Management of acute myocardial infarction and accelerating angina

Shock in acute myocardial infarction: evolution of physiologic therapy

In the past 25 years the treatment of shock in myocardial infarction has evolved into a physiologic approach based on on-line measurements of hemodynamic variables. This has aided in the development of new pressor agents so that a family of pharmacologic agents is now available. Appropriate use of vasodilators and recognition and treatment of intravascular volume depletion have increased survival. Recognition and appropriate treatment of the preshock state have decreased the incidence of shock. The criteria for use of mechanical support and surgical intervention are soundly established; the use of thrombolytic therapy and balloon angioplasty for this syndrome is ready to be evaluated.

Disabling angina pectoris with normal coronary arteries in patients undergoing long-term hemodialysis

Reports of patients undergoing long-term hemodialysis presenting with angina pectoris have usually shown severe coronary atherosclerosis. We studied a series of nine patients undergoing regular maintenance dialysis referred for incapacitating angina. Of them, four had strictly normal coronary angiograms. The patients with normal angiograms were all females who were significantly younger (p less than 0.05) and had more severe hypertension and higher left ventricular wall stress than patients showing coronary artery lesions. Anemia and increased myocardial oxygen consumption due to high blood pressure may explain the syndrome of angina pectoris in the presence of long-term dialysis in patients with normal coronary arteries. The prevalence of this association cannot be ascertained unless prospective studies are conducted. However, our data suggest that it might not be an uncommon finding.