James H. O’Keefe, MD, interviews Robert D. Conn, MD, who has recently retired after 50 years in cardiology as an academician and practitioner. The diagnosis and treatment of common cardiovascular conditions are compared and contrasted between 1960 and 2010, and “game changers” are discussed and placed in context with current and future practices, taking into account the impact of economic and sociological changes.

Dr. Robert D. Conn was born on May 9, 1934, and grew up in Wichita, Kansas. He received his undergraduate and medical degrees from Kansas University, and in 1960, he did his internship at the New York Hospital. Conn did his internal medicine residency and cardiovascular fellowship at the University of Washington and stayed on as a faculty member, during which time he was chosen as Outstanding Clinical Teacher for 4 consecutive years and Teacher Superior in Perpetuity (the first such award given at the University of Washington).

Conn went on to serve as professor and chairman of the Department of Medicine at Southern Illinois School of Medicine and as professor and chairman of the Department of Medicine at the University of Missouri–Kansas City. He was a clinical cardiologist at Saint Luke’s Cardiovascular Consultants, Mid America Heart Institute, from 1974 to 2010. He is a teaching scholar with the American Heart Association, and his interests include cardiac physical diagnosis and sports cardiology. Conn developed preparticipation screening programs for high school and college athletes.

James H. O’Keefe, MD (O’Keefe): You have been a cardiologist for 50 years; you were trained as an intern at the New York Hospital in 1960, and then moved to the University of Washington for your residency and cardiovascular fellowship. If a 55-year-old man presented with an acute myocardial infarction (AMI), with “tombstones” across his anterior precordial leads, how would you have managed him then?

Robert D. Conn, MD (Conn): We would have followed the standard AMI routine for that era: he would be treated with intravenous morphine and placed on strict bed rest: 2 to 4 weeks of lying supine in bed. The goal was as little movement as possible, no sitting up, not even when we listened to his lungs, no getting up to go to the bathroom, and only clear liquids or soft diet for the first 2 weeks.

O’Keefe: Would he receive any aspirin or warfarin? Any prophylaxis for deep venous thrombosis?

Conn: This was before the atherothrombotic nature of acute coronary syndrome was appreciated. We did use warfarin derivatives (dicoumarol), but not consistently. Many who were lucky enough to survive the AMI succumbed to thromboembolic events during the month of strict bed rest without anticoagulation. There was also no electrocardiographic monitoring and no resuscitation if the patient suffered a cardiopulmonary arrest. Occasionally, if a surgeon was nearby when a patient coded, he might perform an urgent thoracotomy at the bedside so as perform manual cardiac massage.

O’Keefe: Did that ever actually restore a stable rhythm and blood pressure to where the patient survived?

Conn: No, not that I ever witnessed.

O’Keefe: How has the treatment of heart failure changed during your career?

Conn: Our only heart failure meds when I first began my career were digitalis and intramuscular mercurial diuretics. Acute heart failure was treated with tourniquets placed on the limbs to sequester blood in the periphery so as to reduce preload; we also used phlebotomy and morphine. Chronic heart failure was treated with digitalis, salt restriction, periodic mercurial diuretics, and bed rest. Not until angiotensin-converting enzyme inhibitors and loop diuretics became available did we really begin to make a positive impact on the dismal prognosis of unchecked heart failure.

O’Keefe: How did you use digitalis in the early days of cardiology?

Conn: Digitalis had remained the primary treatment for heart failure and some arrhythmias for over 200 years. Physicians in my early years invested a great deal time and effort initiating and monitoring digitalis. Recognition of digitalis toxicity-induced arrhythmia was a mantra of the cardiologist, and we agonized over dosing and drug levels. The challenge of the early years was to be sure the patient was “adequately digitalized.” Fortunately, with the recognition of the major contribution of neurohumoral compensatory mechanisms to heart failure, digitalis was relegated to an ancillary role in the heart failure therapeutic armamentarium. It has been years since I have seen a bona fide case of digitalis toxicity, attesting to its infrequent and low-dose use.

O’Keefe: Describe how you treated atrial fibrillation as a young cardiologist.

Conn: The standard treatment for atrial arrhythmias was digitalis, and we often pushed this therapy to the point of toxicity. Perhaps appropriately named, one of the most popular formulations of that day was Digitoxin. Pharmacologic conversion usually was attempted with quinidine by giving incremental doses on successive days until conversion or toxicity. We would routinely escalate the quinidine dose until we saw of widening of QRS, or ventricular premature complexes or worse. We were oblivious to the toxic interaction of digitalis and quinidine, and no blood levels were available. The only intravenous drug available was procainamide. Everything changed when Dr. Bernard Lown introduced electrocardioversion.

O’Keefe: What is your perspective on the evolution in the treatment of stable coronary artery disease?

Conn: Nitroglycerin was the only drug available until β blockers were approved in the 1960s. After coronary arteriography was introduced, primarily by Dr. Mason Sones, coronary anatomy became the gold standard from which most therapeutic decisions made. “Lesionology” became the dominant science in the management of coronary disease, and even up to present times, many cardiologists still make primary therapeutic decisions based on semiquantitative visual assessments of the coronary anatomy. With the recognition of the unstable plaque as the culprit for acute coronary syndromes, the paradigm of treatment for stable coronary disease was altered, and enlightened clinicians now deploy medical therapy to aggressively normalize cardiovascular risk factors, reduce inflammation, regress atherosclerosis, and prevent ischemia rather than simply addressing the “angiographically significant” lesions via coronary revascularization. The COURAGE [Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation] trial provided solid evidence-based validity for the use of aggressive medical management, reserving invasive revascularization using coronary bypass surgery or percutaneous coronary intervention (stents) as a fallback strategy for patients with acute coronary syndromes, refractory or limiting anginal symptoms, or major ischemia by objective testing that is uncontrolled with aggressive medical therapy.

Actually, the introductions of statins and general preventive measures may have had greater global impact than coronary angiographic and revascularization procedures. Now it is somewhat uncommon to see compliant patients in the average office setting with unstable symptoms. Over the decades, significant numbers of stable patients probably had unnecessary multivessel bypass or percutaneous coronary intervention as an “occulostenotic” reaction to the coronary anatomy.

Simple calcium scoring via computed tomography (without intravenous contrast angiography) has greatly facilitated the identification of preclinical coronary disease and assists the clinician in the tailoring of an appropriately aggressive preventive regimen, and also improves patient adherence to such a program.

O’Keefe: What developments in cardiology have been real “game changers” in your opinion?

Conn: Although every imaging specialist will state that his or her imaging modality is going to revolutionize cardiac diagnostics, in my opinion, echocardiography has had the greatest impact on the understanding of cardiovascular disease anatomically and physiologically. Its ease of use, absence of toxicity, progressively clearer imaging, and relative low cost has given it universal application in virtually all cardiovascular arenas. No imaging modality has had a greater impact on the diagnosis and assessment of cardiovascular disease.

O’Keefe: How has the treatment of hypertension changed?

Conn: The dramatic advances in the treatment of hypertension have greatly altered the outcomes of this disorder over the years. In 1945, at one of the most critical junctures in modern history, President Franklin D. Roosevelt died from uncontrolled hypertension; at the time of his fatal intracerebral hemorrhage, his blood pressure was 300/190 mm Hg. In my early years, we often fought and lost the battle of accelerating hypertension and its complications of heart failure, encephalopathy, stroke, and progressive renal failure. Our armamentarium consisted of salt restriction, mercurial diuretics, ganglion-blocking agents, reserpine, hydralazine, and α-methyl dopa. These drugs were poorly tolerated and inconsistent in their efficacy .Today we have an impressive array of effective and well-tolerated drugs for the control of blood pressure, and it is the rare patient in whom adequate blood pressure cannot be achieved.

O’Keefe: Early in your career, telemetry did not exist, even for AMI patients. What is your perspective on our approach to the electrical aspects of cardiology today?

Conn: The development of the field of electrophysiology has certainly been another game changer, and this is now one of the most sophisticated and important subspecialties in cardiovascular medicine. An ever increasing proportion of our patients now benefit from pacemakers, defibrillators, and ablative procedures that were inconceivable when I was a young cardiologist. In the future, electrophysiology, along with science and application of genetics may be the fields which will have the greatest impact on cardiovascular medicine.

I was involved with the development of Medic One in Seattle in the late 1960s, which included the initiation of educational courses for the firefighters who became the first paramedics. This was the prototype for all similar programs and created the emphasis on prehospital care that has now progressed to the placement of automated external defibrillators for public use. The recent changes from cardiopulmonary resuscitation to cardiocerebral resuscitation (rapid chest compressions only and the omission of rescue, mouth-to-mouth breathing) may represent a significant advance in prehospital care, although we are still a long way from significantly altering the bleak outcome for most patients following and out-of-hospital sudden cardiac arrest.

O’Keefe: Do you see genetics playing an increasing large role in the day to day management of cardiovascular issues?

Conn: It has always been my opinion that any mechanical fix for chronic disease will ultimately be replaced once the cellular biology of the disorder is understood. The understanding of the renin angiotensin aldosterone system and the 3-hydroxy-3-methylglutaryl coenzyme A reductase pathway in cholesterol metabolism are examples of how biochemistry was exploited in order to dramatically improve the treatment and prognosis for cardiovascular diseases where ineffective therapies had previously prevailed. In a few decades, we will look back at the medicine we are practicing in 2011 and consider it to be relatively primitive.

O’Keefe: Is the “art of medicine” irrelevant in the “digital age of medicine”?

Conn: I believe the practice of cardiology has become too much of a business and lost some of its professionalism and personal touch. Certainly, one of the casualties of the digital age is the close interpersonal bond of trust and understanding between physician and patient. The increasing roles of the telephone and computer, the large and impersonal physician groups, and the replacement of “the laying on of hands” with complex imaging modalities all conspire to make patients feel that medicine is no longer a personal encounter with their doctor. Physical diagnostic excellence has become a relic, and the patient encounter is frequently devoid of both empathy and a “hands-on” approach. Even the terms we now use demean the uniqueness of the patient-physician relationship, as we have become “providers” and “consumers,” highlighting the weakening of the personal bond between doctors, nurses, and patients. Often the culture of business first, medicine second, prevails. I have, however, had a significant experience of providing cardiovascular consultation to underserved areas using telemedicine and found this to be a most satisfactory marriage of clinical skill and technology. As the younger generation who have grown up in the digital age becomes the dominant “consumers” and “providers,” these problems may become attenuated, since the expectations may change when everyone is on the same digital page.