Myocardial
Infarction
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Vergleich: Siehe: Krankheiten + Difference
between Angina pectoris and Myocardial infarction
Usually patients suffering from myocardial infarction do not consult a homoeopathic
physician. They prefer going to a cardiologist or they get themselves admitted
to any hospital where they are shifted to intensive care coronary unit and
they get treated there. This has been my observation when I started my practice
in the year 1979.
But then over a period of years, I was called very frequently to see such
cases. The reason was the complications’
Complications of coronary infarction are too many and at times do not respond
to modern medicine. I will just narrate a small case to begin with. Last week,
I was called upon to see a patient who was sinking. Reason? He had a massive infarction
and there were two such episodes within the last 10 days. He was unable to
maintain his blood pressure, which was in the range of 70/40. Medications like
Dopavin were given to him to increase the blood pressure but he did not respond
to it. There was a renal shutdown due to low blood pressure, so he was on dialysis.
The cardiac pumping, though was strong and good, which was in the range of
30-40, i.e. the ejection fraction. But he had all the signs of cardiac failure.
He was given many antibiotics and medicines for better pumping and all the
necessary precautions were taken, but yet he did not respond.
I was asked to see him and after examining him and taking his homoeopathic
history, I could arrive at a drug, which helped him to maintain his blood pressure,
thereby improving his renal function which in turn put him off dialysis and the
patient was out of danger. So these are the situations where a homoeopathic physician
is called. Now, before tackling such difficult diseases, one must have a basic understanding
of such illness, and that is - acute myocardial infarction, more often, gets
triggered off during physical effort than at rest, or, any unaccustomed effort may
precipitate an attack, emotional state – whether acute or prolonged can also
induce an attack, the attack can also come after a heavy meal and I have many times
seen, that when there is a sudden fall in blood pressure as in the case of a shock
or in the case of anesthesia, the attack is precipitated. The pain is usually
abrupt and the intensity varies from agony to dull ache and the pain may vex
and wane. The location is usually behind mid-sternum, but it may be higher or
lower, radiating to the right or left arm and the discomfort in the arm is often
described as ‘heaviness of the arm’ and is frequently accompanied by sensation
of numbness or tingling in the hands and fingers. The pain may also radiate to
the neck, jaw, back, in-between shoulders or abdomen. At times
the pain can only be felt in the epigastrium, left elbow, or either side
of the left or right arm or left or right shoulder. The duration of the pain may
last from a few minutes
to several hours. However, the residual soreness in the area of pain may
remain for several days. The patient can get a little breathless and the most
common symptom that I have seen is nausea, vomiting and varying degree of shock.
The patient is cold, pale and looks ash-gray or cyanic. There is profuse
sweating, which may drench the pyjamas,
shirt or bed sheets. The patient is usually restless, confused or excited
and sometimes he even becomes unconscious. This restlessness may be due to anxiety
or due to pain.
There is abdominal distension, a sense of epigastric fullness and hiccups,
which are very common due to irritation of the diaphragm. When one examines
such patients
with a stethoscope, one will find
that the heart sounds are muffled and distant. Usually there will be tachycardia
with a tick-tack or a gallop rhythm. This definitely suggests left ventricular failure
or a cardiogenic shock. A fourth sound can be heard frequently and in absence
of hypertension it is almost diagnostic of myocardial infarction.
Systolic murmurs are not unknown because this can be due to relative mitral
regurgitation from cardiac enlargement or it could be due to malfunction of papillary
muscles.
The blood pressure may show transient rise due to the attack but is
often quickly reversed. A slow, progressive fall of blood pressure occurs over
a period of days and
eventually there will be a severe fall of blood pressure if there is a cardiogetic??
shock. The pulse is usually rapid unless there is atrio-ventricual block but
the volume will always be poor and if there is an irregularity in pulse, it is
almost always due to cardiac arrhythmia. On the 2nd or the 3rd
day of the infarction one usually has very low-grade fever. This is usually due
to cardiac failure, pulmonary infarction or edema. The electro-cardiogram may show
tall T-waves or inverted T-waves which indicates Ischemia, an ST??? segment elevation,
especially those leads?? which overlies the infarction. But the typical is ST segment
elevation with T-wave inversion.
Whenever one sees a Q-wave, then this indicates cell death or death of cell??.
Cardiac enzymes are very important to study and one must have a basic knowledge
of them.
Myocardial necrosis results in release of certain intra-cellular enzymes
into the blood.
There are certain enzymes, which are present in a very high concentration
in the myocardium, and they are not present at all in a non-cardiac tissue. If
one wants to know
the prognosis, especially in the first two hours, then it is extremely
important to take help of certain cardiac exams??
which are being done through--------------------nowadays in any hospital
of Mumbai. The first will be
CKMB – Creatinine Phosphokinase MB fraction or MB fraction of Creatinine
Kinase which is the name of the enzyme. The peak of this enzyme is in 24 hours
and
within 48-72 hours it comes to normal, so this enzyme must be advised very
fast.
The highest will be between 3-12 hours.
The second that comes is the LDH enzyme whose peak is between 24-48 hours
but it remains so for at least 15 days.
Recently induced new enzymes were cardiac-troponines. The troponine-T especially
can be picked up in the first few hours, i.e. between 3-5 hours and its peak
would be
within 12 - 48 hours. Troponine-T can also remain high for a fortnight. Another
troponine will be Troponine-I which has a peak of 24 hours and which can also remain
for 10 days. Then comes the myoglobi---.
Myoglobi--- remains high in the first 1 or 2 hours maximum, and within
24 hours it comes back to normal, so this is a very specific investigation. The
last investigation will be the
fatty acid binding protein
, which is also high in the first few hours,
i.e. between 1-3 hours, and within 24 hours it comes back to norm
al. These are some of the
common observations that I have made in patients having infarction.
Now, as I have mentioned earlier, these patients do not come to us
, and as homoeopathic
physicians, we can only see them when there are severe complicatio
ns, and I got most
experience during these complications. I will go from the most c
ommonest to the least
commonest of the complications that I have seen and experienced. Th
e commonest ones
that I have seen are the
arrhythmias and conduction blocks
. Arrhythmias are directly
proportional to the size and site of infarction, especially with
the first 2 days after the
infarction, the ventricular tachycardia ventricular
fipliration???
-----------
are very common,
or, sometimes supra-ventricular arrhythmia such as sinus tachycardi
a or atrial flutter or
fipliration suggest infarction of a large portion of ventricular muscle.
Thus, many times this
is called
‘
pump failure arrhythmias
’
. Another very common condition where I have been
called many times is the
‘
cardiogenic shock
’
. When we say that a person is suffering from
a cardiogenic shock, his systolic blood pressure has to be
below 90 mm of
HG
, his skin
should be cold and clammy, he should have
oliguria or N-urea
, he should have cerebral
symptoms such as anxiety, confusion, apathy,
somnolence(somnambulation??)
and fatigue,
he should have symptoms suggestive of metabolic acidosis. Som
etimes the patient may
also have pump failure as one of the complications, especially th
e left ventricular failure
with typical
pulmonary congestion, tachycardia and hypotension
My first book was “Homoeopathic treatment of the disease of the heart” by
Dr Jean Poirier.
My second book ‘Disease of the heart‘ by A. L. Black Wood,
the third will be ‘Diseases of the heart’ by Edwin Hale,
the fourth book will be ‘Remedies of the circulatory and the respiratory
system’ by Fortier Bernoville,
the fifth will be ‘Treatment of heart condition’ by Douglas
--
----------
. There is also an Indian author who has compiled in a
very nice manner all the information from various source books in his book
called
‘Cardio-vascular disease and homoeopathic treatment’ by Dr E
Balakrishnan.
These are some of the useful therapeutic books which I have gone through
and my experience is chiefly from these books.
Books on Materia Medica and reference books, the Encyclopedia Homoeopathica
Programme, the Synthesis repertory and the Radar software has been of great
help to me in solving the most difficult cases and understanding a
remedy in a much better manner.
My first remedy will definitely be Ars. Now with this remedy, one can typically
see a mentally distressed person with extreme fear, extreme anxiety with mental
and
physical restlessness and constant thirst with desire for sips of
ice-cold water. So, as far as the actual local symptoms are concerned the main complaints
are -
a feeling of extreme cardiac pressure, a feeling of heavy weight on the chest
or constriction in the chest that is associated with a feeling of not getting
enough
air in the lungs and the patient feels that he will die. He complains
that he is feeling cold though he may also complain that there is burning in
the chest. In appearance,
the patient looks extremely anxious. The expression looks confused, distressed,
haggard and tired. The face appears slightly greasy. The patient appears grey
and the lips are pale and cyanotic or cyanic?? giving one the impression
of being dangerously ill. The patient often has a peculiar pinch, wrinkled and grey
appearance
but as a rule, in these cases one gets the history that the attack was
developed quite suddenly and the respond through Arsenic should be --------
??
Now, with this particular symptomatology, if one gives Arsenic and the response
is not good within 30 - 60 minutes, i.e. by giving Arsenic if the mental anxiety,
fear and restlessness of the patient does not subside or if the patient
does not become warmer than before, then one must change the remedy because
Arsenic, when indicated
very nicely and properly, will show results with a few hours after its
administration. In such a case where one sees a perfect picture and similarity
to Ars., please do not start
with a low potency, start directly with a 10M, 50M or a CM potency on a centesimal
scale. Now here, the question arises – ‘what should be the frequency of repetition?’
The repetition that I usually use is any time between 15-45 minutes. One
must put a drop of medicine in a glass of water and stir it and with every repetition,
one must
stir at least 10-15 times with a spoon.
Now here, if one gives Arsenic and the patient feels better, do not prolong this
remedy for many days. Arsenic may not hold the patient for long in this particular
situation. I have seen that after initial major improvement for 1 - 2, the
patient will suddenly die and one will be disappointed and
ask that why this happened. This is because,
Arsenic is a remedy that, by itself, will never help the patient to pull
through from this particular situation. One has to immediately support this
with another remedy and the remedies that I have found to be very useful in
supporting Arsenic is Phosphorus or Sulphur.
Though this helps in majority of the cases, it does not always prove to be
successful. I have used other remedies like Lycopodium also. Now, what is the
difference?? between
-------??
We discussed earlier that the patient was grayish looking, pinched??,
anxious and he was getting better and warmer, he was appearing less grey, less pinched??,
face was a little
less drawn, anxiety was less and the reddish color was appearing back on
the face. This is the transition phase that the patient is going through, i.e. from
Arsenic to Phosphorus. But at times, while Arsenic is helping the patient, the patient
becomes too hot with irregular waves of heat and cold, tending to push the
blankets off still with air-hunger
– then this is the Sulphur stage. So one needs to be careful when one understanding
the remedies. Now, let us discuss certain clinical observations that I have seen
in Arsenic. The head will be extremely sensitive to cold air, the head may be drawn
sideways, there may be slight jerking of the head, the head may be restless,
the eyes may be slightly agglutinated, there may be injection of the conjunctival
blood vessels, there may be a certain degree of photophobia, the pupils would usually
be insensitive to
light and they may be dilated or contracted, the face appears bloated
especially around the eyes (above/under), there may be dropping of the jaw, the
face may appear greasy
and sunken, the tongue may be bluish, dark or pale or it may have red
stripes down the center, the mouth may be dry with thirst, Arsenic may
sometimes have a mapped tongue
with offensive odour from the mouth, the speech may be difficult and at times
it may be lisping, the respiration is especially accelerated with a typical air-hunger
and it can get arrested when the patient makes an attempt to cough,
there may be gasping respiration, and it must be noted that in Arsenic, the respiration
is always affected by anxiety, cough is usually + salivation and slightest cold
air will excite the cough, the arrhythmias that I have usually
seen in Arsenic are either atriovenous noodle rhythm with extra systole
or intraventricular block, especially the right bundle branch block or simple
tachcardia due to anemia or due
to anxiety, I have sometimes seen in Arsenic that when one gives a lot of
salbutamol??, there is tachycardia, there is tachycardia after a history of chronic
smoking of tobacco, the heart failure is usually accompanied by severe weakness
and prostration, the murmurs will definitely be present especially the murmur of
aortic regurgitation
which is highly characteristic of Arsenic album, the pulse can be bounding
and this occurs especially when the patient is anxious, but otherwise the pulse
will be imperceptible, irregular and slow in Arsenic album.
The second remedy that I have found to be very useful in such conditions
is Antimony tartaricum. Ant-tart patient presents a somewhat similar picture as
Arsenic album??
but there is a clear point of differentiation, i.e. in Ant-tart there is
a more definite cyanosis than in Arsenic, one usually does not see a Ant-tart patient
without cyanosis and this may either involve the full extremities or only a finger
or toe-nail, one never sees the same type of mental anxiety in Ant-tart as in
Arsenic, the patient in Ant-tart is down and out, much more hopeless and
depressed, the patient is not quite so restless and pale as Arsenic, there is
no thirst in Ant-tart that one sees in Arsenic, in fact, anything to drink
seems to increase the patient’s distress in Ant-tart and even though Ant-tart is
listed as a remedy of ??? thirsty patients, in pracicality, I have hardly seen Ant-tart
patients being thirsty and if they do drink water, they develop a lot of distress
in the heart and abdomen. Another contrasting feature is that Ant-tart patient is
aggravated by heat, especially by any stuffiness in the atmosphere. There is
one point worth noting that as a contrast between Ant-tart and Carb-v. Ant-tart
will not like stream of air circulating around them, they want a room fresh and
they like it still???
In most of the Ant-tart patients, there is a very early tendency to
edema of the lower extremities. Another point that will help one in the
selection of Ant-tart is that practically
all these patients will have a very thickly coated tongue, a white coat with
a rather strictly uncomfortable mouth. They have a feeling of fullness in the chest
rather than
the feeling of acute pressure as in Arsenic and one usually finds generalized
and diffused Rails in the lower part of the lungs. In contrast to Arsenic, if
one has a case of this
type, then it is a kind of collapse one meets after a pneumonic crisis
if the patient responds to Ant-tart it will carry him through. Now, we will
discuss some of my observations
of Antimony-tart, which I have confirmed in my practice. The first and most
important observation is the perspiration, especially cold perspiration on the
forehead. Perspiration on the head when coughing and trembling of the head when
coughing are also the important characteristic features of Ant-tart that I have
witnessed. The eyes will be injected, the pupils are usually contracted in
Ant-tart, the face appears dark, cyanotic or cyanic?? and bluish, the lips are
chapped, the face is bloated, the expression is usually of suffering and anxious,
there can be cold perspiration even on the face with slight trembling of the jaw,
the gums can be bleeding, the tongue is usually bluish or pale or having red stripes
down the center, but the characteristic is the coated tongue and the coating is
tough and white. There can also be an indented tongue or a mapped tongue like
Arsenic that I described earlier. The mouth is usually open, the speech is
difficult, on examining the mouth one may see that the gums are spongy, the
respiratory rate will be accelerated, especially when the patient is in lying position,
at times the respiration may be abdominal, and if there is severe respiratory failure,
then there can be
gasping and irregular breathing. One can also find moaning in Ant-tart
patient. The cough is dry and constant during day and night in Ant-tart, and it
can get < by
eating and can be better by eructations. There may be pulmonary edema
and the common arrhythmias that I have seen is the right bundle branch block in
Ant-tart.
There may be palpitations with anxiety, and the palpitations may be so strong
that they can be audible and visible. The pulse can be frequent, imperceptible,
slow, soft,
thready and weak. The next remedy will be Carbo-veg and this presents a
classical picture of patients with all forms of collapses. They have cold and sweaty
skin, they
are mentally dull and foggy in their outlook, they do not have a clear
idea of where they are or what is going on or what is going to happen to them, they
have a very intense air-hunger and in spite of their cold clammy extremities,
they want air blowing on them, they cannot bear to have bed clothes around
their neck and they definitely benefit
from the administration of oxygen, the more oxygen given to them, the
better they feel. They are paler than Ant-tart patients and the lips are pale
rather than cyanotic or cyanic??
and there is none of the underlying blueness that one associates with
Ant-tart. So, if one has to give marks to blueness in the remedies, then Ant-tart
gets 5 marks and Carb-v.
gets 3 marks. The next point is that Carb-v. patients always have a terrible
feeling of distension. This is often not so much in the chest as in the upper abdomen
and the cardiac distress is always associated with a great deal of
flatulence. Like Ant-tart patients, any attempt to eat or drink tends to
increase the distress a great deal and they have none of the Arsenic thirst. Another
apparent contradiction that one comes across in Carbo-veg patients is that in
spite of the desire to be uncovered and
the intolerance of blankets around the upper part of the neck or chest,
these Carbo-veg patients complain of ice-cold extremities and they feel as if
their legs are lumps of lead and they cannot get them to be warm at all. I
think that in Carbo-veg one has to be careful as to how long one is to keep up the
administration once the patient starts
responding when the sweating is less, the surface becomes warmer and the
distress is less acute????
It is wise then to hunt around
for a second drug in need because some Carbo-veg patients do relapse although
many of them make quite straight recovery on Carbo-veg.
The remedies that usually follow Carbo-veg would either be Sulphur or
Kali-c.
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