year's plays . Fourth year plays are tinged with sentiment and morals; third year plays are bursting with cynicism and hard core humour; second year plays arc over-dramatized by clouded minds ; and first year plays have a simple yet amusing quality . Overall. the plays were entertaining. Nonetheless, the plays genera lly lacked the flavour, colour, and fluidity consistent with

a professional performance--perhaps the participants should consider an alternate full-time endeavour. .Justin (imprt'Ssl'd by Trevor's concise analysis): Well done Trevor. But fear not; all performers shall be docto rs first, and actors a close second . Jt-ff: On to other matters J. What does Ray have in his left pocket? Justin: Why do you ask"? Jt>ff: I was just curious--he seems to have his hand there all of the time, so I thought that it might be something interesting . .Justin: I sec. Tell me Jeff have you any funny stories or interesting anecdotes to tell me? .Jt>ff: Well for PBL, Debbie impersonated Mrs. Costa Knockcnbruch in o rder to gain valuable information regarding transfer of patient reco rd s once a physician dies . And although Alex has been dreading this, I can't ho ld back -du ring the most critical set of Leopo ld maneuvers of his life, Mr. Baro n got called "dainty " by his patient. What abo ut you Justin? Justin: Recently, I hallucinated during an exam . Jt-ff: Hallucinated? Justin: Yes . I was sitting at my desk when suddenly things began to flash in front of me on a screen . I'd never seen anything like it before and I can't even describe what I saw. Jeff: Hmmm! There's been a rash of that lately. Well J. This 2"" term is over and I feel no need to prolong it any further. It 's time to rclax--l'm headin' fo r the slopes. Justin: And I'm headin' for cover (blanket cover that is)--Happy Holidays everyone. â&#x20AC;˘

"You'll Never Know Enough" by Harsh Hundal, Meds 95 A,atomy. It is the psychovortcx of first year medical school. Like some stealthy saboteu r it slips quietly into one's subconscious, and at exam time subverts one's co nscious thoughts and behaviours . It insistently whispers in your ear, " You 'II never know enough. You 'II never know enough. " Tracey Elliot sat in the UH cafeteria, eating suppe r with one hand and thumbing thro ugh notes with the othe r. She looked up and said," Something's going to ---g suffer!" And Anatomy whispered, "You'll neve r know enough." Sitting at his carrel. with a skull to his left , Paul Howa rd looked up from his Grant's Atlas . He rubbed the bridge of his nose between thumb and fore finger, sm iled and shook his head . And Anatomy whispered, "You'll never know enough ."

It was just past midnight in the Anatomy Lab as Candice Buetow lifted a prosection out of its container onto the table. I watched as the embalming fluid pooled in a fold of the body bag that was on the table. Sue Ward began naming off the branches of the external carotid as Candice pointed to each branch . I suffered a lapse of concentration. I began thinking of the cadavers . I wondered if these people would be upset if they knew how clumsy we were? How often we got lost? I wondered if the grieving process for their loved ones would only be completed with the service in June? And then it was on to the motor branches of the facial nerve. At around half past one we washed up. As I switched o ff the lights and closed the door behind me, I wished the cadavers pleasant dreams . And I dreamt of Anatomy whispering ... â&#x20AC;˘

TACHYCARDIA! T his

y~ar I could hav~ sworn that the Facult y of M~dicine had

th~ largest concentration o f p~udo- Briti sh ac ce nts out s id~ of a Monty Python fa n club meeting . Seriously. it reminded m~ of a Red Ro~ Tea commercial colliding with a Brixton riot! Ap p li~d H ~alth Sciences opened the show with Sta r T rek: The Perpkx~d Generation. Jean Luc C hretien and his crew searched fo r the mu rd~ rer of Ensig n Toast o n planet Sony. Unfortuna tely they faikd to appr..:ciate the fact that Patrick Wayn~ was selected to play a fre nchman because only a British actor can play a fo n:ig ncr well. Consider Ghandi and Hannibal the Cannibal! T he n Meds 95 presented a moonwalking Robin Hood in search of Maid Ma rian's stolen heart . Youse~. the Sheriff had decided to do a Ca l St iller on his evil hearted mum . Robin and his m~n used the shotgu n formation to rctri.:ve it. It gav~ new meaning to having a hea rtless mum! Anyway, the skit was so cl.:a n you could have taken your temperance minded grandmother to sc~ it. Dentistry and Nursing's Fraudville was probably th~ closest in spirit to the skits at th~ Dean's BBQ in 1923 ... not that I was there. They posed the qu.: stion -who in their right mind would go into m~di c in~ fo rt h~ money? Oh, a certain Mr. R a ~ made the first of various ca m~o appearan es to the tunc of " H ~y Big Spend~ r Âˇ.

by Harsh Hundal, Meds 95 The magica l mystery tou r of Meds 93 pu lled in with of the Pre-Fab Four on clerkship. This was definatdy a nifty pice~ of work, which mad~ me long fo r bang~rs and beans , and life in a sh~box. All you really need is love and a link help from your friends to survive clerksh ip! The highlight of Meds 94 was the choreographed mating of Alice in Wonde rland with the Caterpi llar. The entomologists w~re delirious with rapture at the prospec t of interspecies coupling! However, I could hear the geneticists gnash th ~ir teeth wh~n Ali c ~ found out that the Rabbit had died . Th~n th~re was M~ds 92 with thei r fa rewell performance. Th~ y pr~sent~d the story o f a coup!.: of med gceks who rip off va rious childhood storybook characters in orde r to r~duc..: the duration of internship. R ~ally, Ray, what son of moral turpitude is this! Ripping off Link Red Riding Hood's hood?! I no ca n say no mo r~ 1 The hosts , kff Stal and Greg Hancoc k, combined with Dave Fisman . as a witch docto r, to determi ne wh~ther Western medici ne is any match for traditionftl fo lk medicine. I must rememb~r not to ~at by the light o f the full moon or I' ll b~ a flli cted with pneumonia! Anyway. I r~all y enjoy~d th~ swing medley with o n~ of my faves Dr. Akira Sugimoto on piano ' I can just imagi n~ him playing in a smoky 1940s underground jazz club. H eath ~r Murray and Jacquel yn Do u c en~ joined our hosts to sing . Here's to Tachy! â&#x20AC;˘ th~ a d v~ nture s

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The High Cost to Cure by Dave J. Hack.am , Meds 92

Attempting to Solve the Problems in Ontario's Health Care System

1 has b~com~ quite cl~ar that thcr~ arc major problems facing the hcalth ca re system. Whether in the newspapers or the doctor's Ioong~ . the taiL: is wry much thc sam.: - the health ca re system is sick and dying and in vital need of resuscitation. Yet, it should not be su rprising that the health care system is b.:ing criticized -most large government programs arc al one point or another. But this lim.: around the taiL: is somewhat differe nt. For some r~a so n , there is much tension surrounding discussions on th~ health care system. Peop le sense that change is impcnding, and ye t many feel that they are incapacitah:d lo do anything about it. This article will allempl 10 exami ne and understand the financial crisis present in today 's Health Care System . We must incrcasc our level of understanding about health care problems in the province, in order lo search for new ways lo solve them. This article will begin by providing figures which g ive an overvicw of the difficulties facing thc system . Following this, various aspects o f the system will be examined lo explain why the system is in the stale that it is. Finally, s.:veral solutions will be highlighted in an all~mp l lo secure the reader thai there is indeed a future for the H~alth Care System in Ontario - a systcm bascd on the principle of exceptional patient car.: that wc havc all com.: to cxpccl in thi s province.

I. Are Things Really as Bad as They Seem? In answering thi s question, let us examine the following data . In thc last len years, the cost of health care in Ontario rose by 63 .4% . In the same time period howcvcr. the entire Provincial economy grcw by only 42 .7 % - a fulllwcnty percent l~ ss (1). The Ontario govemm~nl prcsently commits 34 cents of ever)' doUar it owns to health. This will amount lo around S 1600 million in the 1991 / 1992 year. Canada as a whole spe nds the grealcsl amount of money per capita on h~alth than all cou ntries in the world, except the United Stales (S 1500 in 1987), compared with S900 in England . The distribution of this moncy is somcwhal surprising in that a third of it ($530 million) goes to pay doctors, while the rest is sp lit bctween hospitals (43 %) and "other" costs. Almost no data is available on what thcsc "other" costs are, although it is estimated that ten percent o f health care costs arc administrative - much lcss than ou r American colleagues . It should nol be su rprising that Health Ca re is expe nsive. Thc problem however is that the province is broke. The projcctcd defec itthis year is S9 .7 billion dollars, and is expcc ted to shrink by only 10 % next yea r to S8 .9 billion (2) . Perhaps this then is the proverbial "whopper" , so touted by th.: fast food

business - a business that most doquently states what the greatest challengc of the medical profession is today - "Become more kan , and avoid gclling fricd! ". II.

llol~

in the Sieve -Where has all the money drained to?

As the abov~ figures indicate , the cost o f health car.: in thc province is grcal , and it is cxpanding at a rapid rat.: . There are two main factors that contribute to such spiralling costs those due lo patients, and those due lo physic ians . These fa ctors span a spcclrum ranging from blatenl patient misuse to appalling physician mismanagement , and will now be considered in some detail. I. Patielll Driven Costs- "Fix me, Doc"

One of the primary reasons for the rising cost of health car.: in the province is that patients are overusing the health care syst.:m , thus st raining il beyond capacity. Patients are visiting doctors in larg.:r numb.:rs than ev.:r, for reasons that are becoming increasingly Jess easy lo justify. To see the extent of this phcnom.:na, consider tho: following . Between 1971 and 1985 , per capita us.: in Canada of health care rose by 68 %, whil.: the population growth rate in the same time frame was only 17 % (3,4,5). That is, thc us.: of health care increased by a rate which was four times that o f the entire population growth . It is th.:reforc not surprising that when asked if there was "patient abuse of the health care system ", 95% ofU .W.O. graduating medical students eilh.:r agreed or moderaleley agreed that thcr.: was (Figur.: 1) . Various factors are involved in explaining increased patient usc of health care . First and foremost is that health ca re is free. in that pati.:nls ar.: practically unrestrict.:d in using it. In fact , th.: time frame quoted above approximately parallo:ls the introduction of comprehensiv.: medica l insurance for Canadians . Yet it seems that the expectations that patients have of their doctors has also increased- so that the demand to "fix me doc" rings louder than ever before. It is not difficult 10 understand this - with m.:dia allention foc using on medical breakthroughs at an exponential rate , one ca n understand why patients may assume the simple correctability of all ailments. Other factors at play include double doctoring, increased pressures placed on physicians by their patients for rderra ls to specialists, and incr.:asing us.: of the .:m.:rgcncy room for trivial reasons. Littlc hard data is available to quantify th~ se factors, yet few would deny thcir presenc.: . Clearly, patient misuse of the Ontario Health Car.: system is an important factor in driving up the prescnl cost of health care .

2. Physician Dliven Heallh CoslS- M.D. or M. B.A? h goes without saying that o n.: mu st tread gently when blaming doctors for the current h.:alth system crisis. The focus of this s.:ction is lo show that by ignoring cost-effectiveness in th.: ways they practic.: , physicians are unnecessa rily driving up the cost of health car.: .

"Cost-effectiveness· can be defined as placing a dollar value on a clinical decision, after accounting for all the ramifications involved with that decision. If one is to seriously examine the reasons for our health care cost crisis, one mu st object ively exa mine the economics behind each aspect of clinical decision making . By comparing data on cost-effective ness in various clinical situations, information is prov ided on the cheapest method of practicing . When combined with the parameters of clinical judgment, this data provides the physician with what should be the best way of dispensing health care . Ignoring the cost-effec tiveness of clinica l decision making ca n be very costly, as the following examples will show.

I. 77re Pap smear- friend or foe? The Papanicolau (Pap) smear for example has been shown to be very effectivo: as a screening tool in detecting cervical dysplasia and carc inoma-in-situ (7) . Consider asymptomatic sexually active women between the ages of 20 and 75 . One can calculate the cost per year of life saved when screening occurs at different frequencies . It has been shown that by to:sting every 3 years , the cost is $13,300 (1985 U.S. dollars) per year of life saved (3). Testing biannually and annually incur costs of $419,800 and $1 ,064,300 per year of life saved re spectively. Why is there such a disproportionate increase in costs with increasing frequency? The answer relates to the pick-up rate o f the test. As as screening test, the Pap smear would be performed on millions of women , few of which will have the pathology searched for. A recent report from a workshop group supported by the Canadian Cancer Soc iety .:ntitlo:d "Report o f a National Workshop on Screening fo r Cancer o f the Cervi x" reviewed all available data , and conclud.:d that "sc reening every three yea rs from age 25 to 64 gives 90 % o f th.: maximal protection . Screening annually from age 20 giv.:s just ove r 90% protection· - indicating the lack of clear benefit from annual scree ning (7) . By sc reening annually, a greater expenditure is required for each positive lest, hence the cost data given above . There are howeve r advantages to annual sc reening. According to Dr. S. Brown , Assoc iate Professor of Obstetrics and Gynecology at the University o f We sh:m Ontario, "wo men o ften vi.:w tho: pap smear as a necessary component ro:quir.:d fo r overa ll health maintenance, and will o ft en visit their physicians annually with this in mind . This provides the physician with the opportunity to manage other issues related to their ove rall hea lth - an opportunity which may otherwise not prevent itself so readily ". It is possible that practicing in such a way saves money in the long run, as the patient's overa ll health is improved . Herein lies the root of the difficu ltie s with costeffectiveness data - the balance between providing quality patient care with economic facts . 2. "Yu your Honour, I checked the senmr rhubarb. •

Given the increasingly letigino us climate that physic ians find thcmsdv.: s practici ng in , there ha s bc.:n a move ment to practice medicine with an eye to the court s. Hence test s arc o rdered for sometimes medically unjustifiable reasons . The probl.:m is much more severe in the United States, where a study looking at indications for m.:dical tests showed that 17 % of upper endoscopies were performed for inappropriate indicatio ns in 1986 (8) . With the increasing number of medico-legal su its. the use of excess medical p rocedures will probably cont inue to riSe! .

III. Is There a Solution'? As the above indicates, the current health care system is costly and getting more costly annually. What fo llows is a desc ription of various potential mea ns that may move toward solving the current c ri sis in health care . I . A Role for Guidelines - Clinical judgment and the dollar.

As the above data suggest, the time has come when clinical judments mu st be made with cost effectiveness in mind . The que stion remains however, of where doctors get information on the most cost effective way of doing things . More importantly, since doctors have been trained to make decisions on th..: ba sis of sound clinical judgment, will cost effectiveness g..:t in the way of patient care? What if the best test medically is the worst financially? In answering these questions, physicians might consider turning to "guidelines of practic..: ·. In this context, these are recommendations on particular aspects of c linical practice , dev ised hy experts in the relevant field , in association with economists and epidemiologists. Their role is to guide doctors to the most effic ient means of practice . For example, the Task Forc e on the Use and Provision of Medical Services produced a report entitled "The Detection and Management of Asymptomatic Hypercholesterolemia ", in which they provided a protocol for te sting and treating chole sterol levels in patients within particular age and risk groups (9). The guidelines in this report helped to characterize hypercholesterolemia treatment , and assist physicians in providing clinically sound , cost effective

Figure I .

PoD conducted on 86 students of the graduating class of the University of Western Ontario. A = agree, MA = mod . agree, MD = disagree , D = disagree .

mod

MA MD D

I . I feel th.:rc is a crisis in the health care sysh:m

65 % 32% 2 %

2. I fee l there is patient abuse o f the system .

57% 38 % 3 % 2%

3 . I feel disease preve ntion could save money.

42 % 50% 8 %

4 . I feel user fee s could save money.

38 % 32 % 21 % 9%

5 . I feel cost-effectiveness

58 % 34 % 7 % 1%

at.

should be an important part of clinica l dec ision making .

health care . Guidelines are of course fraught with probkms. The cost required to produce and distribute them is great , and there is a real danger that the large time period needed to produce the m may lead to disparity between current therapy recommendations and the latest current technology. Furthennore, physicians, may feel threatened in their freedom to practice as they choose , and elect to ignore guidelines altogether. Finally, as patients get transformed into a series of measures of relative cost to benefit, medicine is threatened with losing its focu s, becoming instead an extension of an economics textbook . However, guidelines do have a role in that they can provide physicians with mechanisms whereby medicine can be practiced effectively while controlling costs.

2 . A Gram of Prevention is Wonh a Kilo of Cure. There is a general belief among various hea lth care planners that preventing disease is as important as treating it. By preventing disease from occuring, the savings to th.: health care system are potentially large . Take for example the antenatal care given to expecting mothers. An ardent effort by those involved with obstetrical care has produced a formula which foc uses on those factors that affect the health of the mother and child . Nutritional status is optimized, ultrasoundsare us.:d appropriately, and serial exrnainationsare used to monitor fetal growth . As a result, there has been an impressive impact on newborn health - with neonatal mortality dec reasing by over 20 % in all weight groups (9) . It is encouraging to learn that 92 % of recently polled graduating medical students felt that money could be saved by focusing on disease prevention . Hopefully these emerging doctors will embrace one of the gr.:at challenge s o f modern society, and search for areas where health prevention can make improvements before di sease strike s.

3 . User Fees - a biller bill necessa1y pill ? Various people believe that the panacea for the health care crisis comes in the form of user fee s. In fact, 70 % of the graduating class in medicine at U.W .O . felt this way to some degree . The data on this issue however is not so convincing . It has been estimated that user fees would affect those that need health care the most - the less economically secure . An examination of user charges in Sa sl::atc he"~Wn found that "such charges detem:d use by the poor but not by the middle and upper classes • ( I) . Furthermore, there is no evidence to show that so called "unwarranted " health care would be limited by use r fee s . A major U.S. health insurance experiment found that user charges deterred both necessary and unnecessary care in nearly the same proportion ( 1) . Thus. user 1\:es may not ac tually provide the savings that appear intuitiv.:ly obvious when one considers charging patients to see their doctors. If patients inappropriat.:ly utilize the health car..: system , such behaviour should be modified as it occurs through education by their physic ians. This requires o f course knowledgable practitioners and a receptive public. If the crisis in health care is allowed to wo rsen howev..:r, the government might impose behaviour modification in ways it deems to be fit , at the potential cost o f universality, and freedom for doctors to practice as they choose . IV. Summing Up Th.: health care sysh:m is plagued by spiralling costs in

the face o f resource s which arc gradually drying up due to deficit-c rippled government policy. Factors contributing to such costs occ ur at both the patient and physician level. In att.:mpting to improve this situation. focu s should be placed on costeffective practice and disease pr..:vention, while arguments for the use o f user fee s should be met with skepticism. It is hoped that th.: reader is perhaps more aware of issues facing health care practition.:rs today , and is therefo re in a better position to ensure that a system remains which allows the continued provision o f excellent patient care , now and well into the future .

•

Acknowledgments : Special thanks go to Dr. L. Valberg , Dr. G. Chance , Dr. M. Carrie , Dr. S. Brown and Dr. K. Stewart for their assistance wilh 1his article.

References. I . Woodward , C.A. and Stoddard, G .L, Is the Canadian Health Care Sysum Suffering From Abuse? A Commentaty , Can. Fam. Physician , Vo l 36, Feb 90 , p283-289 2 . Ontario Ministry o f Health . Ontario 's health care system: some faclS and figur~s. Toronto: Ontario Ministry of Health , April 1989 in reference I . 3 Bogart, David , Ministry of Health . Financing Heallh Care, a presentatio n to Meds 92 . 4 . Russel . LB Some of zhe Tough Decisions Required by a Na1ional Heallh Plan , Sci.:nce Nov 17, 1989: 891-897.

5 . Barer M . Evans R . Labell.:d R . Fee control as cost control : Tales from the frozen North . Milbank Q 1988: 66(1) : 1- 63 6 . Statistics Canada. 1971 Census: population ethnic groups, Ottawa, Ontario: Ministry o f Supply and Services , Octob..:r 1973 , catalogue no 92 733 7 . Statistics Canada . 1986 Census, labour force activity, Ottawa , Ontario: Ministry of Supply and Services, March 1989, catalogue no 93 Ill

7. Report of a National Workshop on Screening for Canur of 1he Cervir •, from a Wo rkshop group supported by the Canadian Cancer Soc i.::ty and oth.:rs; 1990. Pag.: 10 8 . Kahn KL, Koseco ff J . Chossin MR ct al. The us.: and misuse o f upper gastrointestinal .:ndoscopy. Annals of In/~ mal M~di cine 1988 ; 109 :664-70 , as included in reference I. 9 . "Detectio n and Management of Asymptomatic Hypcrcholersterol.!mia ", Prepared by the Task Force on the Use and Provision of Medical Services - A cooperative venture between the Ontario Ministry o f Health and the Ontario Medical Assoc iatio n·, 6/89

10 . Dr. Chanc.:·s Handout s

The Learning Resource Centre by Dr. David Uoyd , LRC Dirt!ctor & Bt!th Thomstt!itr , LRC Managu

hu been said that during the coune of your medical educatio n you

will have learned the equivalent of a nev.• language in the terminolo gy alone. If thU. was all there was to learning medic ine. some wo uld argue that the task ;, easy. However. you need to acquire a variety of skil ls and attitudes that dU.tinguU.h the physic ian as a person with v.•cll developed altru ism. ethica. communication, judgement , and knowledge o f thera.peutia.

Much of this ;, learned during the first fo ur years of your educatio n and the rest U. gathered over a life-time of lea rning . mainly by practice and through example. While cognitive P"Ycho logy tries to explain how we learn by using c ircuit diagrams. the process o f info nnatio n storage . processing . and retrieval from the brain . is far mo re complex. What i• obvious is that each of us hu our own individual way o f lea rning and o ne method of instructio n is not appropriate fo r all student< o r fo r all di<K ip lines . Learning is enhanced and memory i~ improved when material is presented by a var-iety of media. Fo r e xample . cross-sectional anato my of the brain can be better woderstood when reinforced by images fro m CAT SC1Ulll , especially if some clinico-patho log ical correlation is provided . Concepts are remembered better when taught in the context o f a problem which resembles the s ituatio n in which the information v.•ill ultimately be applied. The strongest ' medium' fo r the stud ent phys ic ian is direct patient co ntact. While th is is essential. good examples are not always ava ilabl<. o r certain aspects o f the patient contact are jLLiil too sensitive fo r everyone to ex perience . With appropriate teaming materiMls . students can be presented with opportunities no t otherw ise available to them or improve their clinical skil ls through practice to become bencr prepared prio r to patient contact. The Learning Resource Centre prov KI. es alternative o pportunities fo r "lea rning by d o ing" . The Faculty t• in the process o f develo ping a stud ent facility which will provide self-instructio nal resources that co mplem ent the undergraduate medical curriculum. The l.....caming Resource Centre is located in room Ml39 of the Medical Sc iences Building . in what wo.• the Medical Sc icnCCii Libnuy . alo ng with the re- located medical stud ent lo unge and additio nal study space . Mino r renovt~tions to the ares include co nnecting the Computer Based Learning Centre to the Learn ing Resource Centre . Twenty four ho ur accCAS to the Learning Resource Centre is pr-ovtded by security cards avu ilable to underg raduate medi al students. Fwoding fo r the Centre has been generous ly do nate-d by graduating medical students through G radPact. Fowodatio n Weste rn . Richard and Jean lvey Fund . and the J. P. Bickell Foundatio n . The types of resources wh ich will eventually become available within the Centre include: mannequins for practising variou.• phys ical exam and procedure skills . videotapea covering to pics in the basic and clinical sc iences. dU.plays of spec imens . s lide/tape presentations. model•. C D-RO M databases including Medline and Sc ient ific American Co nsu lt. and e ight additio nal computers co nnected to the Compute r Based Learning Centre network fo r acce.u to o ver two hundred educatio nal programs . To os.• ist you in finding the rig ht info rmatio n quickly. all of the resources within the Centr-e will be catalogued using relevant keywo rds . A compute r- search facility v.•iU allow y ou to enter the nwnc of a to pic you wo ukf like info nnation about tt.nd a llsting o f all reso ur-ces pertain ing to that topic will be presented . The Faculty o f Med icine hu d evelo ped the Lea rning Resource Centre with the intent that stud ents will be provided w ith a rich learning env iro nment that will no t only impro ve the overall educational mi lieu but also provide a wider range of cho ices for independent instructio n. •

t Dean Russell . responding lO the needs or the medical prolt.'ssion is a team approach. And. as a 1eam. we sec our mos1 imponam job is LO ensure CUStOmer satisliiCiiOn. Speed of response and llexibilily. from initial sales roman. through order processing. shipping and loiiL'II'·up is wha1 Dean Russell cuswmers have come to depend on. Dean Russell is a tilll·line distribuLOr or medical diagnostic equipment , surgical supplies & instruments and drugs & pharmaceuticals LO thousands or health care professionals throughout Omario. lidk fLJ a Dean Russell npn·smraril ·c today and jiiul <Wl JLN how rcsponsil·c our ream can be.

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RESP0\51\'f SER\ l(f

Trying to Understand the Puzzle of Licensure and Post-Grad Training by Craig Markle, Meds 93

L my attempts to understand the changes that are being made to licensure and post-graduate training in Canada, l have become aware that no one person knows all the pieces of this puzzle. To add to the confusion is the fact that the information that is known has changed several times over the past months . What we do know, as students, is certainly limited, and the information I have to share is far from comprehensive. In the following paragraphs , I have chosen a few of the pieces of the puzzle to explain some of what is known .

Two-Year Licensure Two year licensure is not a new idea. The push for two years of post-graduate training dales back to the 1970's with the push for primary care physicians to be trained in Family Medicine as opposed to Rotating Internships . The recent changes that have been made are such that, to get a license, the medical school graduate must achieve certification in either a Family Med icine or a Royal College program. Thus, "two-year licensure" is actually a misnomer, as only Family Medicine residents will have a license after two years, while Royal College residents must complete their programs before receiving a license .

Senior CFMS Represemative UWO

Concluding Comments The above information is only a brief overview and is far from being comprehensive. However, many questions and concerns arise from what is known . Will Family Medicine prog rams not get flooded now that rotating internships arc potential dead ends? Is there any flexibility for change? What about those who arc unable to enter o r complete certification progra ms? How is it that we will be trained well enough to pass the MCC part 2 exam, but not well enough to be gr.tnted a license? I am certain that each of you could add to these questions . A few years down the road, this new system will likely be the accepted norm . During this transition period however, in which decisions seem ru shed and last minute changes are being made, I find it difficult to believe that a price will not be paid -especially be the students. •

Core In an attempt to standardize training, the co ncept of "co re" was introduced whereby every candidate in a Canadian post-graduate program wo uld have a common 8 months in their post-grad year l program . This however, jeopardized the comprehensive/st raight res idencies by threatening an increase in the length of these programs. A compromise could not be reached and "core" was thrown o ut. "Core" is of historical significance only now.

MCC Exam Part II There are many unknowns which still surround this exam . What we do know at this stage is the following : the exam will be in the format of an OSCE , it will be taken in November of PGY::! (Post-g raduate year ::!), it will cost in the neighbo rhood of S 1300, it is planned to have the exam available in only 7 centres in Canada, and it will be required for licensure (although the full training program must be co mpleted before a license is granted).

CIMS Post-graduate programs arc required to have their program information to CIMS by April I, 1992. The classes graduati ng in 1993 will receive this information some time after that.

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Newer Approaches to Interventional Cardiology by Dr. /an M. Penn, Division of Cardiology, Victoria Hospital in assoc. with: Dr. R. /.G. Brown & Dr. J. B. Foley

Despit~

a lack o f prospective studies on its

mod~ of action.

angiopla sty ha s become an acce pt~d thcrap y fo r a rterial n:moddling . It is a relatively inexpensive and sa f.: means o f opcning a coronary art.:ry, with access being gained by a s imp!~ percutaneous puncture . Thc two major complications of PTCA. ea rly closure (a c u t~ closure) and late closure (restenosis), ar~ both indcpendcntly predicted by thc final lumen obtained ( 1.2). Balloon angioplasty use s pressure {or barotrauma) to obtai n a larger lumen by cracking , sp lining and dissectio n of the plaque {3). Fn:quently the tea r will penetrate the media and adv~ntitia unknown to operator until thc balloon is deflated (4). Although then: are anatomical predictors of dissection, this complicatio n occurs mostly in an unpred ictable manner {5,6). Post PTCA di ssec tion is the major pred ictor o f acute ve sse l closun:, which is the most s~ riou s complication of PTCA. incorpo rating most o f the post PTCA deaths and Q wave myocardial infactions (7 ,8). Thi s problem has st imula t ~d a sean:h fo r a saf~ r short term technique . The second major limitation of PTCA is restenosis at 6 months , which occ urs , depending on the selling , in 25-60% of procedures {9) . Pharmacological agents hav.: b.:~n unsuccess ful at altering this process ( 1). Mechanical , thennal and la ser devices hav.: prolife rated to alter the initial injury and thu s hope fu lly n:duce the rate o f restenosis . Based on ea rly result s th~se devices do not alter the rate o f rcstcnosis except in some patient subsets {3) .

Evolving Approaches to Obtaining :Uid Maintaining An Opening: Steot and Rotational Atberectomy The limitation o f balloon induced barotrauma has stimulated novd devices and techniques to remove plaque {rotational and dir~c tio nal athe rectomy}, to remodel arteries using them1al and laser ene rgy (them1al balloon and lase r catheter) and to buuress zhe anery with internal sc affold (ste nts) resisting elastic recoil. These procedun:s arc being perfo rm~d at limited sit~s as an investigational procedure . Anecdotal and nonrandomized data suggest each device despite its learning curve. r~ s ult s in a smoother post procedure lumen than PTCA alone .

Coronary Artery Stea1ts Coronary stcnts ar~ balloon expandable sca ffold s. We began clinical studi~s in 1989 with the Palmaz-Schatz stent , a slollo!d tubular mesh stent , balloon deliverab le with an ~xpans ion ratio o f 6 : I . The stent is able to bulln:ss fl ow limiting dissection and co mpr~ ss ti ssue thus acting as an int~mal sca ffold . Thi s has r~sultcd in maintenance of vesse l patency after faikd PTCA r~sulting in the widespr~ad usc of the stent as a hail out device in thi selling. We have repo rted an increased inc idence of complications following stent placement in the selling o f faikd PTCA (12 .5 % versus 2 %) as compared to de c ti v~ stenting: there wen: however no new Q wave infarcts or d~aths in this high ri sk selling (10) .

We hav~ co mpan:d imm~diat~ post p roc~d u ral angiograms in pati~nt s undergoing coronary artery stents to ma t c h ~d control s (II ). Early multicentrc clinical data suggest it is as safe and .:ff.:ctiw as routine PTCA with a majo r complication ra t~ (d~ath , Q wave, infarc t, urgent CABG) of 2 % (12,8) . The st.:nt produ c ~d a larger intimal lum~n with less elastic recoil (18% st.: nt versus 30 % PTCA} (13) . W.: have also cxamined the mechanism of benefit in patients undcrgoing redilation for a stc ntthat had renarrowed at 4 months ( 14) . Most o f the luminal enlargement with n:dilatio n was due to tissue compression and cxt ru sion through the stents while o nly 15 % was due to stent reexpa nsion. In the first 50 procedures our restenosis rate with stc nl was 20% ( 15). Thu s, coronary artery stents may produce a reduction in n:stenosis by improving the immediate post PTCA vessel geometry : prospectiv.: studies are few . The Trial of Angioplasty and Stc nts in Canada (T .A .S.C .) has bcen developed to determine if the usc o f coronary art.:ry stent s confers a bcnefit both early (acutc hospital outcome) and laic (reste nosis) as compan:d to PTCA alone.

Atbe.r ectomy - Coronary Artery Rotablatioo A novd method of removing plaque has been developed called Perc utan~ ou s Coronary Rotational Ablation (PTCRA) using a high spc~ d (160 - 180,000 rpm) rotational catheter with a diamond microc rystal tip which ablat~s inelastic a th~rosc l~rotic plaque while sparing no rmal elastic ti ss u~ (15). Clinica l trial s in selec ted patic nt s suggest that the micropulvcriz.:d pla qu~ does not cause dista l left ventricular dys fun ction {16 , 17} . Initial multic ent~r clinical experie nce suggests a sa fety profile similar to routine PTCA ( 18). It is pa rticularly dfcctivc in calc ific, ecce ntric and bifurcated lesions and diffuse multile sion disease (19). Conventional balloon angiop lasty resu lts in a higher acute complication in these sellings. Thus. PTCRA has been targeted in Ca nada for the use in these specific areas . PTCRA has also been used successfully in lesions in which it is not possible to pass a balloon (uncrossable) or lesions that fail to dilate {undilatable) by our group. As with the st.:nl study w~ inh:nd to develop a multicenter rando mized exa minatio n of its u s~ in di ffuse multilesion disease . Current data availabk is case control data a nd this will be the subject of analysis.

Summary Newer devic es may imp rove on the r~ su lts of co nv~n tional angiop lasty in certai n se lect cases. Randomized st udi~ s will be requ ired to heller determine thei r role . •

Refereoces MacDona ld RG. llcndcro<>n MA, llirshfeld JW, Goldber, Sit, 8,... T,

Vctrovcc G. Cowley M, Tauuig A, Whitworth It, M argolis JR. Hill JA, Jlllo R. F\cp~

~tclll'lliis after pei'C\JI.a.neoUi lnll\ill.mina.l from tb: M-llc<&rt group. Am J Cardiol 1990:66:9"'_6..

CJ: P... ticnt-n:: latcd varUiblc.s and

cororw ry

~K,>luty

·a

n:port

931. 1. Black AIR. Namay DL. Nicdcmw1 AL, Lembo N, Roubin FS, Oouj;lu JS. Kin& S B: Tear or d iss«1im afte r coronary angioplasty: M orpho~ic rorndatu o f an i.schemic complication . Circulation 1989; 79: 10 35-J().J:!.

\Valier BF: "Cracb:.N, breakers, stn:tcbcs, drilk:r.i. Kr.&p:.n, $havc:r.c, rur.un: lrea~nl o f a ~ raodcrotic C"'O''OllOr)' artery

12. Schatz RA , Bairn OS, Leon M , Elli. SG, Goldbor& S, Hirohfcld JW, Clcman MW, Cabin liS, Wal lrcr C. Sta&& J, Buchbinder M, T icrotein PS, Topol EJ, Savage M , Pe rez JA, Curry RC, Whitworth II , Souu JE, T;o F, Alma&or Y, Pordcr R, 1\:nn IM, Leonard B. Levine SL, Fi h D, Palmaz JC : Clink-a! cxpcriena: with tho: P... J.ma-Sc:-hol.tz coronary sle.nt: Initia l ~ ut t5 of a mu!tia:nler t tudy. Ci rcula tion 1991 ;83: 148-161.

bu.mc rs, V.'Cidc rs and mel te n" • ~

13.

disease? A dinical-morphologic-.ill a.sscumenl . JAm Coli Cardiol 1989;13:969-87.

Rc k::no8is at the si.Cnf. a rt iculation: ls this a dcsi&.n flaw? American Col\eec o f

Penn IM , Broo.n RIG, G.llir,an L, Foley JB, Murr..y-Pa'"""" N, White J:

CardioJo&y 41" Alvwal Scientific S.:..ion. April 12-1 6, 1992. 4. Waller BF: The eccent ric coronary a rtlx: rot~Clcrotic plaque: obtervatiom an:l dinial rc k:v-.ancc . Clin Cardtol 1989; 12: 14-20.

~ic

Elli. SG, Roubm GS, Kin& SB, Oouj;la.• JS, Wc intraum WS. 'fllcoTw RG.

Cox WR :

An&i~raphic

and clinica l pra:lictors of acute closurc al\er native ves!CI

14. MacDonald RG, O' Ne ill BJ , C rci&Jlton J, a..,_., RIG . Slivocb J, 1\:nn IM: b coronary sk::nt exparwion tb: mechanis m for suc.x:eu ful d ilation of ak::nt rcale.nosis? A quantitati\t an&~rapbic st l.dy . Ca.Ndian Journal of Cardiology, Vol 7, Suppl. A, Auc.-t 1991 .

coronary -iopluty . Circulaticn 1988;n:3T.!-379. IS . 6.

Sinclair IN, McCabo CJI , Sil'l"'rly ME, Bairn OS: PmdictON, th.:rapcuti<:

""'"""'· and lonj:-tenn outcomo of abrupt n:d(}Oun: . Am J Ca rd iol 1988;61 :61G-66G.

Elli. SG, Roubin GS, Kin& SB III< Oouj;las JR . Shaw RE, St.:rter Sll ,

Myk: r RK : ln-ho8pita l cardiac mortality af\cr aC\dc ciOiiun: after corm.ll')' angiopluty:

Analy•i. of ru k facton from 8,::07 proocdw-es. J Am Coli Cardiol 1988; II :111 -116.

llarw:n DO, Auth OC, Vracko R , Ritchie J L : Rotat tonal athcrcctomy in

a tb::rwdc: I'Oiic r-•hhit iliac a rtcric5.

~ rican

Ucart Journal, VoLI I.S, No. I, Part I,

J.,...ry 1988, 1ti0- 165. 16. Z.cca NM, RaW.:r AE, Noon GP, Short Ill DH, Wdboccbo r OG, Gotto Jr AM , Roboru R: Short tenn follow up of paticnli treated with a rcrently developed rot.atiaul atb:n:ctomy dcvia: and in-vivo auc.umr:nl o( the p;.t rticlc:s &enc:ratcd.

JACC, Fcbtuary 1988, 11 :2. 109A. 8.

O.trc KM , l lolmo& DR, llolubkOY R, C""·lcy MJ, lkouras.<a MG. Faxon DP. llorf'O!J G R. Bentivoglio LG, Kc:nt KM , Mylocr kK an:l co-invc.stigat~ of lhc National , lleart Lt..t& and Blood ln:nitUlcll Pc: rcutancot.t~ Trans lum.i.noll Coronary AJl&ioplasty Rce,istry : lncidc.ncc of comc.quel'lO:S o f p= riproa::dur2l ocdusion: l'hc: 1985-1986 national heart, June and blood in.ititutc p: rcula.JlCOU:'J lr4..n5lurni.n..l l coronary angiopluty regist ry . Ci rculation 1990;8~ : 739--750 . 9.

Serruys PW, Luijk::n HE, Beau KJ ct al : lncidcncc: of re!ok::ll('t!.is afk:: r

~ucce~~ful

coronary

an.giopluty:

tlmc-rc latcd

phenorn:non .

Circulation

17.

Fricdrno.n lfL. Elliot M A, Goulic:.b GJ, O"Nc ill WW: Mccbom.ical rotaty

ath:rcctomy : The c:ffc:cu o f miCTOparticlc c:mboliz.ation on myocard ial blood f1aN and function. Journal of lntc:I"\'CntioNJ Cardio iCJt:Y. Vo lume !, No .

2. 1989.

18. Huchbindcr M . O "Ncill W . Warth U. Zacu N, O.Ctz U, Hc rt r~ M E. Fou.rrie r J L, l....eccl MH : Pc ~ coronary rotational abla tion u:otin& lhc Kotablator : Kc:sult.sofa muhia:ntcr tW y. Circulation. Supplc:mcnt Ill , Octobe r 19'Xl,

Vol 8c, Nwnbor 4, 111-309.

1988;77:361-71. 19.

Brown lUG, Galligan L, Penn IM: Multivc.sc:l PTCA: Do tandem balloon catb:k::rs o ffer any advanta&c over CUlvcntional balloon catb:k::rs? Catb:tcriz.ation ard Cardi.,.--..cula r Diagnoois :J:TI-80 (1991) . 10 .

Bertrand M E, Fourrie r J L. Auth DC, LcBianchc JM , Gummaux AF : C'Ot'Oilat)' rotationa l an&iopluty . In~ T opol EJ. ed . Tc:xtbook of in'-enticnal c•rdioJo&y. Phi ladelphia: W. B. Saundc.,., 1990:580-9. Per~

l:iucbbindcr M, O" Ndll W, W a rth D, 7....aC'C".J N. Dietz U. Be rtrand M E, Pe r<.'\Jl~ corona ry rotalie41al ablation using the: R otabl<o~tor: Rc.•u!L<J of a m uhiccntc r study. CircuJation. Suppk.rn.:.nl Ill , Oct r 1990. II .

f<'IU1'1'ic r J l., Leon MB:

Vol 81, Numbor 4, 111-309.

bEPRE~5 £b

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The Current Status of Cardiac Transplantation by Stuart 1. Smith, M.D. F.R. C. P. (C), Clinical Fellow in Cardiology, University Hospital Over the past 20 years dramatic progr.:ss has occ urr.:d in th.: medical therapy of h.:art failure , artificial c irculatory assist devices and cardiac transplantation . Since 1967 when the first h.:art transplant recipient died 19 days aft.:r transplantation, cardiac transplantation has evolved into an established therapeutic option in the management of end stag.: congestive heart failure (CHF) of NYHA Class III/ IV functional status . The 1 year survival rate has improved from 25 % ( 1970) to 90% (1990), with a 5 year survival of 60-70 %. Through ca rdiac transplantation "survival " as well as the "quality of life " of patients has been improved substantially, with a good cost/benefit ratio.

Improving Morbidity and Mortality Major advance ments in treatment o f cardiac transplantation have led to this procedure being a therapeutic option for end stage CHF. These include: refinements in selection criteria of both Do nors and Recipients; improvements in myocardial protection of the Dono r heart ; long distance procurement of Donor hearts; th.: use of cyc losporine in combination with predni sone and/or azothioprine for immunosuppre ssion; the use of endom)OCardial biopsy in th.: diagnosis o f rejection; and improvement in the treatment of infectious complications secondary to immunosuppression. Despite: thi s, mortality and morb idity remain maj or issues. The major causes of mortality in the first year after transplant are acute graft rejection and uncontrolled in fectio n. Aft.:r the first year, accelerated g raft atherosclerosis (coronary occl usiv.: disease) is the most common ca use of mortality. The proximal and distal coronary arterie s are the most affected, with the atherosc lerosis tending to be diffuse . In many se rics up to 40-50 % of longtem1 survivors show evidence of graft atherosclerosis by 5 years post transplant. Other problems commonly experienced post transplant include impairment of renal function, hypert.:nsion, hyperlipidemia ((50-70 % of patients by 6 months) and wors.:ning obe sity. Most of the se problems are felt to be related to immunosuppressive therapy. Despite these probl.:ms, the majo rity of patients a re well rehabilitated and active within 6 month s post transp lant. Patients r.:quire close follow-up in the first year post transplant , and regular follow-up with inva sive and non-i nva sive rea ssessment each yea r ther.:aft.:r.

Supply and Demand of Transplant Organs Over the la st 10 years, guidel ines for candidate selection have broade ned significantly. Th is has lead to the supply of donor o rga ns being unable to keep up with demand , resulting in longer waiting lists at transplant ce ntre s . Since 1986, the number o f donor referrals in Canada ha s remained relative ly constant , with 150 transplants being perfonned in 1991. In Canada , 10 ce ntres perfo rm cardiac transplants, but only 3 ce ntres perform > 20 heart transplants/yr. As a result. patient s accepted for transplant wait an average o f at least 6 month s to > 1 year. Despite this, > 80 % of patients re ferred fo r ca rd iac

transplant can be stabilized with medications and discharged from hospital to await transplant with a waiting list mortality of 10-20 %.

Management of Eod Stage Heart t'ailure In general, patients with CHF have a poor prognosis . It should be noted however that much of this data has come from retrospective analysis of data from patients referred to tertiary ce ntre s i.e . patients in the late stages of CHF, and in most cases antedating the use o f vasodilators. Over the past 5 years a number o f trials using ACE inhibitors and/or other vasodilators have show consistent benefits in improving survival and symptoms in end stage CHF. Nevertheless the overall prognosis still remains relatively poor. A number of treatment options are available for the management o f end stage CHF. These include : I. 2. 3. 4.

Empiric therapy -eg . ACE inhibitors, Digoxin, Diuretics Hemodynamically directed vasodilator therapy Drug trials Cardiac transplantation 5. New surgical treatments -eg . Cardiomyoplasty

tâ&#x20AC;˘atieot

~ectiou

Criteria

The proper selection o f patients for cardiac transplant is a difficult and so m~time s controversial proce ss. The selection of patient s who a rc "too sick " for transplant is a disservice, both to th~ patient and to others on the waiting list, given the shortage of donor organs and the low likelihood of success. C onverse ly, prcmatur~ transplantation of patients who have been stabilized on m~dic al therapy should also be avoided . Ideally, th.: type o f adult patie nt most likely to benefit from a cardiac

Table. 1: Absolute and Relative Cootraiodicatioos to Cardiac Transplantation - Ull Guidelines Absolute: 1. Active lnf~ct ion 2 . Pneumo nia , r~c.: nt or unresolved pulmonary infarction 3 . Seve re pulmonary hypertension with a fixed pulmonary vascular resistance > 6-8 PW units 4 . History of alc ohol abuse , drug abuse or mental illness 5. Significant systemic disease (eg . malignancy, irrev~rsibl~ renal , hepatic or pulmo nary disease , diabetes mellitus with complications, etc.) 6 . M.:dical noncompliance

Relative: I . Peripheral and/or ce rebral vascular disease 2 . Insulin requiring diabetes mellitus 3 . Recurrent peptic ulcer disease 4 . Obesity - excessive recipi.:nt w.:ight will create a problem in finding a suitable donor and also contribute to post-operativ.: morbidity 5. Ab~ s ncc o f appropriat.: social support

transplant is a young person with stable , symptoma tic end stage heart disease. with a poor prognosis for survival beyond I y.:ar, lacking evidence: of .:nd organ damage beyond that related to impaired cardiac output. The etiology for end stage heart disease is usually due to left ventricular failure secondary to coronary heart disease (48 %) or cardiomyopathy (40 %). Valvu lar heart disease. congenital heart disease and myocarditis account for a small percentage of heart transplants . As in other c.:ntres, most transplant recipients are male (70% male vs 30 % femal e) . While age is not an exclusion criteria, biological ag.: should be considered as w.:ll as chronological age befor.: re ferring a patient for consideration for cardiac transplant. Patients being considered for transplant should hav.: heart failure despite optimal medical and surgical therapy and have a poor I year prognosis . Over 95 % o f patients referred for transplant have NYHA Class III/IV h.:art failure symptoms, while a small number have life-th reatening dysrhythmias (despite anti-arrythmic agents and/or automatic internal defibrillator), or inoperable severe limiting angina . Th.: great variablity in the natural history of these problems and th.: small donor pool argues against cardiac transplantation being a primary treatment option for patients. ~ymptomatic

Summary There is little doubt that cardiac transplantation is a highly effective treatm.:nt for patients with end stage heart failure. As the gap widens between the demand for transplantation and the supply of organ donors ove r the next decade , health ca re workers will be forced to make difficult decisions regarding allocation o f organs. Both quality of life and survival will have to be considered . Efforts must be mad.: to make th.: best use of the donor o rgans available with aims to increase the number of functioning donor organs 5 to I 0 years post transplant. When confronted with sic k cardiac patients difficulty still exists in identifying which patients should rece ive the available organs. No precise formula exists for determining , in any individual patient , sho rt term prognosis or projected survival. In each case, a clinical decision must be based on knowledge of prognostic factors , the experience of the transplant centre and an awareness of current indications and contraindications to transplantation . This information has be.:n defined empirically over the past I 0 y..:ars and constitutes impo rtant guidelines in patient selection fo r cardiac transplantation. â&#x20AC;˘

When to Transplant

Timing of transplant may be difficult in some patients. This is due to many variables in the natural hi story o f cardiac problems requiring transplant. For example, th.: symptoms o f cardiac decompensation in patients with inoperable coronary heart disease remain quite stable , unless th.: patient suff.:rs a further ".:vent " which can lead to either furth.:r myocardial damage or mor.: likdy death . In contrast, patients with dilated cardiomyopathy haw a variabl.: course with periods of stability, decompensation and even improvement o f sympto ms. Laboratory investigations such as MUGA sca ns (EF <20 %) , treadmill testing , etc. are gen.:rally useful for identi fying pot.:ntial patients fo r transplant, but are unhelpful in identifying patients who arc likely to deteriorah: in the ncar future or experienc.: cardiac death . Careful follow-up o f heart failure patients is still the best method in which to dec ide on necessitation of transplantation . Typical highe r risk patients d.:monstrate progn: sion o f sympto ms, clinical or hemodynamic instability on ma ximiz.:d medical therapy (digoxin, diuretics, and vasodilator combinations), o r continued escalation in diuretic need s owr time . G..:nerally accepted indicators are a poor I year surv iva l of NYHA Class rv functional status, maximum oxygen uptake with e xercise o f < 14 ml oxygen/ kg/ min , the presence o f progressive cardiac cachexia , elevat.:d ncuro.:ndoc rinehormones and th.: presence o f high grad.: ventricular dysrhythmias . As patient survival has improved over th.: pa st decade, exclusion crit.:ria for cardiac transplant have been g radually modified or eliminated . The existcnc.: o f absoluto: and relative contraindications to cardiac transplant can vary between centre s. The fo llowing is a guideline of contraindications used at University Hospital , London , Ontario (fable 1):

Suggested Readings: I. L.W. Stevenson and Leslie W. Miller; Cardiac Transplantation as Therapy for Heart Failure; Current Problems in Cardiology, Vol. XVI , No. 4 , (April 1991 )

2. R. Pifarre et at ; Cardiac Transplantation . Cardiology Clinics : 7:183- 194 (February 1989) Pet.:r M . Scho field; Indications for Cardiac Transplanta3. tion: Br. Heart J . 65 :55-56 (1991 ) L.W. Stevenson et al ; Decreasing Survival Benefit from 4. Cardiac Transplantatio n for Outpati..:nts as the Waiting List Lengthens: JACC 18:919-925 (October 1991)

5. L.W. Stevenson; Tailor.:d Therapy Befo re Transplantation for Treatment o f Advanced Heart Failure : Effective Usc o f Vasodilators and Diuretics : J . Heart and Lung Transplant 10 :468-476 (May/June 1991 ) 6. Conside rations Fo r Cardiac Transplantation - University Hospital Guidelines ( 1992). Availabl..: from Dr. W.J . Kostuk , Cardiac Investigation Unit , University Hospital , London, Ontario. Organ Donation: A Practical Guide ( 1991 ) . Available 7. from Du Pont Pharrna. Mi ssissauga, Ontario.

Limiting Myocardial Reperfusion Injury Current Concepts and Future Directions by Morris Kannazyn , Ph.D. Professor, Depa11me111 of Phamwcology and Toxicology. Unil路usity of Wesiem Omario

Mechanisms aud Therapeutic Interventions Timdy rcperfu sio n o f the ischemic myoca rdium represent s o ne of the most impo rtant procedures aimed at salvaging myoca rdial tissue fo llowing infarction. a fa ctor which reflect s increased availability o f reperfusio n proc edure s including thrombolysis, angioplasty and coronary rcva sc ularization (2,3.7,15 , 18). Despite the potential promise o f reperfusion, substantial evidence has been presented in rece nt years that reperfu sio n actually represents a double-edged sword such that re sto ration of coronary blood flow can produce a paradox ica l extension and excac erbation of already-exi sting tissue damage . This damag.: can manifest itself either as irreversible ce ll necrosis or a reversible but prolonged derangement o f contractile function , a pheno menon termed myocardia l "stunning" (2 ,4.15 , 18). The importance of this phenomenon is now wdl-recognized and has led to ext.:nsive research aimed at understanding the mechanisms underlying such injury as well as to the devd opment oftheraupeutic approaches , such as adjunct therapy to reperfusion or improvement o f ca rdioplegi c solutions. The mechanistic basis fo r myoc ardial repcrfu sion injury is poorly understood , particularly because o f the complex nature o f the phenomenon which involves numerous processes ac ting in concert to produce cdl damage . Th is review will concern itself with di sc ussing selected aspects o f myocardial repafu sion injury with particular emphasis on pot.:ntial mechani sms and approaches aimed at attenuating this form o f myoca rdia l dys function .

Nature of Myocardial Reperfusion Injury Extensive labo ratory investigation have doc umented complicated manifestations of myocardial reperfu sion injury. These include impaired systolic and diastolic function. numerous biochemical derang.:m.:nts. electrical disturbance s, as well as ultrastructural damage (2,4 , 10 , 11-19.23.24 ,26,28 ,32). The se defects arc most likdy interrelated . For .:xample. inability to replete high energy phosphates , particularly ATP. after re sto ra tion o f fl ow along with con omitant d evation in intracellular ca lcium l.:vel s contribute to mechanica l and electrica l dysfunction as well as morphologica l changes se.:n in the repertused myoc ardium . In the laboratory setting, reperfusion injury can be readily produced using various experimental procedure s such as isolated cardiac tissue preparations or in various modds of myoca rdial ischemia and reperfusion in vivo. A prerequisite for such injury is th at the initial ischemic episode is o f sufficient duration as to reveal dysfunction followi ng re storation o f fl ow . Clinically, the existence of myoca rdial reperfu sion injury is mo re difficult to demo nstrate particu larly with regards to morphological and biochemical ab normalities. No neth.:l.: ss. there is substantial evidence for this phenomenon particularly with electrocardiographic demonstration o f rhythm disturbances following resto ration of fl ow as well as augmented enzyme rdea se. indicative o f mu scle nec rosis (6 ,8,21,25.27.33).

Although the precise mechanisms arc poorly understood, there is substantial evidence regarding some of the key cellular ev.:nts which account for reperfusion inj ury and as a corollary, approache s which could be used to minimize injury by targeting thes.: process.:s . Irrespective of the precise mechanism, it is widdy felt that the final mediator of cell injury or cell death is elevation of intracellular calcium leading to disruption o f cellular hom.:osta sis. Indeed , it ha s been demonstrated that calciu m channel bloc king age nts such as verapamil and dihiazem o ff.: r protectio n against repcrfu sion injury when administered prior to restorati on of flow (2 , 15) . One of the most intensive areas of research involves the role of rcactiv.: oxyge n species , particularly oxygen free radicals in reperfusion injury (18 ,22) . By vi rtue of the fact that they possess an unpaired electron, these compounds, which include the supe roxidc anion and the hydroxy l radical , are highly reactive with cell m.:mbrane constituents such as phospholipids r.:sulting in lipid peroxidation and membrane damage (18). h has been demo nstrated extensively that these products produce substantial cell damage when administered to cardiac preparations (I , 18) . Free radicals can be produced both by activat.:d neutrophils accumulati ng in the infarcl region or by the heart itself ( l8 ,24) . With respect to the former. a numberofinvestigators have d.:monstrated that neut rophil depletion o r prevention o f n.:utrophil ac tivation o ffer bene fi cial effects in reperfusion injury (24). Int racardiac free radi al production can occur via the degradation o f ATP during ischemia thereby providing substrates fo r th.: enzyme xa nthine oxidase. Thi s enzyme cataly7.cs the production o f superoxide anion during the reintroduc tion o f oxygen upon reflow ( 18) . Aside from the well documented ability o f oxyradicals to damage the heart , their role in r.:p.:rfusio n injury is also based on their detection in the rcpe rfu sed myoca rdium ( 18). As we ll , the administration of fr.:e radica l scavengers such as supcroxide dismutase (SOD), which scave ng.:s the superoxide anion. catalase and allopurinol. a xa nthine oxidase inhibito r. confer p rotection particularly against reversible dysfunction such as that seen with myoca rdial "stunning " ( 10. 11.18.19 ,22,26) . Other investigators, how.:ve r, have failed to demonstrate prot.:ction usi ng anti-free radical interventions . Thi s is likely is a reflection o f the complexity and diversity of mechani sms involved in the generation o f this forn1 of injury (I 8) . The importance o f reactive oxygen species to reperfusion inju ry may represent the ba sis for cardiac protection obse rved following induction o f so~alled heat shock or stress proteins prior to isc hemia and reperfusion (5.16) . The synthesis o f thi s family of proteins is increased following introduction of various stressors. such as hyperthe rmia , and is thought to bestow subsequent cell p rotection against diverse forms of ti ssue inju ry. Interestingly, induction of stress proteins 24 hours prior to ischemia confers substantial protection against repe rfu sion injury in the heart . a phenomenon most likely mediated by enhanced intracellula r content of catalase (5 . 16). Although still

an experimental observation, pre-induction of stress proteins could represent a novel approach to improve myoca rdial salvage in patients undergoing reperfusion proto.:ols. Although the above studies deal primarily with experimental observations, it is pertinent to point out that c linical evidence of lipid peroxidation by free radical s has recently been de mo nstrated in patients with suspected acute myocardial infa rc tion, thus implicating spontaneous reperfusion as a factor contributing to myocardial injury in these patients as we ll as a role for free radicals in production of such injury (34) . Cellular processes which normally function to ma intain no rmal intracellular homeostasis also likely contribute to myocardial reperfusion injury. For instance, although v irtually all cells produce numerous products fro m the metabolism of arachidonic acid , one of these groups o f compounds, the prostagla ndins (PGs), may contribute to injury associated with rcpcrfusion which is a potent stimulus for their production (12, 14) . Moreove r, studies have shown that non teroidal antiinflammatory drugs such as aspirin , indomethac in o r ibupro fen , all of which inhibit PG biosynthesis, also allcnuate myoca rdial reperfu sion injury, whereas PGs themse lves increase the severity of such injury (12,14, 17) . Inte restingly, clinical n:ports have demonstrated a significant reduction in mortality fo llowing coronary thrombolysis with streptokinase in pat ients who al so received adjunctive aspirin therapy (9). Whethe r this salutary effect was due to inhibition of repe rfusion injury is unce rtain , since an alr.:mate explanation may invo lve asp irinmediated inhibition of reocclusion as a result of inhibition o f platelet aggregation (29). A most inten:sting approach aimed at further understand-

ing mechani sms of myocardial repe rfusion injury as w.:ll the development o f approac hes aimed at minimizing such injury involves the role o f the sodium/ h)drogen exchanger. This exchanger, located in the cell membrane in virtually all tissues, represe nts the primary mechani sm fo r restoration of nom1al pH following intracdlular acidification such as may occur during myocardial ischemia (20) . Thus, this system serves to extrude protons in exchange fo r sodium which enters the cell. Although the system is c ritical for intracellular pH ho meosta sis, a paradoxical detrimental effe ct ca n occur by the concomita nt entry o f sodium which can produce a sub sequent elevation of intracellular calc ium via anothe r membra ne system, called the sodium/calcium excha nge (32). It is widely believed that the sod ium/h)drogen excha nge r is rapidly activated upo n n:pcrfu sion o f the ischemic myoc ardium and studies have shown a concomitant rapid devation of both sodium and calcium during ea rly reflow which can be allcnuated by sod ium/h)drogen exchange inhibition (20,32) . Indeed, pharmacolog ica l studie s with sodium/h)d roge n exc hange inhibitors, such as the pota ssium-sparing diuretic amiloride , o r various amiloride analogues which are more potent and selective inhibito rs of sodium/h)drogen exchange, have n:v.:al.:d substantial protection of the rcperfused myoca rdium ( 13 .23 .32). Moreove r, it is interesting that sodium/h)drogen exchange n:presents a n important mechanism for activation of various blood cell constituents which likely also contribute to reperfu sion injury, includ ing neutrophil s and platdets (30,31 ) . Thus, the use of sodi um/h)drogen exchange inhibitors offers the allractive possib ility of effective allenuation of reperfusion injury th rough simultaneous inhibition of various processes

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known to participate in this type of cardiac damage.

Summary and Conclusiom The above discussion is not meant to repr~sent an exhaustive description o f myocardial rcperfu sion injury. which is comp l~ x and multicausal in nature . Thu s, many potentially important aspects with regards to mechanisms or therapeutic app roac he s were, of necessity, omitted . The study of myocardial reperfusion injury represents one of the most active areas of ca rdiova scular r~searc h since it is likely that improved app roaches aimed at minimizing such injury will exert a favourahlc effect on prognosis in ca rdiac pat ient s und.:rgoing rep.:rfusion protocols. For a more in-depth treatment of thi s top ic. various reviews are suggested (2.3 .4 .7,15 , 18). â&#x20AC;˘

)

Acknowledgements R~ searc h

from the author 's laboratory is support.:d by grants from the Heart and Stroke Foundation of Ontario and the Medical Research Council of Canada . The author is a Career Investigator o f the Heart and Stroke Fou ndation of Ontario.

References I . Basu DK , Karmazyn M : Injury to rat h.:arts produced by an exogenous free radical generating system. Study into the rok of arachidonic acid and eicosa noids. J Pharmacal Exp Tha 242 : 673-685, 1987. 2 . Becker r~pafusion.

LC , Ambrosio G : Myoca rdial consequenc.:s of Progr Cardiovasc Dis 30 : 23-44. 1987.

3 . Braunwald E: Myoca rd ial reperfusion, limitation of infarct siz.:, reduction of lefl ventricular dysfunction , and improved survival. Sh ould the paradigm be extend.:d? Circulation 79 : 441 -444. 1989. 4. Brau nwald E. Kloner RE : The stunn.:d myocardium : prolonged, postischemic v~ntricula r dysfunc tion. Circulation 66: 1146- 1149,1982 .

5. Currie RW, Karmazyn M , Kloc M , Mailu KM : H.:at-shock response is assoc iated with enhanced postischemic ve ntricular recov.:ry. Circ Res 63 : 543-5 49, 1988 . 6. Forman MB, Perry JM , Wilson BH. Verani MS , Kaplan PR , Shawl FA . Friesi nger GC : De monstration o f myoca rdial reperfusion injury in humans: Results of a pilot study utilizing acute coronary angioplasty with perfluochemica l in anterior myocardial infarction. J Am Coli Cardiol: 18: 91 1-918 , 1991 .

Dr. Jack Sales . Urologist. St. Joseph 's Health Cmtu

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7. Ganz W: The que st for the ideal repafusion strategy continue s (editorial) . Circulation 83 : 1818- 1821 , 1991 . 8 . Goldbe rger S, Greenspan AJ . Urhan PL , Muza B, Berger B, Walinsky P. Maroko PR : Reperfusion arrhythmia: a marker of re storation of ante grade flow during intracoronary thrombolysis for acute myocardial infarction. Am Heart J 105 : 26-32. 1983 9. ISIS-2 (Second Internat ional Study of Infarc t Survi val) Collaborative Group : Randomised trial of intravenous streptokina se, ora l aspirin , both , or neither among 17 187 cases

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of susp~ct~d acute myocardial infarction . 1988 .

Lanc~t

ii : 349-360,

10. Jolly SR, Kane WJ , Bailie MB, Abrams GO. Lu cch~si BR : myocardial reperfusion injury. Its reduction by th.: combined administration of superoxid.: di s muta s~ and catalase . Circ R~s 54: 277-285 , 1984 . Canin~

II. Johnson DL, Homeffer PJ, Dinatale JM, Gon VL , Gardn.:r TJ : Free radical scavengers improv.: functional recovery of stunn~d myocardium in a model of surgical corona ry revascularization . Surgery 102 : 334-340, 1987. 12 . Karmazyn M : Contribution of prostaglandins to reperfu sion-induced ventricular failure in isolated rat h~ans . Am J Physiol251 : HI33-HI40, 1986 . 13 . Karmazyn M : Amiloride enhances post ischemic ventricular recovery : possible role of Na '/H • exchange . Am J Physiol 255: H608-H615, 1988 . 14 . Karmazyn M : Synthesis and relevance of cardiac eicosa noids with particular emphasis on ischemia and reperfusion. Ca J Physiol Pharmaco167: 912-921 , 1989 . 15. Karmazyn M : Ischemic and rep.:rfusion injury in the heart. Cellular Mec hani sms and pharmacolog ical interventions . Can J Physiol Pharmacol. 69: 719-730, 1991 . 16 . Karmazyn M , Mailer K, Currie RW : Acquisition and decay of heat -shock~d enhanced postischemic ventri ular recov~ry . Am J Physiol 259 : H424-H431. 1990. 17. Karmazyn M , Nedy JR: Inhibition o f postisc hemic ventricular recovery hy low concentrations of prostacyclin in isolated working rat hearts. Dependency on concentration, ischemia duration . ca lci um and rdationship to myoca rdial energy metabolism . J Mol C.:ll Cardiol 21: 335-346, 1989. 18 . Kl oner RA , Przykknk K, Whinaker P: Deleterious effects of oxyge n radicals in ischemia/ r.:p.:rfusion . Resolved and unresolved issu~s . Circulation 80: 1115- 1127. 1989 . 19 . Lasley RD , Ely SW. Bern.: RM , Mentzer Jr RM : Allopurinol enhanced adenine nuc leotide repl.:tion after myoca rdial ischemia in the i solat~d rat heart . J Clin lnv.:st 81 : 16-20. 1988. 20 . Lazdunski M , Frdin C, Vigne P: The sodiumlh)drogen exchange system in ca rdiac cells: it s biochemical and phannacological propertie s and its role in r~gulating internal concentrations of sodium and internal pH . J Mol Cdl Cardiol 17: 10291042. 1985 . 21. Lockerman ZS, Ros.: OM, Cunningham Jr JN , Lichstein E: Reperfusion ventricular fibrillati on during corona ry artery bypass op~ra ti o n s and its association with postoperative enzyme release. J Thorac Cardiovasc Surg 93: 247-252, 1987 . 22 . Maza SR. Frishman WH : Th~rapeutie options to minimiz.: fre~ radical damage and thrombogenicity in sc hemic/ reperfusedmyoca rdium . Am Heart J 114 : 1206- 1215 . 1987 .

23 .

M~ng

H-P, Pie rc.: GN : Protec tiv.: effects o f 5-(N,Non ischemia-reperfusion injury in hearts . Am J Physiol 258 : HI615-HI619 , 1990.

dim~lhyl }a miloride

24 . Mullane KM , Westlin W, Kraemer R : Activated neutrophils r.:kas.: mediators that may contribute to myocardial injury and and dys function associated with ischemia and reperfusion . Ann NY Acad S c i~nces 524 : 103- 121 , 1988 . 25. Nienabe r CA , Brunken RC, Sherman CT, Yeatman LA , Gambhir SG, Krivol.:apich J, Dem.:r LL, Ratib 0 , Child JS , Phelps ME. Schelben HR : Metabolic and functional recove ry of ischemic human myocardium after coronary angioplasty. J Am Coli Cardiol 18 : 966-978. 1991. 26 . Prqklenk K, Klona RA : Superoxide dismutas.: plu s catalas.: improv~ contractile function in the canin.: model of th~ "stunned myocardium" . Circ Res 56 : 148-156 , 1986. 27. Rubin DA , Ni~mins ky KE, Monteferrante JC, Magee T , R~cd GE , H~nnan MV: Ventricular arrhythmias after coronary artery bypa ss graft surgery : incidence, risk factors and longh:rm prognosis. J Am Coli Cardiol 6: 307-310, 1985 . 28. Schaper J, Schaper W: Reperfusion of ischemic myocard ium: Ultrastructural and histoc hemical asp~cts . J Am Coli Cardiol 1: 1037- 1046, 1983. 29 . Shi Y. Zalewski A, Walinsky P, Goldberg S : Does antiplatelet therapy enhance myoca rdial salvage after coronary r~p.:rfusi on ? J Am Coli Cardiol 15 : 1662- 1666 , 1990. 30. Siffen W. Siff~n G. Scheid A, Akk~rman JWN : Activation o f Na '/H · exc hang~ and Ca' • mbilization stan si multaneously in thromhin-stimulated platelets. Bioc hem J 258 : 521 -527, 1989 . 31. Simchovitz L, Roos A: Regulation of intracellular pH in human neut rophils . J Gen Physiol 85: 443-470, 1985 . 32 . Tani M. N~ely JR : Role of intracellular Na ' in Ca' · overload and depr~ss~d recovery of v.: ntricular function of r~perfu sed isc hemic rat hearts. Possible involvement o f H • -Na • and Na '-Ca' ' ~xc hang~. Ci rc R~ s 65 : 1045-1056, 1989 . 33 . van der Laars~ A, van der Wall EE, van den Pol RC , Ve rn1eer F. Verheugt FWA , Krauss XH, Bar FWHM , Hermens WT, Willems GM, Simoons ML: Rapid .:nzyme r~h:ase from acutely infar~ ted myoca rdium after early thrombolytic therapy: Washout or reperfusion damage? Am Heart J 115 : 711-716. 1988 . 34 . Weitz ZW, Birnbaum AJ , Sobotla PA , Zarling EJ . Skosey J L: High hreath pentane conce ntrations during acute myocardial infarction . Lancet 337 : 933-935. 1991.

The Preoperative Assessment and Postoperative Management of Cardiac Patients Undergoing Noncardiac Surgery by Kevin M. Deitel, Faculry of Medicine , Medical College of Wisconsin

Pati~nts

with cardiac disease may have a limited ability to

respond to the hemodynamic and m~tabolic stresses of surgery and anesthetic. The pain , volume loss, and stress of surgery lead to increased myocardial oxygen demand . Increased oxygen demand in these patients occurs secondary to compensatory c hang~ s rdated to sympathetic nervous system stimulation and to increasing myocardial contractility (Starling 's Law). This may have ominous consequences for patients with already compro mised cardiac function . In light of these potential risks, the preopl!rativ.: assessment of ca rdiac patient s undergoing no nca rdiac surgical procedures serves thl! following purposes: (i) To predict the risk of cardiac complications prior to surgery; (ii) To formulate preop.:rativl!. perioperative and postop.:rative management strategil! s to minimize ca rdiac risk; (iii) T o det~rmin~ which complic ations are most likely to occ ur during the postoperative period so that early detection and intervention may occu r. The overall goal of preoperative assessment is to mini mize ca rdiac morbidity and mo rtality for surgica l proc~dures .

Preoper ative Evaluation HistOI)', Physical Eraminarion, and utboratOI)' Testing The hi story should include the following sy mptoms o f heart disease: chest pain , dyspnea , palpitations. exercise tolerance, cough , hemoptysis . .:dema. dizziness or syncope. As well , documentation of a past hi story of myocardial infarction (Mij or othe r cardiac disease should be obtained . A current list of the medications the patient is taking should also be obtained as they may affect card iovasc ular hemodynamics during su rgery. A comp kte ca rdiova sc ular examination must be done. The exam is directed towa rd ass.:ssing the ri sk for coronary artery disease, hypertension. valvular dis.:asl!. congenital heart disease. arrhythmias. and congestive heart failure . Labo ratory studie s shou ld include co mplete blood count. se rum electrolytes, glucose , BUN , and creatinine. In addition. chest roentgenograms and an electrocardiogram should be obtained on all patients over 40 yea rs of age or when it is appropriate in younger patients. The resu lts of the se tests may indicate the need for further preoperative investigation . sugg~stive

111e UWO Medical Journal encourages submissions from other medical schools as a means offosrering rhe exchange of information and communication berween di.fferem medical faculties. Kevin Dei tel is a studem of Medicine at rhe Medical College of Wisconsin who will be graduating in 1992. Mr. Deirel intends to specialize in orthopaedic surgery. â&#x20AC;˘

luOueoce of Underlying Cardiovascula r Disease Ischemic Heart Diseau Isc hemic heart disea se is a major determinant of periope rative morbidity and mortality. Several stud ies have shown that the earlier noncardiac surgery is performed after an MI. the greater the morbidity and mortality. Various studies reveal.:d that patients who were ope rated on within 3 months of an Ml had a 30% risk of rl!infarction o f cardiac death . These risks fo r surgery performed 3-6 months and greatl!r than 6 months post -M I were 15 % and 5 %, respectively' 1 â&#x20AC;˘ More recent studies on surgery using invasive hemodynamic monitoring and regulation of oxygl!n, <!lectrolytes, volume, and he malo.: rit hav.: shown a substantial reduction in reinfarction rates to 6 II'Âˇ within 3 mo nths after a preoperativ.: Ml and 2 % from 3 to 6 months post-Mr. In patients with life threatening conditions which require emergent surgica l intervention (e .g . ruptured aortic aneurysm , perforated , necrotic or obstructed bowel , or life threateni ng hemorrhage) su rgery must be performed regard less o f the patient's operative risk. Elective surgery should be delayed to 6 months post-MI , when the ri sk o f reinfarction and ca rdiac death is n1inin1izcd . In some situations survival does not depe nd upon immediate su rgica l intervention. but prolongationofint.:rvention may endangerthe patient 's lifl! . An example of th is is a patient with a re sectable neoplasm . Deferring surgery b.:cause of cardiac risk may allow a newly diagnosed tumour to enlarge , invade, or metastasiz.:, rl!sulting in a worse prognosis . In this situation, since full healing of an Ml takes 4-6 weeks. one approach is to have the patient undergo post-M I prognostic testing , suc h as a sub ma ximal exercise stress t.:st 6 weeks afte r the event' . This testing allows electrocardiog raphic evaluation of the patient's response to moderately inc reased myoca rdial activity . Results of this test may indicah: whether the patient shou ld go to surge ry or defer until a later date.

Hypertension Studies have shown that hype rtensive patients have an inc reased risk of cardiac complications during o r shortly after surgery than normotensive patients. This increased risk. however. can be attributed to a greater prevalence of ischemic heart disease. left ventricular dysfunction. re nal failure, and other abnonnalities in hypertensive patients. In patients with mild to moderate hypertension (diastolic pressure < 110 mmHg) and no evidence of serious end orga n damage , general anesthesia and major noncardiac surgery are well tolerated'.

Valvular Heart Disease In undergoing anesthesia and surgery, patients with valvu lar heart disease have the potential risks of heart failure , infection, tachycard ia and thromboembolization. The lesions and their hemodynamic significance, the need for antibiotic

TABLE 1: COMPUTATION OF THE CARDIAC RISK INDEX Assessment Technique

Risk

Points

History

a) Age > 70 years; b) MI in previous 6 months.

5 10

Physical Exam

a) S3 gallop or JVD; b) Significant aortic valve stenosis.

11 3

a) Rhythm other than sinus or PAC on last preoperative ECG; b) > 5 PVCs/rnin any ti me pre-operatively.

Electrocardiogram General Status

Operation

p02 < 60 or pC0 2 > 50 mmHG; K < 3.0 or HC0 3 < 20 meq/L; BUN > 50 or Cr > 3.0 mg/dL; abnormal SGOT; signs of chronic liver disease; or patient bedridden from noncardiac causes. a) Intraperitioneal , intrathoracic, or aortic operation; b) Emergency operation. Total Possible Points

3 3 4 53

ABBREVIATIONS: Ml, myocardial infarction; JVD, jugular venous di stension; PAC, prematur..: atrial contractions; PVC, premature ventricular contractions; pO,, partial oxygen pressure ; pCO, , partial carbon dioxide pressure ; K, potassium; HCO,. bicarbonate; BUN, blood urea nitrogen; Cr. creatinine ; SGOT, serum gluatamic oxalacetic transaminase . (Adapted from Goldman L., et al.)'

prophylaxis for endocarditis, and th..: ne..:d for anticoagulation should b..: assessed prio r to surgery. Th..: cause and severity of va lvular disease may b.: clarified by two dimensional and Doppl.:r ..:choc ardiography or by cardiac cath..:t..:ri7..ation. Pati..:nts with minimal limitation in their physical activity du.: to angina (i ..:. N.:w York Heart Association (N YHA) classes I and II) require antibiotics for infectiv..: ..:ndocarditis but typically tol.:rate surg..:ry well'"9 . Howeve r, pati..:nts with a more serious impairm..:nt in their cardiac function (i.e. NYHA classes III and IV) tol..:rah: major surg..: ry poorly and hav.: a much wors..: prognosis 3 · ' 0 • Patients with symptomatic aortic or mitral stenosis a rc ..:sp..:cially pron..: to sudd.:n death o r acute pulmonary ed.:ma perioperativcly. The se complications can be precipitated by inc r.:a sed d.:mands on the cardiac output or if atrial fibrillation with a rapid ventricular rate occ urs. Such va lvu lar lesions should b.: corrected surgica lly or by va lvuloplasty prior to und.:rgoing surgery". Valvular di scas..: patients in s.:vere failur..: who r..:quir.: emerg.:ncy su rgery may b.:n..:fit from intraoperativ..: h.:modynamic monitoring. aftcrload reduction, and prd oad augtn..:ntatio n 1:

Pati..:nts with m..:chanical prosth..:tic valves a r.: chronically tr.:at..:d with anticoagulants to prevcntthro mbo..:mbolic complications. Oral anticoagulants (i.e. warfarin) should be discontinued 1-3 days preop.:ratively and resumed 2 days postoperatively,

achieving a prothrombin tim.: within 20 % o f normal at the time o f surgery". Other strat.:gi..:s add to the above regimen full dose intravenous h.:parin until six hours preoperatively, resuming 12-24 hours postop.:rativety•. Cong~srive

Hean

Failur~

Co ngestiv.: h.:art failur..: is a maj or d..:h:rminant o f perioperative risk. Mo rtality is incr..:ased with worsening card iac cla ss10 · " , and with pulmonary congestion , especially when a third heart sou nd is audible'·' 6 • Perioperative mortality is related to the patient's condition at the time of surgery, not to th..: most seve re depression in ca rdiovasc ular status that the patient ha s ever expcrienc..:d . Thu s, aggressive tr..:atm..:nt of congestiv..: h..:art failure prior to surgery is impo rtant. Care should be taken to avoid hypovolemia and hypokalemia which may result from diur.:tic th.:rapy.

Arrhythmias Supraventricular and ..:sp.:cially ventricular arrhythmias may r..:O.:ct und.:rlying heart disease. These arrythmias have been ind.:pcnd..:ntly assoc iated with increased perioperative riskJ.al .

Atrial arrhythmias are often a manifestation of atrial

enlargement. A supraventricular rhythm other than sinus is a risk factor for perioperative complications'. The risk, however, seems to be more related to the underlying ca rdiac disease than to the arrhythmia itself. Therefore , patients with well controlled atrial fibrillation do not need to be cardioverted for elective noncardiac surgery if such management was otherwise not appropriate. Similarly patients with conduction defects such as bundle branch bifa sc icular or trifascic ular block , who are asymptomatic, ar.: not more likely to have advanced or comp lete heart block during noncardiac surgery" . Another conduction disturbance to consider as a cardiac risk in su rge ry patients is premature ventricular contraction (P.V.C.) . The frequency of P.V .C .'s correlates with left ventricular dysfunction and th.: severity of coronary artery disease"·". Patients with P. V .C. ·s in the absence of underlying heart disease , however, are not at an increased risk of cardiac complications'•. Complex P. V .C. "s (greater than five per minute , multifocal , in runs of two or more. or of R on T phenomenon) in a patient with a histo ry of symptomatic ventricular arrhythmias should be considered for prophylactic intravenous lidocaine prio r to surgery.

Preoperative Testing Exercise treadmill or bicycle testing arc objective and no n-invasive methods o f assessing exercise toleranc.: and thus myoca rdial reserve. These tests arc particularly useful when the patient"s history of ischemic hea rt disease is unreliable . In the se te sts, the patient walks on a treadmill or rides a bicycle while heart rate and blood pressure arc recorded . Using standard tables. the product of heart rate and blood pressure arc conve rted into metabolic units (METS) . During this procedure , an electrocardiogram is being monitored for changes indicating isc hemia . In studies on patients over 40 years of agc"2 and 65 years of age" , the inability to perform two minutes of exercise at a heart rate great.:r than 99 beats per minute was an independent predictor of cardiac complications in noncardiac surgery. Some patients, however, have physica l limitations which do not allow them to perform exercise testing . These limitations include peripheral vascular, orthopedic or neurologica l diseases. advanced age or deconditioning . In these cases. dipyridamo le (persantine) thallium imaging studies are usefu l in identifying general and vascular patients at a high ri sk for postoperative M I o r cardiac death24 ·" . Intravenous dipyridamole causes a

graft (CABG) procedure. Mortality assoc iated with a CABG was 1.4 %. Thu s, the group having a prior CABG and then elective nonca rdiac surgery had an estimated total mortality of 2 .3% compared with 2.4 % in the group not having a CABG . Th~ risk o f MI wa s not significantly different between the two groups 16 • That is, th.: data from this study does not support prophylactic CABG in patients prior to undergoing declive nonca rdiac surgery .

Posto perative Management Myocardial infarction during o r aft.:r surgery may be precipitated by tachycardia, hypoxemia, hypotension , hemorrhage , o r a low cardiac output. The time of onset of perioperative Ml's reflects the tendency for postoperative medical and su rgical problems to precipitate cardiac complications . Within the first three postoperative days , 60 % of Ml's occur. The remaining 40% of Ml's occurs mainly between the fourth and sixth postoperative days"- Postoperative Ml 's may be related to stresses including su rgical complications, hypoxia and other pulmonary complications, mobilizing intraoperative fluid leading to fluid and electrolyte abnormalities , inadequate analgesia l.:ading to inc reased catecholamine release and postoperative ambulation. The following may be implemented to reduce the incidence of postoperative MI's in high risk patients . I)

dc:crl.!asc in coronary vascular rcsistanc.: and an incn:as.: in

coronary blood flow. Areas supplied by stenotic arteriosclerotic vessels, however, do not show a hype remic re sponse. The variab le uptake o f thallium by myocardial ce ll s results in hypope rfu sion defects which are reversible on sub sequent delayed images. In thi s manner, ischemic heart disease can be assessed . Therefo re , considering a patient's clinical history suppleme nted by exercise or dipyridamole thallium testing is an dfective manner of identifying patients at high risk for cardiac complications of noncardiac su rgery. In patients with a severe limitation in phy sica l activity due to angina (i.e. NYHA classes Ill or IV) coronary arteriography should be done in ordu to ass.:ss the coronary vasculature . Revascularization procedures such as coronary angioplasty, corona ry athercctomy or coronary artery bypass grafting should be considered prior to elective non-c ardiac su rguy in these patients. The Coronary Artery Surgery Study (CASS) found a 2.4 % operative mortality rate in patients with sevuc coronary artery disease undergoi ng elective noncardiac surge ry. There was only .9 % mortality in patients who had a prior corona ry artery bypass

The patient shou ld b~ followed for at lea st six days postoperatively due to the time course of Ml's . Myoca rdial oxyge nation should be maintained by increased inspired oxygen tension, and by avoiding atelectasis by coughing and deep breathing exercises such as incentive spirometry. Prophylactic anticoagulation with low dose heparirP and the usc of lower extr~mity stockings or sequential compre ssio n devices to reduce the occurrence of deep v.:nous thrombosis and thromboembolic complications . Monitoring patients at high risk for MI in the intensive ca rdcardiac ca re unit postoperatively. Invasive hemodynamic monitoring may be used. Obtaining an ~arly postoperative electrocardiogram and anoth.:r on the third to fifth postoperative day. Patients at particularly high risk o r those having symptoms of ischemia should have electrocardiograms more frequently . Cardiac ~nzymes and isocnzymes should be obtained if the patient ha s postoperative arrhythmias, hypertension, hypotension, or alte red mental status . Up to one half of postoperative MI's are painless"·" .

Cardiac Risk Index Since th.:rc ar~ many potential causes of perioperative ca rdiac complications , a multifactoria l index to assess risk was designed by Goldman et al, in 1977'. Multivariate analysis of 39 variables on I 00 I noncardiac surge ry patients ove r 40 years of age revealed nine variables that had statistically significant and independ~nt predictive value for perioperative cardiac ~vents. A point system was derived for each variable to reflect its statistica l weight in the analysis. From the total number of points , a preoperative cardiac risk index with four classes was made (Table I). In the study, there were a total of I .9% postoperative ca rdiac deaths and 3 .9 % had one or more lifethreatening cardiac complications (perioperative pulmonary edema , MI o r ventricular tachyca rdia) without cardiac death .

cardiac risk ind~x corrdated wdl with cardiac events. Class I (0-5 points) had .9 % cardiac .:vents; Class II (6- 12 points), 7 %; Class III (13-25 points), 14 %: and Class IV, 78 %. Further studie s validated these findings"", revealing a clear difTer~nc~ in perioperative risk h~tw~cn classes I and II and classes III and IV. Studi.:s applying the cardiac risk index to major intrathoracic. upp~r abdominal or great v~ssd surgical proc edures showed significa ntly highe r rates o f cardiac complications' ·" ·". Preoperative cardiac risk indic~s arc us.:ful in identi fying patients at high ri sk for cardiac events. A low cardia risk index score docs not .: xc lude a patient from periop.:rativ.: risk hut rather indi c at~s low probability. The magnitud.: of the surgical procedure, the su rgical and anesthetic ~xpertise, and the patient population must also be considered in assessing risk . A ca rdiac ri sk inde x shou ld be viewed as an aid which is a suppl.:ment , but not a substitute for cli nical judgement. • Th.:

pr~op~rative

subs~quent

References I.

7. 8.

Steen P.A., Tinke r J .H. , & Tarha n S. Myocardial reinfarction aft~r anesthesia and surg.:ry. lAMA 239:2566 ( 1978). Tarhan S., Molin E.A., Taylor W.F., & Gui lioni E .R. Myoca rdial in farction after general anesthesia . lAMA 220:1451 (1972) . Go ldma n L., Caldera D.L., Nussbaum S.R ., Southwick F.S., Krogstad D., Murray B.. Burke D.S .. O'Mall.:y T .A., Go roll A.H .. Caplan C .H. , Nolan J ., Carabel lo B., & Slat.:r E. E . Multifactorial inde x of ca rd iac risk in

10. II. 12 .

nonca rdiac su rgical proc~durcs . N. Engl. J. Med. 297:845 (1977) . Rao T .L.K., Jacobs K.H. , & El-Etr A.A. Reinfarction followi ng anesthesia in patients with myocardial infarc tion. Anesthesiology 59:499 ( 1983). D~Bu sk R.F., Kra~mu H.C., Nash E ., Berger W.E. , & L.:w, H. St ~pwise ri sk strdtilication soon aft~r acut~ myocardial infarction. Am. J. Cardiol. 52:1161 (1983) . Goldman L. & Cald.:ra D.L. Risks of general anesthesia and d.:ctiv.: su rge ry in the hypertensive patient. Anesthesiology 50:285 ( 1979) . Campeau L. Grading of angina pectoris. Circulation 54:522 ( 1975). Goldman L. , Hashimoto B., Cook E .F., & Loscalzo, A. Co mparative rep roduc ibility and balidity of sysh:ms for ass.:ssing card iovasc ular functional class: Advantages of a n.:w Specific Activity Seal.: . Circulation 64:1227 ( 1981) . Goldman L., Cook E .F.. Mitchell N. , Glatt.:y M ., Sh erman H. , & Cohn P.F. Pit fa lls in th~ se rial assessment of cardiac functional statu s. J. Chronic Dis. 35:763 (1982) . Sk inner J .F. & Pearce M.L. Surg ical risk in the cardiac patient. J. Chronic Dis. 17:57 (1964) . Rahimtoola S.H . Catheter balloon valvulop lasty of aortic and mitral stenosis in adults . Circulation 75:895 (1987) . Stone J .G., Hoar P.F .. Calabro J .R., D.:Petrillo M .A., & Bendixe n H.H. Afterl.:ad red uction and preload aug1n..:ntation in1prov..: th¢ a nesth etic rnanagcment of

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Free Parki ng a t all Pati ent Sen·ic:es Cen tres

7 p .m .

13.

14 .

15 .

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patients with cardiac failure and valvular r.:gurgitation. Anesthe. Aha/g . 59:737 (1980). Tinker J.H . & Tarhan S. Discontinuing anticoagulant th.:rapy in surgical pati-ents with ca rdiac valv.: prosth.:ses . lAMA 239:738 (1978) . Katholi R .E .. Nolan S.P., & McGuire. L.B. Th.: manag.:m.:nt of anticoagulation during nonca rdiac op.:rations in patients with prosthetic heart valv.:s: a prospectiv.: study. Am. Heart). 96:163 (1978). Goldman L., Caldera D.L ., Southwick F.S., Nu ssbaum S.R. , Murray B. , O' Malley T .A., Go roll A.H. , Caplan C.H . , Nolan J., Burke D.S., Krogstad D .. Carabello B., & Slat.:r E. E.: Cardiac risk factors and complications in non-cardiac surgery. Medicine 57:357 (1978). Foster E. D., Davis K.B., Carpenter J.A., Abde A .â&#x20AC;˘ Fray D., and principle investigators of CASS and th.:ir assoc iates . The coronary Artery Surgery Study (CASS) registry experience. Ann. 7horac. Surg. 41:42 (1986). Schulze R.A . Jr., Rouleau J., Rigo P. , Bowers S., Strauss H .W., & Pitt B. Ventricular arrhythmias in th.: late hospital phase of acute myocardial infarction: Relation to left ventricular function d.:t.:ct.:d by gated cardiac blood pool scanning . Circulation 52:1006 ( 1975). Schulz.: R .A. Jr., Stauss H .W., & Pitt B. Sudden d.:ath in the year following myocardial infarction: R.:Jation to ventricular prcmatur.: contractions in th.: lat.: hospital phase and left ventricular ejection fra ction. Am. J. Med. 62:192 (1977) . K.:nn.:dy H .L. , Whirloc k J.A., Spragu.: M .K .. Kenn.:dy L.J ., Buckingham T .A., & Goldb.:rg R.J. Long-t.:nn follow-up of asymptomatic healthy subjects with fr.:qu.:nt and complex ventricular .:ctopy. N. Eng. J . Met/. 312:193 (1985) .

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Go ldman. L. Assessment and ma nagement of the cardiac patient b.:fore, during , and afte r noncardiac surgery. In : Ca rdiology. Vol. 2 (Pa rmley W.W. & Chatterje-e K., Ed s.). Philad.:Jphia : J .B. Lippincott Company. pp 1-15 ( 1988). Pastore , J .O ., Yurchak P.M ., Janis K.M. , Jurphy J.D., & Zir L.M . Tho: risk o f advanc.:d heart block in surgical patients with right bundle branch block and left axis deviation . Circulation 57:677 (1980) . Ca rliner N .H., Fisher M .L., Plotnick G.D., Garbart H. , Rapoport A., Kelemen N .H ., Moran G.W. , Gadacz T ., & Peters R.W . Routine preoperative exercise testing in patients undergoing maj or no ncardiac surgery. Am. J. Cardia/. 56:51 (1985). Ge rson M .C .. Hurst , J.M. , Hertzberg V.S., Baughman R. , Rouan G.W. , & Ellis K. Prediction of cardiac and pulmonary complications r.:latcd to electiv-e abdominal and noncardiac thoracic surgery in geriatric patients. Am. J. Med. 88:101 (1990). L.:tt.: J ., Waters D., Lassond.: J . , Dube S., H.:yen F. , Pica rd M ., & Morin M . Postoperative myocardial infarction and cardiac d.:ath : Predictive valu-e of dipyrida mol.: thallium impaging and five clinical scoring systems based on multifactorial analysis . Ann. Surg. 211:84 ( 1990). An International Multiccntre Trial : Prevention of fatal postoperative pulmo nary embolism by low doses of h.:parin. Lancet 2:45 (1975). Z.:ld in R .A. Assessing cardiac risk in patients who und.:rgo noncardiac surgical proc edures . Can. J. Surg. 27:402 ( 1984). J.:ffr.:y C .C. , KunsmanJ . , Cull.!n D.J ., & Brewster D.C. A prospective evaluation of cardiac risk index . Anesthesiology 58:462 ( 1983) .

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THINKING ON YOUR FEET Thinking On Your Feet is an entirely new section of th.: UWO M.:dical Journal. This s.:ction may in pire you to n.:w heights, or it may just bug th.: dickens out of you . Thinking On Your Feet is comprised o f two segments: (i) clinical asse ssm.:nl and diagnosis based on pali.:nl history and examination results ; and {ii) m.:dical vocabulary and facts . Answ.:rs follow th.: clinical case scenario and vocabulary section (and in the ca s.: o f patientbas.:d qu.:stions, answ.:rs are sometime contain.:d within th.: history) . We ask you, in th.: name of Hippoc rates, not to peak at the answers pr.:maturely. Compare your r.: spons.:s with the most app ropriate answers or definitions provided . Award yoursdf with one point fo r each match .

SCORING:

85-100%-Yip.:s! Time for a night out, you probably need one ; 72-84%-Strong work ; 59-71 %-Good eye ; 40-58 %-- You might consider purchasing a dictionary, some texts, and some coff;.:.: ; 0-39 %-Yip.:s! Tim.: for a night in. a long night, and no pudding until you r.:ach th.: n.: xt l.:vd.

CASE Syncope and Abnonual Electrocardiogram in a Youn g Adult A previously h.:althy 33 year old po lic.:man d.:vd op.:d sudd.:n lighthead.:dn.: ss whil.: carrying his sle.:ping I I year old son up stairs , two steps at a tim.: and in a hurry. He squan.:d while still holding the boy and managed to lay him dow n o n the lloor. Th.: lighth.:ad.:dness disappear.:d promptly h:aving no ati.:r .:ffects . H.: didn' t pay much an.:ntion to this .: v.:nt. Two w.:.:ks later h.: .: xperienced an epi sode o f loss o f consc iousn.: ss while running and wh.:n h.: regain.:d consc iousn.:ss. h.: was tak.:n to the hospital. On arrival in th.: Em.:rgency D.:panm.:nt , h.: wa s asymptomatic: BP 120/80: HR 70/ min and r.:gular. Th.: examining physician noted a systolic mum10r alo ng the left sternal edge , which was known to th.: patient sine.: age 15 . His che st x-ray wa s no rmal. His ECG is shown below (Fig. 1).

STOP PLEASE AND ANSWER Til ESE QUESTIONS ... ( I) (2) (3)

What is your initial diagnosis? What qu.: stions do you ne.:d to ask this pati.:nt ? What , if any. sp.:cific physical signs ar.: you looking for?

{4)

What us.:ful t.: sts shall you order now?

fath.:r had died sudd.:nly at age 28 . On.: younger broth.:r was healthy. as were th.: patient's two young sons . Physical examination at th.: time o f reassessment six weeks later showed a pl.:a sa nl ma n in no ac ute di str.:ss. Jugular venous pulse and contour wen: normal. The anerial pul se showed a brisk upstroke and a normal volume . The h.:an wa s not enlarged. Auscultation showed a loud midsysto lic murmur. loudest on the Jet\ sternal .:dge. It did not radial.: to the neck and showed decreased intensity on squalling . Lungs wer.: clear. Abdom.:n and limbs were negative . A rep.:at.:d ECG (Fig . I) was identical to th.: first one . An echocardiogram showed asymmetric septal hypenrophy (septal thickness = 30 mm , poster wall thickness = 12 mm) , th.: aonic va lve was structurally normal but it showed panial midsystolic closing. There was also systolic anterior motion of the mitral va lv.: into th.: J.:ft v.:ntricular outllow tract.

STOP PLEASE ANJJ ANSWER Til ESE QUESTIONS... (I) (2) (3 ) {4 )

What is your final diagnosis? How do you treat this patient? What is the etiology o f this condition? Have you any advice for this patient's famil y? by Dr. L.J. Melendez Division of Cardiology

Victoria 1/ospiJa/ Exp:Uid your vocabulary (l)o you know these tenus'! ) I. 2. 3. 4.

5. 6. 7. 8.

9. 10 . II. 12. 13. 14 . 15 .

Amgerg ris? Butyroid Tumour? Antidinic Agent ? Rathk.:'s Pouch Tumour? Anticath.: xis? Trachdomyiti s? Bordia Vinc.:nti? Pa nial Thromboplastin Time ? Phocomelia ? Pac hon' s T.:st? Landau R.:llex? Mayo 's Sign? A oustic R.:ll.: x? Psil o~y b i n ?

Snd len's Sign?

PLEASE CONTINUE...

ANSWERS TO CASE STUI>Y ANI> VOCABULARY

He wa s admin.:d to the Coronary Care Unit with a tentativ.: diagnosis o f inf.:rio r wall myoc ardial infarction. The ho pi tal course was unev.:ntful and he was sub sequently re ferred to a t.:niary car.: institution for funh.:r assessm.:nt.

Case

A ssc.: ssrnt:nt :

Funher inquiry r.: v.:akd that th.: patient 's

A systolic mum1ur diminishing in intensity on squatting , th.: rapid upstrok.: of the anerial pul se and th.: sudden d.:ath o f the patient 's fath.:r at a rdatively young age were imponant cl ues to th.: diag nosis o f hypenrophic obstructiv.:

cardiomyopathy. This condition may r.:main asy mptomatic fo r a lo ng lime . Syncope , angina pectoris and dyspnea on effort. eith.:r singly or in combination may b.: the initial pr.:senlalion. or th.: condition may b.: uncov.: r.:d by a roulin.: physica l ..:xamination disc losing a heart murmur. or by an un.:xp..:cl.:d grossly abnormal ECG showing left v.:nlricular hyp.:rtrophy. v.:ntricular conduction abnormalities or abnormal Q wav..:s simulating a myoca rdial infarction (as was this patient"s case). Syncope is attribut.:d to dynamic kft ventricular outflow obstruction caused by increased myoca rdial contractility (exerc ise. administration o f sympathomim.:lic agent s). but in som.: pati.:nts it may be due to transient arrhythmias, as d..:monstrated by ambulatory ECG recordings . Sudd.:n d..:alh is. unfortunately. a common occurrence in this condition, and it is not y.:l cl.:ar if any form of pharmacological or surgica l int.:rv.:ntion can avoid it. The prognosis thus remains guarded. Ther.: is no specific treatm.:nt for hypertrophic cardio myopathy. Positiv.: inotropic agents such as dig itali s o r sympathomimetic drugs ar.: contraindicated , and vasodilator agents should be avoided . Drugs that decr.:ase myoca rdial contractility (such as verapimil) have been sugg.:sted , bul th.:re is no ddinitiv.: proof of th.:ir eiTectiven.:ss. Sd.:cled cas.:s may ben.:fit from partial resection ofth.: hypertrophied intraventricular septum. This is a genetically d.:termin.:d condition (a utosomal dominant). Parents. siblings. and childr.:n of newly diagnos.:d patients should und.:rgo a ca rdiac .:valuation.

2. 3. 4.

5. 6. 7. 8.

9. I0 . II . 12 . 13 . 14 .

15.

Medical Vocabulary I.

acids. and b.:nzoic acid (a great first word--we couldn't resist) . A coll.:ction of material in th.: mammary gland clos.:ly resembling butter. An ag.:nt .:ff.:cliv.: agains v.:rtigo . Craniophary ngioma . Expr..:ssio n of an emotional impulse as an emotion of opposit.: character ("count.:rinve stment") . Inflammatio n of th.: musc l..:s o f th.: neck . A para sit.: o f human oral cavity (seen in n.:crotizing gingivitis and n.:crotizing ulc.:rativ.: gingivostomatitis). On.: slag.: clotting t.:st usc to detect d..:ficienci.:s of components of intrinsic thromboplastin system (prolonged time r.:lah:s to deficiencie s of Factors l,II,V, VIII , & XII) . Devd opm.:ntal ano maly characterized by absence of proximal portion of a limb(s). Measu ring of the BP for the purpose of determining th.: stat.: of co llateral circulation in an.:urysm . Wh.:n an infant is hdd in the prone position th.: entir.: body form a conv.:x upward arc . Rdaxalio n uf th.: muscles controlling th.: low.:r jaw indicativ.: of pro found an..:sthesia. Contraction of th.: stapedius muscle in response to intense sou nd . A substitu.:d tryplamin..: and active ingredient of ov.:r 90 mushroom sp.:cies; responsibk for psycheddic or LSDIik.: cff.:cls o f various wild fungi. The bruit h.:ard witha sh:thoscop.: over the closed .:ye in Grave's Disease. •

Grayish waxy ma ss o f material ejecl.:d from th.: inl.:slinal tract ofth.: sperm whale and made up of cholcst.:rol , fatty

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