Herz
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Beta-adrenergic blocking agents exert a number of pharmacologic effects which may potentially be beneficial and warrant their use in acute myocardial infarction: by decreasing heart rate, myocardial contractility and systolic blood pressure, reducing catecholamine-induced lipolysis and antagonizing the oxygen-wasting effects of catecholamines on the myocardium, myocardial oxygen balance may be improved thus reducing ischemia. Theoretically this may lead to a limitation of infarct size by protecting underperfused myocardium from ultimate necrosis. Definite proof for such a positive effect in man, however, is not yet available. ⋯ In conclusion, beta-adrenoceptor blocking agents appear to represent a promising therapeutic principle for protecting ischemic myocardium in acute infarction. Additional investigations are urgently necessary to clarify the question of which patients may profit from such management. Pending the results of such studies, a general recommendation for the treatment of myocardial infarction with beta-blockade can not yet be given.
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We review the hemodynamic effects and clinical usefulness of five natural and synthetic catecholamines. Their actions are best understood by an appreciation of the relative ability of each catecholamine to activate alpha, beta 1 and beta 2 adrenergic receptors in the myocardium and peripheral vasculature. Epinephrine, the first catecholamine isolated, is shown to have little useful role in the therapy of acute myocardial infarction. ⋯ Dobutamine, a new synthetic catecholamine, has primarily beta 1 activity. It increases myocardial contractility with little effect on heart rate or peripheral vascular resistance. It is ineffective in cardiogenic shock, but may eventually be shown to have a role in the treatment of left ventricular failure uncomplicated by severe hypotension.
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Cardiogenic shock and severe left ventricular failure after acute myocardial infarction, refractory angina pectoris at rest either of new onset or superimposed on stable angina pectoris, or occurring in the post infarct (less than 2 weeks) period, and the suspicion of a slowly evolving infarction are the main indications for intra-aortic balloon pumping at the Thoraxcenter. 76 patients were treated with intra-aortic balloon pumping for cardiogenic shock after acute myocardial infarction and left ventricular failure, 42/76 (55%) could be weaned, 9 (12%) died within 3 months, 33 (43%) survived over 3 months, to date 29 are alive. 42 patients with refractory angina at rest were treated with intra-aortic balloon pumping. Pain relief was prompt in 41 (98%), who subsequently underwent coronary artery bypass grafting. Total myocardial infarction rate was 11% (5/42), total mortality rate was 7%. ⋯ In 8 patients a slowly evolving myocardial infarction was suspected. Pain relief was prompt in 7/8 (88%) after institution of intra-aortic balloon pumping. Intra-aortic balloon pumping improves prognosis in cardiogenic shock after myocardial infarction, and abolishes refractory ischemic pain.
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Guidelines for a step-wise plan of treatment of tachycardias have been compiled based on clinical empirical experience and with the aid of surface electrocardiograms, intracardial electrograms and stimulation techniques. The plan is primarily with the aid of surface electrocardiograms, intracardial electrograms and stimulation techniques. The plan is primarily oriented with respect to the antiarrhythmic efficacy, the adverse reactions and the practicability of the respective agents. ⋯ Verapamil and/or ajmaline, are usually very effective for termination of reciprocal tachycardias. Ajmaline or propafenon in combination with a beta-adrenergic blocker is recommended for the prophylactic treatment of reciprocal tachycardia. In patients who additionally have bradycardia, prolonged QT-intervals or pre-excitation syndromes, the guidelines should be modified accordingly.
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Reports of successful attempts at resuscitation have been published for more than 200 years, but systematic analysis of an optimal technique has been undertaken for only the last 20 years. As a result of these experiments and of the many years of experience of resuscitation teams, extensive recommendations were formulated by a conference on cardiopulmonary resuscitation of the "American Heart Association" in May 1973. The superiority of mouth-to-mouth resuscitation in comparison to older methods and the importance of the triple-airway-maneuvre for the maintenance of a patent airway were pointed out. ⋯ Seven patients survived primarily. Of these, four patients died within the subsequent twentyfour hours. One patient survived with permanent brain damage, two could eventually be discharged from the hospital without complications.