RSS Feeds
Evidence-Based Coronary Care
- Eugene Braunwald, MD; and
- Elliott M. Antman, MD
- Brigham and Women's Hospital, Boston, MA 02115 Requests for Reprints: Eugene Braunwald, MD, Brigham and Women's Hospital, 75 Francis Street, Mid Campus 4, Boston, MA 02115. Current Author Addresses: Dr. Braunwald: Brigham and Women's Hospital, 75 Francis Street, Mid Campus 4, Boston, MA 02115. Dr. Antman: Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. Requests for Reprints: Eugene Braunwald, MD, Brigham and Women's Hospital, 75 Francis Street, Mid Campus 4, Boston, MA 02115. Current Author Addresses: Dr. Braunwald: Brigham and Women's Hospital, 75 Francis Street, Mid Campus 4, Boston, MA 02115.
Since Herrick's classic description of acute myocardial infarction was published in 1912, the management of this condition has gone through four phases. The first, which may be called the “clinical observation phase” of coronary care, lasted about half a century and consisted of the simple assessments that were possible at that time. Vital signs were recorded frequently, especially on the first day after infarction; clinical examinations were done and electrocardiograms were obtained daily for the first few days; and chest roentgenograms were obtained once or twice a week. The infarcted heart was considered to be a wounded organ, the repair of which required the equivalent of the immobilization of a fractured bone. Treatment therefore consisted of strict bed rest and sedation. Digitalis was administered for heart failure, and quinidine was given for frequent premature ventricular contractions. Patients were usually hospitalized for 5 to 6 weeks. The major debates during this phase revolved around whether ambulation could be started early (1 week) or late (2 to 3 weeks) after admission. There was also considerable controversy about the indications for anticoagulant agents, which were administered primarily to prevent pulmonary thromboembolism, a major complication of bed rest. The in-hospital mortality rate approached 30%; after discharge, patients usually led restricted lives, and 15% died during the remainder of the first year.
The situation changed radically during the early 1960s in the so-called “coronary care unit phase” [1]. This phase was marked by the refinement of techniques for closed-chest cardiac resuscitation and the gathering in a single location in the hospital of equipment for continuous electrocardiographic monitoring and teams of trained physicians and nurses who could efficiently use the newly available antiarrhythmic agents (such as lidocaine) and could use direct-current defibrillators and pacemakers to treat life-threatening arrhythmias. During this period, patients enjoyed the benefit …
