Time is muscle

It was a long time ago. September 1987. About as far back as my career goes. I had finished undergrad (Glasgow), house jobs (Glasgow), residency (Winnipeg)—and decided to put the skills I had learned into practise—in a community setting. I was in the OR of Winnipeg General. The patient was on bypass, getting a new set of coronaries, when one of the four pumps alarmed. “Ring-ring, ring-ring . . .” What the heck was that? The neosynephrine drip, the narcotic, or what? The head nurse came up to me with a cell phone, and said, “it’s for you.” It was BT, a GP from Mission B.C., inviting me to come visit on the long weekend in May. I said “sure” after checking the snowy landscape from the top of the Health Sciences Tower. The weather, the flowers, the landscape—everything clicked. So, I bought a house that weekend, and flew back with new plans. Not a double fellowship, just me in the trenches. Read: It drives me nuts! Women undertreated for aortic stenosis It was soon into my first job at Mission Memorial Hospital that I got called to see Frank Abernethy, a 67-year-old, pre-diabetic smoker with crushing chest pain. Acute inferior MI was written all over his EKG. “Let’s crack open a vial of streptokinase,” I said to the ER nurse (sort of the way you crack open a bottle of Prosecco). “We’ve got some but we’ve never used it,” she said. Thrombolysis hadn’t reached the local consciousness, but I was sold on it from residency experience. I told Frank about the potential for allergy and bleeding, after making sure he had no contra-indications to its use. Everything seemed to go well, maybe due more to the morphine and aspirin and oxygen, but he seemed pretty stable. Until the seizure. “Oh, that’s not supposed to happen,” I said. The ER nurse seemed to lose confidence. As for me, I was glad I’d put on fresh underwear that morning. “Blood pressure 60/0” gave me something to think about, and we switched strepto for saline. About 2 litres later, Frank was telling jokes and smiling, but this time with substantially lower ST segments. We packed him off for a catheter and a stent, knowing we had started a trend. Read: Quiz: Test your knowledge of cardiovascular complications I had a fax machine at home, in the basement, and it would be the norm to get a call and an EKG when the acute MIs came in at 2 a.m. We transitioned to tPA (alteplase) and then rPA (retaplase), and got pretty slick at reducing door-to-needle times. We signed up for the early thrombolytic trials (Fast-Track II, GUSTO I and 2), and made a name for being ‘the little hospital that could.’ TNK (tenecteplase) was something I learned about later, in another centre. Although it is a one-shot deal, it is more costly, with similar results. Oh well, the economists will have to argue over that one. In my day, an acute MI would spend five days in the CCU/ICU, get loaded with betablockers, ASA and a statin, and then have a stress test on the day of discharge. If they failed, they would head off for an inpatient catheter. Otherwise they were safe to follow an outpatient route. Did I ever lose a patient with this strategy? No. Nowadays, that’s all changed, but access to angiography is not universal. That’s because you need a team of cardiologists and cardiac nurses, a dedicated OR, and a will. Bunbury (rural Australia, population 50,000) has a cardiac catheterisation laboratory. Nanaimo (semi-urban, Vancouver Island, population 100,000) doesn’t. There you go. We know so much more about coronary atherosclerosis. Of course, we need to credit Edward Jenner, who in 1783 surmised his mentor and friend, John Hunter, had coronary artery disease causing his angina, subsequently confirmed on Hunter’s autopsy (1793). And the Russian Nikolai Anichkov, whose pivotal lipid studies were published in 1913. The model Seymour Glagov proposed still holds true. A friable plaque ruptures, LDL is exposed to platelets, clot forms and bingo: downstream infarction ensues. Time is muscle, something we figured out in the 1980s. It changed our approach to myocardial infarction, and now to stroke. All in my lifetime. Magic. References: CH Parry ‘An Inquiry into the Symptoms and Causes of the Syncope Anginosa’ (1799) N Anichkov and S Chalatov, Centrablatt fur Allgememe Pathologie und Pathologische Anatomie 1 (1913): 1 S Glagov (1925-2008)

Casebook of a Community Internist

Time is muscle

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Hector Baillie

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