The Armchair Treatment of Heart Attacks
How a modest proposal of sitting in a chair was met with aggressive dogmatic opposition.
Dr. Istrail is a physician and author of The POCUS Manifesto: Expanding the Limits of our Physical Exam with Point-of-care Ultrasound
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In one lifetime, the treatment of a heart attack (myocardial infarction) has gone from an astrology equivalent to a miraculously efficient and effective medical marvel. From the onset of chest pain, a patient calls 911 and an ambulance arrives within minutes. An EKG is performed which may confirm the diagnosis and they are rushed to the hospital. Within 90 minutes, the patient is given aspirin and anticoagulation and wheeled into the cath lab where their coronary arteries are imaged, ballooned, and stented. Within hours the patient is able to walk around, eat, and is home within 48 hours.
Such spectacular efficiency is the result of decades of research, dozens of hospital staff, paramedics, nurses, physicians, and technicians all working together, and it is easy to take it for granted when working in a hospital that treats so many. But it wasn’t always this way.
As recently as 1950, Dr. Irving S. Wright, the former president of the American Heart Association, published an article in Circulation, explaining two of the mainstays of myocardial infarction treatment: bed rest and alcohol.
There is no question but that rest is essential in the treatment of this condition. A myocardial infarction goes through stages during which the initial anoxemia results in the development of necrosis. Thereafter it takes a considerable period of time for fibrosis and scarring, accompanied by development of a collateral circulation, to restore the muscle to anything like its former strength … It seems quite illogical therefore to place any strain on the heart muscle above minimal activity during the first three or, better, four weeks. If the infarction is large, or if there is evidence of cardiac embarrassment, this period may well be extended to from six to eight weeks. During this time the patient should be at bed rest. There is one exception to this ruling. There are many patients who have great difficulty in using the bed pan.
And of course, alcohol:
Whiskey, or alcohol in other forms, may be used freely. Its benefits may be due to its vasodilating effects or to its sedative and relaxing action, but it frequently proves as effective as the opiates. A few patients become excited rather than relaxed by alcohol, and under such circumstances it is of course contraindicated. Alcohol so used should be regarded as a medication and the patient's tolerance, and the possible development of addiction to it, must be considered.
Forcing a patient to remain on bed rest for two months post heart attack is absolutely barbaric in retrospect, even with the occasional shot of tequila to take the edge off. Yet this was the well-accepted standard of care at the time. It wasn’t until Dr. Bernard Lown suggested otherwise that the mindset began to change.
This is yet another example of how dogmatic, unscientific beliefs dominate medical therapies and remain unchallenged for decades.
Drs. Lown and Levine hypothesized that not only was bedrest not necessary for these patients, it was actively harming them. They felt the sitting position “permits gravity to mobilize fluid into the dependent parts of the body,” while lying down “encourages pooling of the fluid in the pulmonary circuit. The former is essentially harmless; the latter may be disastrous. The abruptness of the onset of coronary thrombosis, with its grave prognostic connotations, afflicting as it frequently does the highly active and previously healthy person, when coupled with long-continued bedrest, saps morale, provokes desperation, unleashes anxiety, and ushers in hopelessness with respect to resumption of normal living.”
So Lown proposed a study to test this hypothesis by getting these patients out of bed and into a chair, a modest proposition met with outrageous opposition.
"Although I knew that the project would be a chore, I didn’t expect it to be an act of martyrdom,” wrote Dr. Lown years later. “Little did I realize that violating firmly held traditions can raise a tsunami of opposition. The idea of moving critically ill patients into a chair was regarded as off‑the‑wall. Initially, the house staff refused to cooperate and strenuously resisted getting patients out of bed. They accused me of planning to commit crimes, not unlike those of the heinous Nazi experimentations in concentration camps. Arriving on the medical ward one morning I was greeted by interns and residents lined up with hands stretched out in a Nazi salute and a ‘Heil Hitler!’ shouted in unison.”
Lown and Levine enrolled 81 patients in their study, encouraging them to sit in a chair within days of their heart attack. While this was an uncontrolled study making it impossible to compare the direct benefits of the upright position, many observations included:
Prompt improvement in shortness of breath and orthopnea (shortness of breath when lying flat)
no appreciable complications
improved psychological state
As Dr. Lown described his observations, a pulmonary embolus was the cause of death in 30% of the bedrest patients who died, while none were observed in the chair group. Other complications like hand-shoulder syndrome vanished, and their overall morale and attitude markedly improved. While the study was largely anecdotal, within a few years of its publication, hospitalization time was reduced by 50%, and the range of activities permitted to these patients grew. The bedpan was abandoned and walking was permitted.
“This was not just a small error,” Lown explained in his book, “it was a colossal misjudgment … once a new paradigm takes hold, its acceptance is extraordinarily rapid and one finds few who claim to have adhered to the discarded method. This was succinctly captured by Schopenhauer, who maintained that all truth passes through three stages: first, is ridiculed; second, it is violently opposed; and finally, it is accepted as being self-evident.”
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Dr. Istrail is a physician and author of The POCUS Manifesto: Expanding the Limits of our Physical Exam with Point-of-care Ultrasound