There are no Justifiable Reasons to Realize Costly and Aggressive Management for Acute Coronary Syndromes

Quintiliano H. de Mesquita, M.D.

During the last 30 years we have been observing the uncontrollable and compulsive interventionism by cardiologists and cardiac surgeons during the unstable angina and acute myocardial infarction. Patients are submitted, independently of sex or age, to angiography and urgent or emergency angioplasty and/or coronary bypass surgery as if these procedures were extreme and exclusive therapeutic measures of death or life.

 In front of the current practice of this interventionism, consecrated almost worldwide as a medical progress, our opinion based in a personal experience since 1941 is that these measures are unnecessary and unjustified apart to be aggressive and with risk for the resolution and the immediate future of the unstable angina and of acute myocardial infarction, in patients with such conditions.

 For better understanding and comparison it is important to tell about our therapeutic actions used in the period from 1941 - 1972 which were based in coronary dilators and absolute rest, representing contemplative and symptomatic attitudes but respectfully with the patient and showing good results for the acute myocardial infarction cure.

 During this period the stable angina or angina provoked by efforts were ever been observed as the long duration stage until the sudden occurrence of spontaneous manifestations, recurrent and reversible which characterize the unstable angina like the pre-infarction stage where frequently and in a short space of time, from 10 - 15 days, may reach a subsequent acute myocardial infarction or remains resistant to all therapeutic in use assuming in the last situation a permanent angina state.

 The unstable angina didn't have a specific remedy at that time so when we had the process starting, the measure was to put the patient in bed in order to avoid complications in case of occurrence of acute myocardial infarction. Coming the infarction the patients were submitted to an absolute rest in bed during 50 days, with a passive movement of limbs and in a posture and respiratory conditioning, as prevention of thromboembolics and pulmonary processes, with the medical therapeutics by coronary dilators plus the eventual use of antiarrythmics and vasopressors

After the AMI, the myocardial return to stability and to symptomatic states were the natural consequences, with our patients receiving an upkeeping treatment by coronary dilators. Nevertheless, the possibility of future evolution to new unstable angina and reinfarction were ever present creating a constant concern, being responsible for our insecurity and even fear from the myocardial infarction occurrence in our patients at that time.

The introduction of anticoagulants realized in 1944 caused a great enthusiasm leading us to apply them for the unstable angina stop and immediate prevention of the acute myocardial infarction in many patients until 1954, when we abandoned the anticoagulants with the conviction of their complete inefficacy. Curiously, only after 15 years (in 1969) the orthodox cardiology gave up about the anticoagulants, confirming our findings.

In 1962 was published our paper "Anticoagulant and Myocardial Infarction, Publicações Medicas; 211:3-12" denouncing the inefficiency of the anticoagulant and presenting 296 cases of acute myocardial infarction treated at home only with absolute rest in bed plus coronary dilators, recording a global mortality of 7.7 % (23 deaths: 9 in 72 hours, 6 in 15 days and 8 in 60 days. As death causes we recorded 14 cases related to heart failure, 6 cases by sudden death, and 3 cases by cardiogenic shock.

 Since very early we have taken care about the pulmonary stasis interpreted by us as an initial heart failure and corrected with the convenient administration of intravenous strophanthin with the aim to avoid its evolution to a major degree of insufficiency, maintaining in this way the functional capacity from the patient with infarction, under a relative normality. We think that the election of the intravenous use of strophanthin, in our patients with acute myocardial infarction, was responsible for our low global mortality of 7.7% in these cases.

In a recent review in literature we found statistics showing unstable angina medically treated (conservative) with records of myocardial infarction of 7.8% and mortality of 6.2% and cases with the UA surgically treated recording myocardial infarction of 9.6% and mortality of 6%.

The recent publication of the results of the VANQWISH study at the New England Journal of Medicine (June 18,1998 - Volume 338, Number 25) joined other 3 large randomized studies including more than 6400 patients. These studies confirm that the aggressive strategy with the use of angiography and revascularization procedures for acute coronary syndromes was associated with increased mortality during hospitalization, at one month and at one year not reducing the incidence of non fatal reinfarction or death as compared with the usual medical treatment by thrombolitics.

After 1972, with the introduction by us of the Myogenic Theory for the myocardial infarction we adopted the cardiotonic as the compatible anti-infarction drug abandoning the old contemplative and symptomatic attitudes with the acquisition of surprisingly results like the clinical stop of unstable angina in 100% of our cases with 0% of mortality, while in the acute myocardial infarction this kind of treatment provided important transformations like low mortality and a guarantee of long survival for the patient with decades of profitable life.

In our point of view there are no acceptable reasons to continue this unruly and compulsive interventionism which is imposed as the extreme measure of therapeutically salvation, moreover when there are insuperable and infallible resources making rich the clinical therapeutic armamentarium for unstable angina and acute myocardial infarction management.

Therefore, we consider coronary angiography, angioplasty and bypass surgery procedures unnecessary, unjustifiable, aggressive and with risk for the patients with UA and AMI. Above all, these procedures are offensive to the rights of the patient, because they are normally imposed in first place with the clinical therapeutic solutions unrespected and absurdly ignored, inside the fidelity to the Hippocratic aphorism: PRIMUM NON NOCERE.

In medicine the prevention and the clinical therapeutic are representatives of progress and only when the medical treatment fails to settle a disease, is the moment of the surgery intervention, in order to cure definitively and in only one act, making the surgeon as the last hope for the patient.

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