Sudden Death due to Acute Myocardial Infarction [antikvár]

PREFACE At first glance it may seem unusual that a research worker engaged in animal experiments would attempt to summarize the essential facts about a characteristically clinical problem such as sudden death due to acute myocardial infarction. I feel, however, that this effort is justified by the fact that the experimenter may act more freely in many respects in animal experiments than the clinician dealing with patients, and this fact perhaps gives more freedom to the imagination of the researcher. In other words, those involved in animal experiments are more inclined to draw conclusions from remote and seemingly unrelated facts, conclusions which could be the starting point of new fruitful ideas but which could appear at first glance as absurd or dangerous to patients from the point of view of the clinician, and are therefore sometimes overlooked by the clinician. I am aware that readers of this book may in part disagree on this point. Nevertheless, some advantages of animal experiments are obvious, e.g., the possibility of using invasive methods not applicable to patients, and methods requiring the sacrifice of the animal. Furthermore, the experiment can be very precisely planned and controlled, and it can be carried out in a large, relatively homogenous population of experimental animals; i.e., it can be done under favorable conditions which are not likely to be present in the clinic. These advantages do not fully counterbalance the well-known disadvantage of animal experiments — that even the best models mimicking human pathological conditions are not identical with the human disease. Furthermore, the responsiveness of animals to metabolites and drugs under physiological and pathological conditions is very much different from that of normal humans and patients. Although these objections are fully justified, we must bear in mind that a great part of our present knowledge of the pathomechanism of diseases as well as of the mode of action of drugs derives from animal experiments. Accordingly, in the following chapters the conclusions are based on the most important experimental and clinical findings. The introductory part of this book is devoted to the epidemiology of sudden cardiac death. The enormity and complexity of the problem is appalling. But there are also some encouraging facts indicating that the apparently irreversible trend of mortality can be reversed. The second part deals with the genesis and pathophysiology of early postinfarction arrhythmias leading to sudden cardiac death. Recent experimental and clinical data have revealed that sudden death is not an inevitable culmination of progressive coronary arteriosclerosis but rather an electrical accident based upon chronic electrical instability and the appearance of a precipitating factor. Both are accessible to therapy, and therefore prevention and reversion of lethal ventricular fibrillation has become a reality. The last part of this work is dedicated to the most promising methods for therapy and possible pharmacological prevention of sudden cardiac death, indicating a fundamental change in our attitude to the problem. The feeling of being completely helpless before an act of inexorable fate has given way to feverish research activity aimed at finding the most effective solution of the problem. In my comments and conclusions I make use of the above-mentioned freedom of the researcher, therefore they will probably not always be in conformity with prevailing views. I would also like to make it clear that it was not my intention to reach completeness in reviewing the vast material accumulated, particularly in the last decades, on this highly important subject. Nevertheless, I shall make an effort to analyze the most important facts and their interactions in order to try to give an overall picture of the sequence and causal relationships of this multitude of closely interconnected events. It is just because of these close connections, that I could not avoid occasionally repeating principles and data discussed earlier; however I felt it was necessary in order to introduce new principles not previously discussed. Finally, I am aware of the fact that selection of the material as well as the proportions of the individual chapters are to some extent arbitrary, reflecting the preferences and scientific activity of this author. U'