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Objective: To determine the relationship of age and the percentage of patients presenting to the emergency department with myocardial infarction who meet conventional electrocardiographic and time-to-presentation criteria for thrombolytic therapy. Design: Prospective cohort study. Setting: Emergency departments of three university hospitals and four community hospitals. Patients: Patients enrolled in the Multicenter Chest Pain Study, an investigation of patients aged 30 years or older presenting to the emergency department with the chief complaint of anterior, precordial, or left lateral chest pain unexplained by obvious local trauma or abnormalities on the chest radiograph. Interventions: None. Measurements: The frequency of patients who presented with conventional electrocardiographic and time-to-presentation criteria for thrombolysis. Main Results: Of a total of 12,140 patients who were enrolled in the Multicenter Chest Pain Study, 10,850 had information about their electrocardiogram and their time-to-presentation. Acute myocardial infarction occurred in 1,584 patients, 746 of whom were over age 65. Among patients presenting to the emergency department with acute myocardial infarction, the proportion who arrived within 6 hours of the onset of pain and had ST-segment elevation or pathologic Q-waves not known to be old decreased significantly with increasing age, from 34% in patients under 65 years to 18% for those 75 years and older. In addition, comorbidities that would have contraindicated thrombolytic therapy were present in an additional 12% of myocardial infarction patients who were older than 65 years. Conclusion: Although other analyses have shown that thrombolytic therapy is cost-effective for eligible elderly patients with acute myocardial infarction, only a small percentage of very elderly patients who present to the emergency department with acute myocardial infarctions meet current eligibility criteria to receive it, so thrombolysis is unlikely to narrow the difference in mortality rates for young as compared with elderly patients with acute infarctions.

OBJECTIVES Coronary heart disease often presents with ST segment elevation acute myocardial infarction (STEMI). The American College of Cardiology/American Heart Association guidelines stress prompt reperfusion for STEMI. Examining geographic variations in treatment with PPCI (percutaneous primary coronary intervention) and CABG (coronary artery bypass graft) among metropolitan, micropolitan and non-micropolitan rural residents provides a descriptive basis for generating hypotheses concerning place and receipt of guidelines-based treatment. METHODS Using ICD-9 codes for STEMI and excluding beneficiaries with pre-existing MI in claims data, yielded a subset of 18,775 Tennessee Medicare beneficiaries experiencing STEMI from 1996 to 2002. The outcome variable is type of treatment, i.e., in accord (PPCI or CABG present) or not in accord (PPCI or CABG absent) with guidelines. Independent variables include type county residence, hospital volume, race, gender, and age. Analyses include cross-tabulation and logistic regression, estimating separate models by age and type of MI. RESULTS Micropolitan residents with STEMI have the lowest rates for PPCI (18.8%) versus 28.1% percent for metropolitan and 24.2% for non-micropolitan rural residents. CABG follows similar patterns at lower overall rates. Treatment at a heart center with high volume PPCI mediated the relationship between the likelihood of PPCI and place. CONCLUSION The correspondence between metropolitan and rural utilization suggests that access to a full range of treatment options and likelihood of "best practice" care is not dependent on metropolitan residence. This presents the possibility that with some policy changes, e.g., centralization of emergency heart care, the same may ultimately be true for micropolitan residents.

The Studies of Left Ventricular Dysfunction (SOLVD) comprises 2 double-blind, randomized clinical trials to test improved survival by angiotensin-converting enzyme inhibitor in patients with left ventricular dysfunction, with or without congestive heart failure. Patients entering the trials may be a highly selected subset of the population of such patients; those with the worst and best prognosis are likely to be excluded. To obtain the clinical history of a broader group, a registry of 6,273 patients included a relatively unselected cohort of patients with heart failure or left ventricular dysfunction, or both, from SOLVD hospitals. Registry data were obtained from hospital records. Because data collection from medical records may lead to incomplete data and more investigations in "sicker" patients, 898 randomly chosen subjects from different disease strata were seen in clinic where neurohumoral measures, echocardiograms, x-rays and electrocardiograms were obtained, and a 6-minute walking test was performed. The design and methodologic features, and the baseline characteristics of the participants in this 2-tiered registry are described, and its use in complementing the results and interpretation of the SOLVD trials is discussed.

Reperfusion may limit the amount of potentially salvageable myocardium through the introduction of cellular elements into previously ischemic but viable myocardium (reperfusion injury). It has been demonstrated that intracoronary infusion of a 20% intravascular perfluorochemical emulsion (Fluosol) significantly reduces infarct size and results in improved left ventricular function in the canine model. This pilot study was performed to explore the existence of myocardial reperfusion injury in humans.Utilizing Fluosol as a probe in conjunction with emergency coronary angioplasty, 26 patients presenting within 4 h with a first anterior myocardial infarction were randomized to emergency angioplasty or angioplasty followed by a 30-min intracoronary infusion of Fluosol at 40 ml/min. Global and regional ventricular function were assessed immediately and a mean of 12 days after successful angioplasty with contrast ventriculography. Infarct size was semiquantitated with thallium-201 single-photon emission computed tomography (SPECT) images before discharge. Twelve patients (six undergoing angioplasty alone, six treated with angioplasty and Fluosol) had an occluded infarct-related vessel (Thrombolysis in Myocardial Infarction [TIMI] grade 0 to 1) at the time of emergency catheterization and were included in the final analysis.At 12 days after successful angioplasty, the improvement in regional ventricular function was greater in patients receiving adjunctive therapy with intracoronary Fluosol versus those undergoing angioplasty alone utilizing both the radial shortening and centerline method, respectively (23 ± 3.1% vs. 8 ± 2.3%, p < 0.02; and −1.6 ± 0.4 vs. −2.9 ± 0.2 SD/chord, p < 0.05). Tomographic infarct size expressed as a percent of the left ventricle was also reduced in Fluosol-treated patients (3.5 ± 2.2% vs. 18.3 ± 4.7%, p < 0.05). No significant differences in collateral blood flow, extent of coronary artery disease or residual stenosis after angioplasty were observed.This preliminary study suggests that myocardial reperfusion injury may be an important factor in limiting myocardial salvage in patients undergoing reperfusion. These findings have important clinical implications because adjunctive therapy may further amplify the beneficial effects of mechanical or pharmacologic reperfusion. Additional prospective randomized trials must be done to confirm and extend these preliminary results.

John Camm, Thomas F. Luscher, Patrick W. Serruys, eds 1136 pages. Oxford, UK: Blackwell Publishing; 2006. $295. ISBN 1-4051-2695-7 Editor’s Note: In our effort to provide an insightful, balanced, and constructively critical review of the new first edition of the ESC Textbook of Cardiovascular Medicine edited by Drs A. John Camm, Thomas F. Luscher, and Patrick W. Serruys that was published under the auspices of the European Society of Cardiology by Blackwell Publishing Ltd (2006), we have obtained the opinions of 3 distinguished senior cardiologists, Drs Gottlieb Friesinger, Desmond Julian, and Elliot Rapaport, to serve as a Select Panel for Review. To ensure the book was read in its entirety, the text was divided into thirds and apportioned equally to each reviewer; all 3 reviewers were assigned 4 chapters in common to read as well. This summary review by 3 individuals, each of whom is internationally recognized for expertise in the broad field of general cardiology, is offered in the spirit of helping the ESC achieve its stated objective of providing a textbook that is successful in covering the knowledge that should be required of all general cardiologists. ### General Comments This textbook is primarily targeted at the specific audience of those wishing to be accredited with the European Board for Accreditation in Cardiology (EBAC). It is not intended to be a work of reference, but, as stated in the foreword, of producing “a clinically focused resource for general cardiologists and trainees.” It presents 36 chapters within 1092 pages, each authored by anywhere from 2 to 6 multinational collaborating members of the European Society of Cardiology. One of its remarkable achievements in addition to the high standard of writing is its superb illustrations, figures, and tables that appear on virtually every page. They are well placed within the text and contribute in making …

OBJECTIVE Chronology poorly predicts biological age (BA) or physiologic reserve (PR). An objective approach to the heterogeneity of aging would greatly help clinical decision making in the elderly. MATERIALS AND METHODS The first pilot study evaluated 130 "healthy" volunteers, ages 70 to 95 years. A summary BA/PR index was developed, using measures of endurance, strength, flexibility, balance, cognition, depression, comorbidity, and exercise. The second study applied the BA/PR concept to prediction of death after a first elective coronary artery bypass graft, using a Veterans Administration database. RESULTS The BA/PR index was a better predictor of 3-year functional outcomes and death than was chronological age. In the coronary artery bypass graft study, the inclusion of BA/PR variables significantly improved prediction of 6-month and long-term death for Veterans Administration patients. CONCLUSIONS The usefulness of a biological age (BA/PR) approach in predicting outcomes in the elderly was supported. Needed research should develop tools for routine "tracking" of the aging process.

Sir William Osler’s contributions to clinical medicine in general are considered by many as unique. His skills as an expert pathologist, master clinician, astute diagnostician, and above all a gifted teacher and author are extolled in numerous contemporary as well as posthumous publications. His observations and writings on cardiovascular diseases are among his most important and influential.’ The congenitally bicuspid aortic valve was one of Osler’s favorite subjects. It was also the topic of his first presentation to the Association of American Physicians published in the premier issue of the association’s transactions.2 In that article, Osler presented his findings in >800 consecutive autopsies which contained 18 cases of bicuspid, aortic valve. His background and expertise in pathology provided a unique opportunity to highlight the relation between observed pathology and the corresponding physiologic derangements. It is, therefore, at first glance, surprising that although infective endocarditis, heart failure, and cardiac hypertrophy were identified as important findings in patients with bicuspid aortic valve, there is no mention of aortic valvular stenosis. Could Osler have missed the now well-established association between this anatomic defect and the propensity for aortic stenosis? We review Osler’s manuscript and propose a simple hypothesis that explains the discrepancy in the prevalence of aortic vaIve stenosis between Osler’s initial report and the current knowledge that a congenitally bicuspid aortic valve with calcific deposits and acquired stenosis is the most common cause of aortic stenosis in middle-aged patients. Table I lists the clinical characteristics of the 18 cases of congenitally bicuspid aortic valve reported in Osler’s autopsy series. When the cause of death was known, infective endocarditis and congestive heart failure were the etiologies in 14 of 16 patients. Varying degrees of left ventricular hypertrophy were present in all but 2 patients. Incompetence of the bicuspid valve was noted in 3 patients and cusp perforation in the setting of infective endocarditis in another 2. Aortic cusp thickening and sclerosis were noted in 13 patients, but frank valvular aortic stenosis was not seen in any patient. He correctly pointed out that the bicuspd aortic valve was “invariably thickened and the seat of sclerotic changes.”

Background . The most effective treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy is still disputed. Treatment options include medical therapy, pacemaker insertion, percutaneous transluminal septal myocardial ablation, mitral valve replacement, and surgical resection of obstructing muscle. The long-term results of the various treatment options are not well defined. We aimed to demonstrate that septal myectomy is efficacious in reducing or abolishing left ventricular outflow tract gradient and leads to long-lasting symptomatic improvement in most patients. Methods . Twenty-two consecutive patients had septal myectomy between 1981 and the present. Their records were reviewed to document the details of their preoperative status, hospital course, their subsequent clinical outcome, and current status. Results . Mean age at operation was 31.3 years. Preoperatively all patients were disabled by typical symptoms despite aggressive medical treatment. Mean resting gradient was 78 mm Hg. Nine patients required simultaneous associated cardiac procedures. There were no perioperative deaths and minimal morbidity. Two patients died at 6 and 9 years postoperatively of congestive heart failure and arrhythmias. Long-term survivors have been followed up for a mean of 6.6 years. Currently all have minimal or no symptoms. The mean resting gradient was 12 mm Hg. No patient has required reoperation for residual obstruction. Conclusions . Septal myectomy reduces or abolishes left ventricular outflow tract gradient in hypertrophic obstructive cardiomyopathy. Myectomy provides long-lasting symptomatic improvement in most patients. The clinical status of patients late postoperatively can be affected by arrhythmias and myocardial dysfunction.

The First American Heart Association/American College of Cardiology Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke was held from May 24 to May 26, 1999, in San Diego, Calif. In this report, the Heart Failure Working Group examines efforts to assess care for patients with heart failure (HF) and makes recommendations about quality measures. The working group includes healthcare professionals (cardiologists, general internists, and nurses) from academia. Representatives of governmental agencies, industry, and healthcare systems also have input. The group has expertise in the treatment of HF and/or quality improvement. Several panel members have participated in writing guidelines for management of HF, and several were involved in the 1994 effort by the Agency for Health Care Policy and Research (AHCPR) to develop guidelines for management of patients with HF and left ventricular (LV) systolic dysfunction. In its effort to develop recommendations for evaluating quality of care, the working group reviewed the literature and evaluated ongoing national efforts in this area. These efforts and specific issues related to measuring structure, process, and outcome of care are reviewed here. This report is intended to provide information for future efforts by national or local organizations to develop quality measures, define research priorities for funding agencies by indicating gaps in current knowledge, and summarize current issues in this field for persons interested in improving the care and outcomes of patients with HF. There is no universally accepted definition of heart failure. HF is a clinical syndrome manifested by characteristic symptoms and signs, none of which are specific, caused by an abnormality(ies) of ventricular function resulting in the inability of the heart to deliver adequate cardiac output at normal filling pressures at rest or during exercise. As the syndrome progresses, a variety of hemodynamic, renal, hormonal, neural, and cellular …

Appropriate care of the elderly patient requires a concerted multi-disciplinary approach before, during, and after surgery to optimize functional outcomes, with the principal focus placed on improving quality of life and strategies for risk reduction. Perioperative physicians must be able to assess the biologic, not the chronologic, age of geriatric patients and their capacity for independent function. Physicians need to understand alterations in the physiology of elderly patients attributable to the normal aging process as well as the prevalence of concurrent pathologic conditions that necessitate special precautions. Maintaining autonomy and function as a result of an acute surgical intervention may be the most important outcome to the elderly patient. Most of the data available and guidelines promulgated do not specifically address the elderly population. It is important to collect data prospectively and use sophisticated methods for analyses to develop better management algorithms for these (often complicated) clinical issues in the elderly.

In 1964, a patient with symptomatic, severe left main coronary artery stenosis underwent operative treatment. Endarterectomy and pericardial patch grafting were performed successfully. The original operation is described, and the 33-year follow-up is provided.

The selective granting of clinical staff privileges to physicians is one of the primary mechanisms used by institutions to uphold the quality of care. The Joint Commission on Accreditation of Healthcare Organizations requires that the granting of initial or continuing medical staff privileges be based on assessments of applicants against professional criteria that are specified in the medical staff bylaws. Physicians themselves are thus charged with identifying the criteria that constitute professional competence and with evaluating their peers on the basis of such criteria. Yet the process of evaluating a physician’s knowledge and competence is often constrained by the evaluator’s own knowledge base and ability to elicit the appropriate information, a problem that is compounded by the growing number of highly specialized procedures for which privileges are requested. This recommendation is one in a series developed to assist in the assessment of physician competence on a procedure-specific basis. The minimal education, training, experience, and cognitive skills necessary for proper interpretation of electrocardiography are specified; whenever possible, these are based on published data linking these factors with competence in certain procedures and, in the absence of such data, on consensus of expert opinion. They are applicable to any practice setting and can accommodate a variety of pathways that physicians might take to attain competence in the performance of specific procedures (see also Guide to the use of ACP statements on clinical competence. Ann Intern Med . 1987;107:588-589.) Introduced in 1903 by Einthoven, electrocardiography is the most commonly used laboratory procedure for the diagnosis of heart disease. As a record of electrical activity of the heart, it is a unique technology that provides information not readily obtained by other methods. The procedure is safe, there being essentially no risk to the patient; it is simple and reproducible; the record lends itself to …