The First Writings of Heart Failure

2. The First Writings of Heart Failure Hector O. Ventura, MD Section Head, Heart Failure & TransplantationChairman, Graduate Medical EducationOchsner Heart & Vascular InstituteNew Orleans, Louisiana

3. T.S. Elliot “The historical sense involves a perception, not only of the pastness of the past, but its presence.”

4. Frank Luttmer There is another reason to study history: it is FUN. History combines the excitement of exploration and discovery with the sense of reward born of successfully confronting and making sense of complex and challenging problems.

5. Hydropsy or “Dropsy” Generalized swelling due to accumulation of excess water

6. The Concept of Heart Failure

7. Paradigms in the Evolution of Our Understanding of Heart Failure Clinical ObservationCase reports describing signs and symptoms Anatomic Pathology Autopsy correlations with clinical findings, microscopy pathology Circulatory Physiology Abnormalities in the circulation of the blood Katz AM. J Card Fail. 1997;3:319-34.

8. Paradigms in the Evolution of Our Understanding of Heart Failure Cardiac HemodynamicsPressure and flow abnormalities in the failing heart Cell Biochemistry Abnormal contraction, and Biophysics relaxation and energetics microscopy pathology Molecular BiologyGrowth abnormalities Katz AM. J Card Fail. 1997;3:319-34.

9. Bloodletting “It is the least equivocal of remedies: its good effects, when properly administered, are, in most cases, so immediate and striking... In short, bloodletting is a remedy which, when judiciously employed, it is hardly possible to estimate too highly." Ventura HO & Mehra MR. J Card Fail. 2005;11:247-52.

10. Egyptians (4000 BC - 2000 BC)

11. Ebers Papyrus “The heart is the centre, its vessels lead to all members, whether the doctor lays his fingers in the forehead, on the back of the neck, on the hands, everywhere he meets with the heart, because its vessels lead to all members.”

12. Contribution to the Knowledgeof Heart Failure The Egyptians were able to count the pulse and used it as means of assessing the function of the heart. Dyspnea was due to the blockage of the flow of blood and employed venesection (bleeding).

13. “When thou examinest the obstruction in his abdomen and thou findest that heis not in a condition to leap the Nile, his stomach is swollen and chest asthmatic, then say thou to him: it is blood that got itself fixed and does not circulate.” Saba MM et al. J Card Failure. 2006;12:416-21.

14. “Do thou cause an emptying by means of a medical remedy. Make him therefore: Cook in beer that has been brewed from many ingredients, strain into one thoroughly, and let the patient drink.” Wormwood 1/8, Elderberries 1/16, Sebester 1/8, Sasa-chips 1/8… Saba MM et al. J Card Failure. 2006;12:416-21.

15. The main and most common word utilized to indicate "weakness or feebleness" of the heart is “wegeg.” Saba MM et al. J Card Failure. 2006;12:416-21.

16. 855m. “Weakness due to old age. These are pain-matters have fallen on his heart.” 855f. “His heart is bored. This means that his heart is weak because of heat of the anus.” 855x. “His flesh is entirely hot, as the heart of a man tires, exhausted by the road. This means that his flesh is tired as a result, like the flesh of a man because he has gone very far.” Saba MM et al. J Card Failure. 2006;12:416-21.

17. 855l. “The heart kneels down because of pain-matter. This means that his heart becomes small inside of his belly. Pain matters have fallen on his heart and it becomes and kneels down.” 855e. “The heart weakens. This means that the heart does not speak or that the vessels of the heart are dumb. Its information under your hands which normally appears because of the air with which they are filled is missing.” Saba MM et al. J Card Failure. 2006;12:416-21.

18. 855c. “The heart is weak. A vessel called "the receiver" is the one that causes it. It is this vessel that gives water to the heart.” 855d. “Debility that has arisen in the heart. This means it is arching out as far as the borders of the lung and liver. It happens there from to him that his vessels become deaf, having fallen down as a result of their heat.” Saba MM et al. J Card Failure. 2006;12:416-21.

19. Ancient Greeks (2000 BC - 100 BC)

20. Contribution to the Knowledge of Medicine The major contribution of the Greeks was to separate the practice of medicine from the disciplines of philosophy and theology. This allowed medicine to develop as a separate craft based on knowledge gained by careful observation of patients.

21. Contribution to the Knowledge of Medicine Hippocrates (460-370 BC) First ethical code Rational scientific Clinical observation

22. Hippocrates “When the ear is held to the chest, and one listens for some time, it may be heard to seethe inside like a boiling of vinegar.” {Diseases II, LXI}

23. Hippocrates “Should [phlegm coming from the brain] make its way to the heart, palpitation and difficulty breathing supervene…for the phlegm descends cold to the lungs and heart, the blood is chilled; the veins…beat forcefully against the lungs and heart, and the heart palpates, so that under this compulsion difficulty of breathing and orthopnea results.” {The Sacred Disease IX}

24. Hippocrates “Dropsy is usually produced when the patient remains for a long time with impurities of the body following a long illness. The flesh is consumed and becomes water… the abdomen fills with water, the feet and legs swell, the shoulders, clavicles, chest and thighs melts away.” {Affections XXII}

25. Romans (100 BC - 476 AD)

26. Contribution to the Knowledge of Medicine Progress in: Public health Sanitation Founded first hospitals

27. Celsus “…when moderate and without any choking, it is calleddyspnea; when more severe, so that the patient cannot breathe without making a noise and gasping,asthma; but when in addition the patient can hardly draw in his breath unless with the neck outstretched,orthopnea. Of these the first can last a long while, the two following as a rule acute…blood letting is the remedy unless anything prohibits it. Moreover even in bed the head is to be kept raised…”

28. The Circulation According to Galen

29. Galen (130 - c 200 CE) . . . in [the heart] there must be warmth in plenty, for it both moves itself and the other parts at the same time as with its pulse, and it also warms them . . . The heart must always be on the boil . . . the heat flows from the heart to the members not only through the arteries but also through the veins . . . On the Use of the Pulse I, 5-7. . . . we breathe for regulation of heat. This then is the principal use of breathing [which] is brought about by both parts of of breathing, both in breathing and out; to the one belong cooling and fanning, and to the other evacuation of the smoky vapor. On the Use of Breathing 5,8.

30. The Middle Ages (476 AD - 1450 AD)

31. Contribution to the Knowledge of Medicine Decline of the Roman Empire Europe was devastated by wars, famines, epidemics and social upheaval which greatly inhibited further progress in medicine.

32. Contribution to the Knowledge of Medicine Galenic Theories The Christian church controlled Europe and repressive regimes prevented further advances in scientific knowledge.

33. Contribution to the Knowledge of Medicine Existing knowledge of medicine was preserved through the early part of this period by Arabic speaking people of North Africa and the Middle East. Rhazes (865-925) Avicenna (980-1037)

34. Contribution to the Knowledge of Medicine Avicenna (980-1037) “Canon of Medicine” compiled the medical knowledge of the Greeks and Egyptians, perpetuating many Galenic and Hippocratic theories. This was the standard textbook in many European Medical Schools until the seventeen century.

35. Avicenna “…pernicious suffocation hastens to stop the breathing; when the patient lies down, his breathing is hindered completely, and when is not recumbent his breathing is difficult also. In addition, he himself keeps extending his neck in contriving to breathe. He is restless and wants to stand erect and cannot lie down.” Canon of Medicine iii.11.1.9

36. Avicenna “For fluids are very often found between [the bulk of the heart and its membrane]. And it is known that when they are abundant they restrain the heart from diastole.” Canon of Medicine iii.11.1.2

37. Alexius I Irene Anna Comnena

38. The Alexiad

39. Alexius I – Rule of the Byzantine Empire “Most of the doctors had no idea at all of the danger with which we were threatened. But Nicolas Kallicles… predicted fearful troubles he told us that he was afraid the humours, having abandoned the extremities, might move to other direction and so endanger the patient’s life… Kallicles foresaw what would happen and told them emphatically, ‘For the time being the matter has left the extremities and attacked the shoulder and neck, but if we do not get rid of it by purging, it will move again, to some vital organ, or even the heart itself. If that happens the damage will be irremediable.’” Lutz JE. Am J Cardiol. 1988;61:494-5.

40. Alexius I – Rule of the Byzantine Empire “He was greatly affected by the pressure of daily business and the many cares of government. I often heard him telling the empress about it; in a way he was accusing the disease. What on earth is this trouble that affects my breathing? I want to take a deep, full breath and be rid of this anxiety that troubles me, but however often I try I can't lift even once a small fraction of the load that oppresses me. For the rest it's like a dead weight of stone lying on my heart and cutting short my breathing. I can't understand the reason for it nor why such pain afflicts me.” Lutz JE. Am J Cardiol. 1988;61:494-5.

41. Alexius I – Rule of the Byzantine Empire “They felt his pulse and admitted that they found all kinds of irregularities, but they were altogether unable to give a reason for this. They knew that the emperor's diet was not rich; it was indeed the sort of food athletes or soldiers have, so that the question of an accumulation of humours from too rich a diet was ruled out; they attributed the difficulty in breathing to some other cause and said the main reason for his illness was overwork and the constant pressure of his worries. His heart they said, was inflamed and was attracting all the superfluous matter from the rest of the body…” Lutz JE. Am J Cardiol. 1988;61:494-5.

42. Alexius I – Rule of the Byzantine Empire “…Every day it grew worse.... He was unable to lie on either side so weak that every breath involved great effort.... He was forced to sit upright to breathe at all... but when his stomach was visibly enlarged and his feet also swelled up and fever laid him low, some doctors, with scant regard for the fever, has recourse to cauterization…” Lutz JE. Am J Cardiol. 1988;61:494-5.

43. Alexius I – Rule of the Byzantine Empire “He was forced to sit upright in order to breathe at all; if by chance he did lie on his back or side, the suffocation was awful: to breathe in or exhale even a tiny stream of air became impossible. When sleep in pity overcame him, there was a danger of asphyxia, so that at all times, asleep or awake, he was menaced by suffocation. As purgatives were not allowed, the doctors tried phlebotomy and made an incision at the elbow, but that also proved fruitless. He was just as breathless as before and there was a constant danger that he might expire in our arms." Lutz JE. Am J Cardiol. 1988;61:494-5.

44. Alexius I – Rule of the Byzantine Empire “She kept nudging me, urging me to tell her about the pulse, but when… I touched it again and recognized that all his strength was going and the circulation of blood in the arteries had finally stopped, then I turned away, exhausted and cold, my head bowed and both hands covering my eyes." Lutz JE. Am J Cardiol. 1988;61:494-5.

45. Contribution to the Knowledge of Medicine Later period of the Middle Ages University of Salerno became for 200 years the outstanding center for medical education Transfer the practice of medicine from the ecclesiastics to the laity Frederick I introduced a system to licensing physicians and encouraged the dissection of human cadavers

46. “…It is shown by an application of a ligature that the passage of blood is from the arteries to the veins. Whence it follows that the movement of the blood is constantly in a circle, and is brought about by the beat of the heart.”