The document summarizes the historical development of cardiology from ancient times to the present. Some of the key milestones included William Harvey's discovery of blood circulation in 1628, the development of the stethoscope in 1819, electrocardiography in the early 1900s, and the creation of the first coronary care unit in 1961. Advances in imaging technologies, cardiac surgery, treatments for arrhythmias and heart failure have dramatically improved outcomes for cardiovascular patients over the decades. Prevention through identification and modification of risk factors is now a major focus of cardiology. The future of the field is expected to include greater use of stem cell therapies, gene therapies and implantable devices.

2. HISTORICAL DEVELOPMENT, TRENDS
AND ISSUES IN THE FIELD OF
ANCY M DAS
2ND YR MSC NSG
J IPMER
CARDIOLOGY.
ETHICAL AND LEGAL ISSUES

3. THE HISTORY OF CARDIOVASCULAR MEDICINE

4. THE HISTORY OF CARDIOVASCULAR MEDICINE
1. The beginning
 The conception
 The birth
 The early years
 Cardiac catheterization

5. 1. The beginning
1. The conception
 ‘Huang Ti Na-Ching Su Wen’, China's Yellow Emperor's
Classic on Medicine, published circa 2600 BC, was aware of
the heart and circulation, writing: ‘The blood current flows
continuously in a circle and never stops’.
 The importance of the heart to the sustenance of life was
appreciated by the ancient Egyptians as early as 2000 BC.
 In London, William Harvey conducted the first hypothesis-driven
experiments in biology.

6. 1. The beginning
The conception…
 In 1628, decades before Isaac Newton, Harvey published his
monumental book De motu cordis, in which he described the
circulation and the function of the heart.
 Heberden - classic description of angina pectoris in 1772
 In 1785, Withering, a British physician, described foxglove
(digitalis), its use in ‘dropsy’ (oedema), and in strengthening
and slowing the heart.
 Brunton described the use of amyl nitrite in the treatment of
angina.

7. 1. The beginning
The conception…
 Physical examination of the heart was greatly facilitated by
the invention, in 1819, of the stethoscope by the renowned
French Professor René Laennec.

8. The beginning
2. The birth
 A technical revolution swept over the medical world at
the turn of the twentieth century with three
discoveries, each of which contributed importantly to
the birth of cardiology.
 The first of these, in 1895, was diagnostic X-ray by
Wilhelm Roentgen, a German physicist who received
the first Nobel prize in physics for this
accomplishment.

9. The beginning
2. The birth…
 The second was a practical, non-invasive measurement
of blood pressure made possible by the twin
developments of the blood pressure cuff by Riva Rocci
in Turin, Italy in 1896, and its use in the auscultatory
measurement of blood pressure by Korotkoff in St.
Petersburg, Russia in 1905.

10. The beginning
2. The birth…
 The third was the string galvanometer for
recording cardiac potentials on the surface of the body,
the electrocardiograph, which was described by
Einthoven in 1902; he, too, was rewarded with a Nobel
Prize.
 Physicians who used all three of these new tools in
addition to clinical findings to study their patients
became identified as the first ‘heart specialists’, i.e.
cardiologists

11. The beginning
2. The birth…
 In 1901, Krehl, a Viennese physician, appears to have been
the first to report that coronary occlusion in patients is
associated with chest pain, that it causes acute myocardial
infarction (AMI), and that it is not uniformly fatal.
 In 1910, Obratzov and Strazhenko in Kiev, described five
patients with AMI. They reported that unusually heavy
exertion and intense emotion could be precipitants.
 Herrick, a Chicago physician, who alerted the English
speaking world to AMI and was also the first to describe
electrocardiographic changes in this condition.

12. The beginning
2. The birth…
 Biochemistry and experimental pathology were the next
sciences to exert important impacts on cardiology.
 In 1910, Adolf Windhaus, the Nobel Prize-winning German
organic chemist, described the presence of cholesterol in
human aortic plaques
 And in 1913, two young Russians, Anitschkov and
Chalatow, carried out one of the most important
experiments in the early history of cardiology which gave
rise to the lipid theory of atherogenesis.
 Thus, modern cardiology was born in Europe and it then
spread rapidly to the rest of the world.

13. The beginning
3. The early years
 Cardiology quickly developed its own journals and societies, both of which are
features of a separate medical specialty.
 In 1908, both the Archives des Maladies du Coeur in France and the Zentralblatt
fur Herzkrankheiten in Germany commenced publication.
 In 1909, Heart, the first English language journal, was started.
 In Italy, Malatti du cuore began publication in 1916 and the American Heart
Journal in 1925.
 Reflecting continental and global interests, the European Heart Journal was
begun in 1980 and the International Journal of Cardiology in 1981.
 At the present time, 114 print cardiology journals are listed in the Index
Medicus, and the number of online-only journals is growing rapidly.

14. The beginning
3. The early years…
 The British Cardiac Club was founded in 1922 and became the British
Cardiac Society in 1937.
 The American Heart Association was begun in 1924.
 The Belgian, Italian, French and Swiss Cardiac Societies were formed
in 1934, 1935, 1937 and 1948, respectively.
 In the US, a second important organization, the American College of
Cardiology was established in 1949.
 National governments also began to support cardiac research.
 In the United States, the National Heart Institute (now the National
Heart, Lung and Blood Institute) was established in 1948.

15. The beginning
4.Cardiac catheterization
 In 1929 Werner Forssmann, a resident in urologic surgery in
Eberswalde, Germany, carried out the first cardiac catheterization, and
on himself !
 His goal was to develop a method of injecting drugs into the heart.
 Cardiac catheterization, first as a research, and later as a diagnostic
tool, was begun in 1941 at Columbia University/Bellevue Hospital in
New York by Andre Cournand (formerly a French pulmonary
physiologist) and Dickinson Richards, who systematically investigated
the haemodynamics in every important cardiac condition.
 They and Forssmann shared a Nobel Prize.
 By the 1960s, cardiac catheterization had spread to most large
hospitals in the industrialized world and had become an indispensible
cardiac diagnostic procedure.

16. The beginning
4.Cardiac catheterization…
 Catheter-based treatments of arrhythmias, including
pacemakers and internal cardioverter defibrillators
followed and catheter-based replacement of the aortic
valve.
 Coronary arteriography, first carried out accidentally and
then developed by Sones in Cleveland in 1958.
 Coronary arteriography allowed the diagnosis and aided in
the management of patients with ischaemic heart disease.

18. The beginning
4.Cardiac catheterization…
 Gruntzig and coworkers in Zurich, developed
transluminal coronary angioplasty; which was
followed by the development of stents and other
refinements of percutaneous coronary intervention.

19. 2. Milestones in the evolution of cardiology
 Treatment of acute myocardial infarction
 Acute coronary syndromes
 Imaging
 Cardiac surgery
 Arrhythmias
 Valvular heart disease
 Heart failure
 Prevention

20. 1. Treatment of acute myocardial infarction
 In his classic 1912 paper on AMI, Herrick stated ‘the
importance of absolute rest in bed … is clear’and for
five decades bed rest was the cornerstone of therapy
 Practice gradually changed; ambulation was
accelerated and convalescence shortened.
 The development of the coronary care unit (CCU) was
one of a pair of signal advances in the treatment of
AMI. The idea of the CCU was proposed in 1961 by
Julian, then a medical registrar at the Royal Infirmary,
Edinburgh.

21. Treatment of acute myocardial infarction…
Four separate concepts made the CCU possible:
 (i) aggregating patients into a single area of the hospital where
trained personnel, equipment and drugs are all available;
 (ii) continuous monitoring of the ECG;
 (iii) development of closed-chest cardiac resuscitation for
ventricular fibrillation; and
 (iv) delegation of the immediate treatment of ventricular
fibrillation and other life-threatening arrhythmias to trained
nurses, in the absence of a physician.

22. Treatment of acute myocardial infarction…
 In the 1970s, the Soviet cardiologist Chazov and coworkers gave
birth to the modern era of management of AMI with the second
signal advance in the care of patients with AMI, i.e. reperfusion of
the ischaemic myocardium by infusion of streptokinase directly into
the thrombotically occluded coronary artery in an effort to limit
infarct size.
 Chazov's paper was not translated and had little impact outside the
Soviet Union. In 1979, Rentrop et al. introduced this treatment to the
rest of the world.
 Thus, limiting infarct size and thereby reducing mortality had moved
from the experimental laboratory to the hospital emergency room.

23. 2.Acute coronary syndromes
 In the first half of the twentieth century, ischaemia was clearly divided
into two separate categories, transient ischaemia, which caused chronic
angina and prolonged ischaemia at rest which was responsible for AMI.
 In the late-1930s, clinicians began to identify a third syndrome, having
some characteristics of both of these conditions. This condition,
ultimately named unstable angina, was considered to be severe angina
occurring at rest.
 it has become apparent that the majority of cases of unstable angina are,
in fact, small non-ST segment elevation AMIs (NSTEMI).
 In these patients, coronary arteriography often shows multi-vessel
obstructive coronary artery disease without recent total occlusion and
are not helped by fibrinolytic therapy and those that are at high risk
require prompt, coronary revascularization.

24. 3. Imaging
 Until the end of the nineteenth century, the disordered
structure and function of the heart could not be
ascertained in living humans.
 The first approaches to cardiac imaging, radiography and
fluoroscopy, followed by peripheral angiocardiography and
then selective angiocardiography, have overcome this
barrier.
 we now have various modes of echocardiography
available, a technique first described in 1954 by Edler and
Hertz in Sweden, computed X-ray tomography, magnetic
resonance imaging and spectroscopy, radionuclide imaging,
and positron emission tomography.

25. 4. Cardiac surgery
 The modern era of cardiac surgery began in the early 1950s
with the development of open heart surgery using
cardiopulmonary bypass, which was necessary for the
successful repair of most congenital and many acquired cardiac
disorders.
 This ushered in a series of spectacular collaborations between
surgeons and engineers. The development of prosthetic heart
valves led to astounding benefits in the lives of patients with
severe valvular heart disease.
 Coronary artery bypass grafting, begun by DeBakey et al. in
Houston in 1964 provides relief from angina pectoris that is
refractory to medical management, and has improved the
survival of patients, such as those with left main coronary artery
disease and three-vessel disease.

27. 5. Arrhythmias
 Serious bradyarrhythmias—particularly advanced atrioventricular
block—was the first arrhythmia to be controlled, initially by an external
pacemaker by Zoll in Boston in 1952 and then an implanted cardiac
pacemaker, developed by Elmqvist and Senning in Stockholm in 1958.
 This was followed by the development of external cardioversion of
ventricular fibrillation, ventricular tachycardia, and atrial fibrillation.
 The development of implantable cardioverter-defibrillators by
Mirowski et al. has proved to be life-saving in patients having ventricular
fibrillation and sudden cardiac death.
 Progressive improvements in electrophysiological testing and endocardial
electrical mapping have led to the abolition of a number of arrhythmias,
including paroxysmal supraventricular and ventricular tachycardias.

28. 6. Heart failure
 Although heart failure was recognized as a clinical entity in the
eighteenth century, the causes were obscure; no effective
therapies other than digitalis were available, and the prognosis
was dismal.
 Mercurial diuretics were introduced in the 1920s, but these
drugs were only of modest efficacy and required painful, deep
intramuscular injections.
 Development of effective oral diuretics; the benzothiadiazines in
1957, the aldosterone inhibitors in 1959, and the powerful ‘loop
diuretics’ in 1962.
 The next important step was vasodilator therapy, which was
first administered intravenously in acute heart failure

29. 6. Heart failure…
 Cohn et al. then led a multicentre trial, the VHEFT trial, which
showed improved survival in patients with chronic heart failure
who received the combination of hydralazine and a long-acting
nitrate.
 Next came the application of neurohormonal blockers—
angiotensin-converting enzyme inhibitors, beta-adrenergic
receptor blockers, and aldosterone inhibitors—each of which was
shown to improve prognosis.
 Cardiac transplantation, introduced in 1967, is effective in
prolonging life by about 10 years in end-stage heart failure, but
because of a donor shortage, it is available only to a small fraction
of patients who could benefit.

30. 7. Prevention
 Up to the middle of the twentieth century, the practice of cardiology
focused on the treatment of patients with established, often advanced,
cardiovascular disease and most treatment were symptomatic.
 Prevention of cardiovascular disease was not deemed possible, and
rarely mentioned.
 At mid-century, the occurrence of an AMI was usually totally
unexpected. Most commonly it struck down apparently healthy
persons in their most productive years.
 However, by 1961, investigators in the Framingham Heart Study had
shown that overtly healthy subjects with hypertension and
hypercholesterolaemia were at higher risk of developing AMI ; they
coined the term ‘coronary risk factors’.

31. 7. Prevention
 An array of additional coronary risk factors is now recognized
which include age, gender, family history, cigarette smoking, low
HDL-cholesterol, elevated lipoprotein, diabetes, inflammation,
and chronic kidney disease.
 The identification of these risk factors
has provided the basis for prevention of
atherosclerotic vascular disease.
 Healthy lifestyles, weight control, cessation of smoking,
reduction of low-density lipoprotein cholesterol, and control of
blood pressure have substantially reduced the incidence and
recurrence of AMI, acute coronary syndromes, stroke, and
coronary deaths.

32. 3. The present
 Evidence-based cardiological practice
 The rise of global cardiology
 The growth of cardiovascular centres

33. 4.The future
 The near term future, i.e. approximately the next decade, is likely to see an
increasing prevalence of atherosclerotic disease worldwide, with the ageing of
the population and the rise in obesity and diabetes.
 Efforts will be intensified to start preventive therapy, such as changes in diet and
the use of statins, progressively earlier in life.
 Perhaps, inexpensive ‘polypills’ containing aspirin, an angiotensin-converting
enzyme inhibitor, a thiazide diuretic and a statin, or some variation thereof, will
prove to be of value for primary and secondary prevention in selected persons in
developing nations.
 Successful use of stem-cell therapy in the prevention and treatment of heart
failure following AMI and in some forms of chronic heart failure is likely.
 Pluripotent stem cells derived from the patient's own cell types, including
fibroblasts, are particularly interesting.

34. 4.The future…
 There will be enormous advances and rapidly growing use of
smaller, more reliable, safer, and less-expensive implanted
ventricular assist pumps as ‘destination therapy’.
 When all else fails, gene therapy may be employed .
 It will be necessary to set up new, specialized clinics to care
for patients who receive cell-based, device-based, and
combination therapy for heart failure and AMI.

35. MILESTONES IN CARDIOLOGY
 1628 : William Harvey, an English physician, first described
blood circulation.
 1706 : Raymond de Vieussens, a French anatomy professor,
first describes the structure of the hearts chamber and
vessels.
 1733 : Stephen Hales, an English clergyman and scientist,
first measured blood pressure.
 1801 : Francisco Romero ,a Spanish surgeon done the first
cardiac surgery known as Open Pericardiostomy

36. MILESTONES IN CARDIOLOGY…
 1816 : Rene T.H. Laennec, a French physician, invents
the stethoscope.
 1896 : Dr. Ludwig Rehn, a German
Surgeon Performed first successful heart surgery on
human being without any complications; he stitched a
wound on the heart of German soldier.
 1899: Two Swiss
physiologists introduces the process of defibrillation
on dogs heart

37. MILESTONES IN CARDIOLOGY…
 1903 :Willem Einthoven, a Dutch physiologist, develops the
electrocardiograph.
 1912 : James B. Herrick, an American physician, first
describes heart disease resulting from hardening of the
arteries.
 1938 :Robert E. Gross, an American surgeon, performs
first open heart surgery.
 1947: Defibrillator was first time used on human being
during the open heart surgery by Dr. Claude Beck(Prof.
Surgeon at Western Reserve University)

38. MILESTONES IN CARDIOLOGY…
 1951 :Charles Hufnagel, an American surgeon, develops a
plastic valve to repair an aortic valve.
 1952 : F. John Lewis, an American surgeon performs first
successful open heart surgery.
 1952 : Dr. John F. Lewis, an American Surgeon
used hypothermia to temporarily slow down the heart beat
making it accessible to lengthen the time of Open Heart
Surgery.
 1953 :Jhon H. Gibbon, an American surgeon, first uses a
mechanical heart and blood purifier.

39. MILESTONES IN CARDIOLOGY…
 1954 : First cross circulation operation was performed by
Dr. C. Walton Lillihie(American Surgeon)
 1961: J.R.Jude, an American cardiologist, leads a team
performing the first external cardiac massage to restart a
heart.
 1964: Dr. James D. Hardy of the University of
Mississippi, attempted the first heart transplant from a
nonhuman primate – a chimpanzee named Bino -- into a
human. The patient was 68-year-old Boyd Rush. After only
90minutes, the heart stopped functioning because it was
too small to maintain circulation on its own .

40. MILESTONES IN CARDIOLOGY…
 1965 :Micheal DeBakey and Adrian Kantrowitz, American
surgeons, implanted mechanical devices to help a diseased
heart.
 1967: Dr. Rene Favaloro , an American Surgeon
used a vein from the leg to bypass a blocked coronary
artery. This procedure, known as coronary artery bypass
surgery .
 1967 :Christian Barnard , a South African surgeon,
performs the whole heart transplant from one person to
another.

41. MILESTONES IN CARDIOLOGY…
 1974: Andreas Gruentzig performed the first peripheral
human balloon angioplasty.
 1980 : Michel Mirowski , a Polish Cardiologist,
the first ICD (Implantable Cardioverter Defibrillators) --
weighing 9 ounces and about the size of a deck of cards –
was implanted into a human patient.
 1982 : Willem DeVries, an American surgeon, implants a
permanent artificial heart, designed by Robert Jarvik, an
American physician, into a patient.

42. CARDIOLOGY'S 10 GREATEST DISCOVERIES OF THE
20TH CENTURY
 1. Electrocardiography
 2. Preventive Cardiology and the
Framingham Study
 3. “Lipid Hypotheses” and Atherosclerosis
 4. Coronary Care Units
 5. Echocardiography

43. CARDIOLOGY'S 10 GREATEST DISCOVERIES OF THE 20TH
CENTURY…
 6. Thrombolytic Therapy
 7. Cardiac Catheterization and Coronary
Angiography
 8. Open-Heart Surgery
 9. Automatic Implantable Cardiac
Defibrillators
 10. Coronary Angioplasty

44. RECENT ADVANCES AND FUTURE TRENDS IN
CARDIOLOGY
 Clinical Cardiology
 Interventional Cardiology
 Stem Cell Therapy
 Cardiac Imaging
 X-ray imaging
 Computed Tomography (CT)
 Magnetic Resonance (MR) imaging
 Nuclear Medicine imaging
 Ultrasound

45. Clinical Cardiology
 Clinical cardiology is never static and lot of effort is put
on development of better drugs.
 The most recent has been the approval and availability of
newer thenopyridine prasugrel which is used in
treatment of acute coronary syndromes for those
proceeding to percutaneous interventions.
 For management of angina we have newer drugs
ivabridine and ranolazine as add on therapy.

46. Clinical Cardiology…
 Dabigatran an oral anticoagulant is a very exciting addition in
stroke and embolism prevention in patients with
atrialfibrillation.
 it does not require INR monitoring as compared to warfarin
 superior to warfarin in reducing stroke or peripheral embolic
events.
 Less risk of hemorrhage is an added attraction.
 Newer antiarrhythmics have become available which includes
drugs like dronedarone which is indicated in prevention of
recurrence of atrial fibrillation.
 Compared to amiodarone the incidence of pulmonary, hepatic
and thyroid related side effects is almost negligible.

47. Interventional Cardiology
 There have been exciting developments in the field of interventional
cardiology too.
 On catheterization table, assessment of lesion severity using Fractional
Flow Reserve (FFR) has gained prominence lately.
 FFR represents the maximum achievable blood flow after challenge
with adenosine to myocardium supplied by stenotic artery as a
fraction of normal maximum value.
 A value of less than 0.75 identifies stenosis with inducible ischemia.
 This has made multi vessel disease angioplasty much more evidence
based and unnecessary stenting in physiologically normal lesions is
avoided.

48. Interventional Cardiology…
 Recently lot of interest has been generated by concept
of thrombus aspiration in primary percutaneous
intervention.
 In a Bayesian meta-analysis, adjunctive thrombectomy
improves early markers of reperfusion but does not
substantially effect 30-day post-MI mortality,
reinfarction, and stroke.
 Thrombectomy is one of the rare effective preventive
measures against no-reflow.

49. Interventional Cardiology…
 Local drug delivery viz Drug Eluting Balloons (DEB) have
generated lots of interest lately.
 Rationale for the development of DEB derives mainly from the
limitations of Drug Eluting Stents (DES).
 DEB may be used in subsets of lesions where DES cannot be
delivered or where DES do not perform well, such as in tortuous
vessels, small vessels, or long diffuse calcified lesions, which can
result in stent fracture
 The most appealing indication for paclitaxel eluting balloons
would be for the treatment of ISR.

50. Advantages of DEB…
Additional potential advantages include
 (a) homogenous drug transfer to the entire vessel wall;
 (b) rapid release of high concentrations of the drug sustained in the
vessel wall no longer than a week, with little impact on long term
healing;
 (c) absence of polymer could decrease chronic inflammation and the
trigger for late thrombosis;
 (d) absence of a stent allows the artery’s original anatomy to remain
intact, notably in cases of bifurcation or small vessels, thereby
diminishing abnormal flow patterns; and
 (e) with local drug delivery, overdependence on antiplatelet therapy
could be curtailed.

51. Interventional Cardiology…
 Percutaneous coronary intervention (PCI) with bioabsorbable
stents has created interest recently.
 The need for mechanical support for the healing artery is
temporary, and beyond the first few months there are potential
disadvantages of a permanent metallic prosthesis.
 Biodegradable stents contain a biodegradable polymer or are
completely biodegradable.

52. Interventional Cardiology…
 Till now management of valvular heart disease was mostly a
surgical domain.
 Recently, the potential for less invasively replicating these
successful surgical procedures without the need for
thoracotomy or cardiopulmonary bypass has generated
considerable interest.
 The Mitraclip device has proven relatively safe and often
effective.
 Using a multiaxial transeptal catheter system, a metallic clip is
used to grasp and approximate the free edges of the 2 leaflets

53. Interventional Cardiology…
 Balloon aortic valvuloplasty replacing Surgical aortic
valve replacement for patients with symptomatic
severe aortic valve stenosis.
 Percutaneous aortic valve replacement (PAVR) using
stent-based prostheses has emerged as a promising
new option in recent years

54. Stem Cell Therapy
 Stem cell therapy as applied to cardiology has shown
partial progress.
 The angina in so called end stage coronary artery
disease is refractory to conventional medical therapy.
 Laboratory and preclinical studies have provided
evidence for the safety and potential efficacy of
autologous CD34+ stem cell therapies as treatment for
angina.

55. Stem Cell Therapy
 Clinical studies investigating intramyocardial
transplantation of autologous CD34+ stem cells by
catheter injection for patients with refractory angina
show that this is safe and feasible.
 Role of stem cells in heart failure is also under
evaluation.
 There appeared to be a significant decrease in long-term
mortality in the stem-cell-treated patients.

56. Cardiac Imaging
 X-ray imaging
 Computed Tomography (CT)
 Magnetic Resonance (MR) imaging
 Nuclear Medicine imaging
 Ultrasound

57. RECENT ADVANCES AND FUTURE TRENDS IN CARDIOLOGY…
 Minimally Invasive Heart Surgery.
 Types of Minimally Invasive Heart Surgeries
Minimally Invasive Valve Surgery
Minimally Invasive CABG Surgery
Off-pump/beating heart bypass surgery

58. RECENT ADVANCES AND FUTURE TRENDS IN CARDIOLOGY…
 Benefits of minimally invasive surgical techniques
 Small incisions.
 Small scars.
 Shorter hospital stay after surgery .
 Low risk of infection.
 Low risk of bleeding and blood transfusion .
 Shorter recovery time and faster return to normal
activities/work.
 Division of the sternum is not needed for robotically assisted
heart surgery

59. RECENT ADVANCES AND FUTURE TRENDS IN CARDIOLOGY…
 Robotically Assisted Heart Surgery
 Types of Robotically Assisted Heart Surgeries
Robotically Assisted Valve Surgery.
Robotically Assisted Bypass Surgery.
Robotically Assisted ASD .
Robotically Assisted Removal of Cardiac Tumors .

60. ISSUES OF CARDIOLOGY
 CARDIOVASCULAR DISEASES
Coronary artery disease (CAD)
Congestive heart failure (CHF)
Arrhythmias

61. CARDIOVASCULAR DISEASES
 Coronary artery disease (CAD) is still the major
cardiovascular pathology, and is expected to remain so for the
foreseeable future.
 However, improved treatment of CAD has resulted in an
increased survival rate, so that there is an increasing
incidence of patients with severe myocardial scars caused by
previous infarction.
 These weakened hearts will lead to an increase in the
number of patients suffering from congestive heart failure
(CHF), who will form an increasingly important group.

62. CARDIOVASCULAR DISEASES….
 A third group of patients that is expected to become
increasingly important is that of patients with cardiac
arrythmias.
 While the number of congenital arrythmias will remain more-or-
less constant,
 the aging population will increase the incidence of atrial
fibrillation, and the increased number of heart attack
survivors will result in an increase in the incidence of
ischemic ventricular tachycardia and the related risks of
sudden death.

63. LEGAL AND ETHICAL
ISSUES IN
CARDIOVASCULAR
MEDICINE

64. LEGAL AND ETHICAL ISSUES IN CARDIOVASCULAR
MEDICINE
 Clinical ethics “provides a structured approach for
identifying, analyzing, and resolving” moral problems and
ethical dilemmas that arise while caring for patients.
 Four ethics principles address most of these problems—
 beneficence,
 nonmaleficence,
 respect for patient autonomy, and
 justice.

65. Ethics principles
 Beneficence refers to the clinician's duty to promote the
best interests of patients.
 Nonmaleficence refers to the duty to prevent or avoid
doing harm to patients.
 Respect for patient autonomy refers to the duty to respect
patients’ values, goals, and rights of self-determination.
 Justice refers to the duty to treat patients fairly (i.e., based
on medical need, not on patient characteristics such as
ethnicity and gender).

66. Common Ethical Dilemmas In
Cardiovascular Medicine
 1. Promoting Beneficence
 Beneficence requires that clinicians promote the interests of
patients, which take precedence over the clinicians’ self-interests.
 Beneficent clinicians maintain clinical competence and strive for
quality, safety, and continuous improvement in clinical practice.
 Beneficence requires that clinicians completely and clearly share
their assessments and recommendations with patients and ensure
that patients understand them.
 Recommendations should not be presented as a menu of choices,
but as a hierarchy of options based on efficacy, safety, and
patients’ health care–related values, preferences and goals.

67. Common Ethical Dilemmas In
Cardiovascular Medicine…
 2. Preventing and Avoiding Harm to Patients
 The ethics principle of nonmaleficence is closely coupled with
the principle of beneficence.
 Weighing the potential benefits versus the potential harms of a
diagnostic or therapeutic intervention is common in clinical
practice.
 Needless to say, clinicians should prevent or minimize harms
associated with any intervention.
 Nonmaleficence also requires that clinicians not abandon
patients.
 conflicts of interests should not compromise clinicians’
nonmaleficence duties

68. Common Ethical Dilemmas In Cardiovascular
Medicine…
 3. Ensuring Informed Consent and Informed
Refusal
 Consent problems arises because patients experiencing
acute, life threatening illness that interfere with their ability
to make decisions on treatment/ participation in clinical
research.
 The informed consent is based on the principle of
autonomy.
 Consent denotes voluntary agreement, permission or
compliance.

69. Legal and Ethical Issues; Informed Consent
 It implies to permission by the patient to perform an act
on his body either for diagnosis or therapeutic
procedure.
 The four elements of consent are;
voluntariness
capacity
knowledge
Decision making

70. Points to be considered in consent…
 Consent must be given voluntarily
 If patient is not mentally capable (critical patients) informed
consent should be obtained from surrogate or legal next of kin.
 It should be given by a person of sound mind & above the age of 18
years.
 Requires the disclosure of basic information considered necessary
for decision making
 Patients providing consent should be free from pain & depression.

71.  Consent obtained from a minor
 Consent given under fear, fraud or misrepresentation
 Consent obtained from the person who is not fit
 Consent obtained in language not understood by the person
 Consent obtained from person under sedation, intoxication or
semiconscious
 Consent obtained without providing adequate information on
the possible risks are invalid under law.

72. Common Ethical Dilemmas In
Cardiovascular Medicine
 4. Handling Medical Errors
 The ethical rationale for disclosing errors to patients is
strong.
 First, clinicians should act in the best interests of the
patient. Nondisclosure does not serve the patient and
damages trust because many patients eventually learn of
errors.
 Second, respect for patient autonomy requires that
clinicians disclose errors to patients to allow for
informed decision-making.

73. Common Ethical Dilemmas In Cardiovascular
Medicine…
 Handling Medical Errors….
 Third, justice requires that patients be given what
is due to them, including information about their
medical condition and compensation if appropriate
(e.g., for injury).
 Finally, clinicians should participate in efforts to
prevent errors.

74. Handling Medical Errors….
Clinicians may feel uncomfortable disclosing errors to
patients. The following steps can lessen this burden:
 Disclosure should be done in private; the patient's
loved ones and essential members of the health care
team should be present. Interruptions should be
avoided.
 Before disclosing the error, the clinician should discern
the patient's perception of the problem.

75. Handling Medical Errors….
 When disclosing the error, the clinician should speak clearly and check
for comprehension (e.g., “May I clarify anything?”).
 After disclosing the error, the clinician should sincerely apologize and
inform the patient that the clinician and organization will act to
prevent future errors. The clinician should avoid attributing blame to
others (e.g., “The nurse must have forgotten to tell me about your
allergy.”).
 The clinician should acknowledge the patient's response to the
disclosure by using empathic statements (e.g., “I can see that you are
upset by this news.”).
 The clinician should describe a treatment and follow-up plan.
 The clinician should document the discussion in writing.

76. Common Ethical Dilemmas In Cardiovascular
Medicine…
5. Addressing Refusals of and Requests for
Withdrawal of Life-Sustaining Treatments
 Respect for patient autonomy is the ethics principle that
underlies a patient's right to refuse or request the
withdrawal of medical treatments
 A patient also has the right to refuse previously consented
treatments if their health care–related values, preferences,
and goals have changed.

77. 5. Addressing Refusals of and Requests for
Withdrawal of Life-Sustaining Treatments…
 Regardless of the clinician's intent, beginning or continuing
a treatment that a patient has refused may be viewed from
a legal standpoint as battery.
 Dying patients (or their surrogates) may refuse or request
the withdrawal of life-sustaining treatments (e.g.,
mechanical ventilation, hemodialysis, artificially
administered hydration and nutrition, device therapies)
that are perceived by the patients (or surrogates) as
burdensome.
 Withdrawal of life-sustaining treatments from dying
patients who no longer want the treatment is widely
practiced.

78. Common Ethical Dilemmas In Cardiovascular
Medicine…
6. Fostering Advance Care Planning
 Respect for patient autonomy is the ethics principle that
underlies advance care planning.
 Advance care planning is a process in which patients, working
with their clinicians and loved ones, articulate their values,
preferences, and goals regarding future health care decisions
 One form of advance care planning is the do not resuscitate
(DNR) order.
 In general, cardiopulmonary resuscitation (CPR) is the default
standard of care for cardiac arrest unless a DNR order has been
written for the patient.

79. 6. Fostering Advance Care Planning…
 Advance care planning also includes completion of an advance
directive.
 ADs are health care instructions used when a patient lacks
decision-making capacity.
 The AD should be regarded as an extension of the autonomous
patient.
 Common types of ADs are the health care power of attorney, in
which a patient designates another person for making future
health care decisions, the living will, in which a patient lists
preferences about future treatments, and the combined AD,
which has features of both a health care power of attorney and a
living will.

80. Common Ethical Dilemmas In Cardiovascular
Medicine…
7. Ensuring Appropriate Surrogate Decision Making
 Patients who lack decision-making capacity are incapable
of being autonomous.
 For these patients, clinicians must rely on surrogate
decision-makers to make decisions for patients.
 If the patient's AD names a surrogate, this choice should be
honored.
 If the patient does not have an AD, the ideal surrogate is one
who best understands the patient's health care values,
preferences, and goals.

81. Common Ethical Dilemmas In Cardiovascular
Medicine…
8. Addressing Requests for Interventions
 Many patients (or their surrogates) make requests for
specific diagnostic and therapeutic interventions.
 Many requests are reasonable and within standards of
care; clinicians generally should grant these requests.
 However, clinicians are not obligated to grant requests
for interventions that are ineffective or violate their
consciences.

82. Common Ethical Dilemmas In Cardiovascular
Medicine…
9. Maintaining Patient Confidentiality
 The ethics principle of respect for patient autonomy
requires that clinicians maintain patient
confidentiality.
 Clinicians need access to patients’ medical information,
ask sensitive questions and conduct thorough physical
examinations to assess and treat patients properly.
 Patients should trust that their personal and medical
information will be kept confidential.

83. Common Ethical Dilemmas In Cardiovascular
Medicine…
10. Bedside Allocation of Health Care Resources
 The ethics principle of justice requires that
clinicians treat patients fairly.
 Injustice occurs when health care–related
decisions are based on patient-specific factors such
as gender, ethnicity, and religion, not on medical
need.

84. THE HISTORY OF CARDIAC NURSING
 The 1960s
 first coronary care unit was founded at the Royal Infirmary
in Edinburgh, Scotland, by Dr. Desmond G. Julian
 cardiopulmonary resuscitation
 The 1970s
 cardiac care units and departments
 more trained cardiac nurses skilled in CPR, cardiac
monitoring and the administration of cardiac medicines.

85. THE HISTORY OF CARDIAC NURSING…
 The 1980s
 Cardiac nursing as an established nursing specialty.
 The Society for Peripheral Vascular Nursing (SPVN), founded in
Boston in 1982 and renamed the Society for Vascular Nursing
(SVN) in 1990
 The American Association of Cardiovascular and Pulmonary
Rehabilitation was founded in 1985
 Association provides education and training for cardiac nurses

86. THE HISTORY OF CARDIAC NURSING…
 The 1990s
The Preventive Cardiovascular Nurses Association
(PCNA) was founded in the United States as the Lipid
Nurse Task Force (LNTF) in 1992
evidence-based study of a wider array of cardiovascular
disorders

87. THE HISTORY OF CARDIAC NURSING…
 The 21st Century
 The American Nurses Credentialing Center (ANCC) is the
world's largest nurse credentialing organization, and a
subsidiary of the American Nurses Association (ANA).
 The first Cardiac and Vascular Nurse examinations were
administered by the PCNA in May 2001 in conjunction with
the ANCC.

88. The 21st Century….
 The PCNA continues to offer the certification exams as well
as continuing education courses online and live seminars
and training events.
 In addition to the ANCC Cardiac/Vascular Nurse
Certification, the PCNA supports the Accreditation Council
for Clinical Lipidology (ACCL) certification examination.
 Cardiac nursing continues to grow as nursing becomes
more specialized.

89. THEORY APPLICATION
 PEPLAU’S THEORY OF IPR

90. PEPLAU’S THEORY OF IPR..
Four Levels of Anxiety:
1.Mild anxiety is a positive state of heightened awareness
and sharpened senses, allowing the person to learn new
behaviors and solve problems. The person can take in all
available stimuli (perceptual field).
2. Moderate anxiety involves a decreased perceptual field
(focus on immediate task only); the person can learn new
behavior or solve problems only with assistance. Another
person can redirect the person to the task.

91. Four Levels of Anxiety…
 3. Severe anxiety involves feelings of dread and terror. The
person cannot be redirected to a task; he or she focuses only
on scattered details and has physiologic symptoms of
tachycardia, diaphoresis, and chest pain.
4. Panic anxiety can involve loss of rational thought,
delusions, hallucinations, and complete physical immobility
and muteness. The person may bolt and run aimlessly, often
exposing himself or herself to injury.

92. JOURNAL ARTICLE
 Journal; Recent Advances in Preventive Cardiology and Lifestyle
Medicine
 Barry A. Franklin, PhD;
 Mary Cushman, MD, MSc
 A Cardioprotective Polypill: Need for a Fully Powered Trial?
Wald and Law proposed a theoretical cardioprotective polypill, on the
basis of a review of the scientific literature, as a population strategy to
combat CVD.
The daily formulation would include a statin, 3 blood pressure–lowering
drugs, folic acid, and aspirin, and could theoretically reduce coronary
events by 88% and stroke by 80%.

93. REFERENCES
 Kaul,U.,Arora,P., Recent Advances And Future Trends In
Cardiology’ , JIMSA,2012.Vol.25.,No.3
 Rasche,V., Gishers,G., ‘Cardiology; trends and
developments’ Mediamundi 47/2., 2003.
 Bonow etal., Braunwailds Heart Disease, A text book of
cardiovascular medicine’ 9th edition.,2012
 Jonsen,a,r., Siegler,M., Clionical Ethics; A practical approach
to decision making., 5th ed., Newyork,2011