Annotahons

heart without the serious adverse effects of total-body hypothermia.

D. J. Viskos, M.D., F.A.C.S. N. B. Karatzas, M.D., D.Phil. Cardiosurgical Unit, Hippokrateion Hospital and Department of Medicine, University of A thens Greece M. V. Braimbridge, M.B., F.R.C.S. Sally Darracott Cardiothoracic Unit, St. Thomas' Hospital London England REFERENCES

1. Robicsek, F., Tam, W., Daugherty, H. K., and Mullen, D. C.: Myocardial protection during open-heart surgery: Coronary perfusion versus topical cardiac hypothermia, Ann. Thorac. Surg. 10:340, 1970. Maloney, J. V., Cooper, N., Mulder, D. G., and Buckberg, G. D.: Depressed cardiac performance after mitral valve replacement: A problem of myocardial preservation during operation, Circulation 51(Suppl. 1):1, 1974. Shumway, N. E., and Lower, R. R.: Topical cardiac hypothermia for extended periods of anoxic arrest, Surg. Forum 10:563, 1959.

4. Burdette, W. J., and Ashford, T. P.: Response of myocardial fine structure to cardiac arrest and hypothermia, Ann. Surg. 158:513, 1963. 5. Niles, N. R., Bitensky, L., Braimbridge, M. V., and Chayen, 3.: Histochemical changes related to oxidation and phosphorylation in human heart muscle, J. R. Microscop. Soc. 86:159, 1966. 6. Braimbridge, M. V., Darracott, S. A. R., Bitensky, L., and Chayen, J.: Cytochemical analysis of left ventricular biopsies in open-heart surgery: A pilot study, Beitr. Pathol. 148:255, 1973. 7. Braimbridge, M. V., Darracott, S., Clement, A. J., Bitensky, L., and Chayen, J.: Myocardial deterioration during aortic valve replacement assessed by cellular biological tests, J. Thorac. Cardiovasc. Surg. 66:241, 1973. 8. Hurley, E. J., Lower, R. R., Dong, E., Jr., Pillsbury, R, C., and Shumway, N. E.: Clinical experience with local hypothermia in elective cardiac arrest, J. Thorac. Cardiovasc. Surg. 47:50, 1964. 9. Chayen, J., Bitensky, L., Butcher, R., and Poulter, L.: A guide to practical histochemistry, Edinburgh, 1969, Oliver & Boyd, Ltd. 10. Chayen, J., Altmann, E. P., Bitensky, L., Braimbridge, M. V., Kadas, T., and Wells, P. J.: A study of the changes in hydrogen transport in an isolated rat heart preparation. J. R. Microscop. Soc. 86:151, 1966.

Now the treadmill!

When a diagnostic procedure necessitates the signing of a consent form by the patient, the immediate presence of an experienced physician, a defibrillator, and necessary drugs for care of cardiac arrest or other serious consequences, it must be a dangerous diagnostic procedure. Such is the case with the treadmill stress test. One then must ask, "Is such a procedure necessary?" "Is it ever needed?" "If so, when?" And, "What are the criteria for its indication?" Also, "If a serious accident or death were to occur as a result of the procedure, could the information that might be acquired justify subjecting the patient to. such a risk, even a fatal outcome?" With the treadmill, patients are tested "quantitatively" for cardiac function and potential function under physical stress to evaluate the state and capabilities of their coronary arteries for conducting blood flow. But, is it quantitative? Can a treadmill program be outlined which could be applied adequately to an 80-year-old lady who spends her life in a rocker at home and also to a 35-year-old jogger who runs 3 to 5 miles per day? Or, is a meticulously obtained history of such patients' responses to daily activity safer, more informative, and clinically more valuable in assessing coronary artery function? If a patient, prior to treatment, says he cannot walk two city blocks without chest pain, is his coronary arterial function known less or better than if he is tested on the treadmill? Is a treadmill test more accurate quantitatively than a meticulous history of the patient's responses to daily physical activity and psychic stress? After all, people live in homes, gardens, streets, offices, etc., and not on a moving treadmill surrounded by flashing lights, defibrillators, compli-

American Heart Journal

cated apparatus disgorging scrolls of paper, syringes, drugs, busy grim nurses and doctors in white. Furthermore. the hazardous treadmill test costs $100.00 or more. whereas the history of performance is routinely obtained by any welltrained conscientious cardiologist, anyway. Not many years ago, even cardiologists were reluctant to subject their patients to Master's 2-step test, a much milder and more appropriate test. Were they ~ight or wrong then? Did they miss something in the clinical cardiac study? With all of the new expensive and hazardous diagnostic and therapeutic procedures of today, is the life span of man being extended? Or. even the life span of one man? The H.E.W. Life Tables show slight to no increase in the life span of Americans for the past 20 years. 1 When the "books are balanced" with proper consideration of information derived from the treadmill test versus the expense, risk, damage, and even possible death associated with the test. is man "better off" with the treadmill or not? These questions must be answered. But who is to answer them? Who will outhne criteria for application of the test, be responsible for serious reactions, and control costs? The patient is usually impressed with the procedure, but he is in no position to understand or know the indication, value, or risks involved. Initially, the treadmil] was used only in the hospital where "adequate" facilities were available to manage properly any adverse responses to the exercise test. including cardiac arrest. Now, the treadmill is being employed in the physician's office. So, now, the treadmill! What next? Can anything be admitted into the practice of medicine and be accepted

671

Annotations

without prior careful evaluation? There is a need for objective evaluation of such diagnostic procedures before they are introduced into general clinical use, just as now exists for drugs:

George E. Burch, M.D. Tulane University School of Medicine and Charity Hospital New Orleans, La.

672

REFERENCE

1.

Vital Statistics of the United States: Life Tables, U.S. Department of Health, Education and Welfare, Public Health Service, Washington, D. C., 1973, Vol. 11, Section 5:

November, 1976, Vol: 92, No. 5

Now the treadmill!

Annotahons heart without the serious adverse effects of total-body hypothermia. D. J. Viskos, M.D., F.A.C.S. N. B. Karatzas, M.D., D.Phil. Cardiosur...
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