Author + information
- Suzanne B. Knoebel, MD, FACC*
- ↵*Address for reprints: Suzanne B. Knoebel. MD. Indiana University School of Medicine, 1100 West Michigan Street, Indianapolis, Indiana 46223.
The development and refinement of techniques relating the determinants of increased myocardial oxygen demand to primary or secondary manifestations of inadequate myocardial blood flow made possible certain major advances in the management of chronic ischemic heart disease over the past 25 years. These include objective and quantitative evaluation of the anatomic basis and the functional consequences of ischemic heart disease, risk stratification for patient subgroups and documentation of the effects of therapy. In addition, studies in which ischemic manifestations were shown to be dissociated from increased myocardial oxygen demand have redirected attention to the supply component of the supply to demand balance for myocardial oxygenation.
Diagnostic techniques, management schemata and therapeutic evaluation methods for the electrophysiologic alterations of ischemic heart disease have matured more slowly than those for the ischemic manifestations. While the pathophysiologic concepts underlying knowledge of the ischemic manifestations of coronary artery disease were formulated 25 years ago, in the case of arrhythmias, new concepts needed to be developed to provide the direction for technologic and therapeutic advances. Although the patients at risk for serious arrhythmias and sudden cardiac events are known to be those with severe coronary artery disease, impaired left ventricular function and preexisting electrical instability as manifested by frequent and complex ventricular arrhythmias, the sensitivity and specificity for any single factor as a predictor of risk remain to be established. Similarly, methods to predict efficacy of therapy are still under development. Progress will accelerate when specific factors that predict risk are identified and the methods for measuring those factors are developed and applied to the patient in an organized and systematic manner.
The thesis underlying this broad conceptional review is that the fostering of the full-time clinical investigator that occurred during the 1960s and the first half of the 1970s and the consequent systematic development and application of quantitative methods to the study of disease in human beings were major forces for the remarkable progress that has been made in the management of all aspects of cardiovascular disease.
- American College of Cardiology Foundation