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J Thorac Cardiovasc Surg 1999;117:199-200
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

High hematocrit value is a risk factor for myocardial infarction

I read with interest the article on the positive correlation between the hematocrit value and the frequency of myocardial infarction (MI) after coronary artery bypass grafting (CABG) by Spiess and associates. ¹ That a high hematocrit value was associated with an increased risk for MI has been known since the early 1960s. ^2-6 George Burch, who wrote numerous articles on this subject,26 advocated bloodletting in patients with coronary artery disease with a high hematocrit value. ⁷ He showed that the clinical state of these patients definitely improved when their hematocrit was reduced to "average normal" levels. ^6-8

Burch ⁸ wondered why bloodletting was rarely used as a therapeutic measure for these patients. It might be appropriate to quote what Burch said in 1979:

It is well known that a high hematocrit is associated with high viscosity and that a highly viscous fluid requires more work of the pump to circulate it than does a less viscous liquid. Furthermore, the flow of highly viscous fluid is reduced, even with all else being equal. Nevertheless, physicians fail to bleed patients with active coronary disease and myocardial ischemia, whose hematocrit is high and whose blood viscosity is increased. It has been shown that bloodletting in patients with ischemic heart disease definitely improved the clinical state of these patients when their hematocrit was reduced to average normal levels....

Could it be that the procedure is rarely used because it appears to be "old-fashioned," "antique," and not "modern"? If the concept is good and the clinical results often dramatic, why not use it? Just because "bloodletting" is a procedure of the old days and one that was misused, this does not justify not using it today.

Some old things are good. Antiques are desirable and appreciated and antiquities are even more precious and valuable. People by the millions visit the King Tut exhibit—including doctors. But, the King Tut exhibit is not modern. That which is good or useful must be preserved—even bloodletting for definite clinical indications, such as with angina pectoris and other types of ischemic heart disease.*

I propose that CABG is simply a more elegant and more sophisticated method of bloodletting. The finding by Spiess and associates ¹ in their study of 2202 patients that a low hematocrit value (less than 24%) at the conclusion of CABG protects against Q-wave MI is a modern proof of what Burch predicted 36 years ago.

Tsung O. Cheng MD
Professor of Medicine
The George Washington University Medical Center
Washington, DC 20037

12/8/94494

References

1. Spiess BD, Ley C, Body SC, Siegel LC, Stover EP, Maddi R, et al. Hematocrit value on intensive care unit entry influences the frequency of Q-wave myocardial infarction after coronary bypass grafting. J Thorac Cardiovasc Surg 1998;116:460-7. [Abstract/Free Full Text]
   
2. Burch GE, DePasquale NP. Hematocrit, blood viscosity and myocardial infarction. Am J Med 1962;32:161-3.
   
3. Burch GE, DePasquale NP. The hematocrit in patients with myocardial infarction. JAMA 1962;180:62-3.
   
4. DePasquale NP, Burch GE. Hematocrit in women with myocardial infarction. JAMA 1963;183:142-3. [Medline]
   
5. Burch GE, DePasquale NP. Hematocrit, viscosity and coronary blood flow. Dis Chest 1965;48:225-32.
   
6. Burch GE. Erythrocytosis and ischemic heart disease. Am Heart J 1961;62:139-40.
   
7. Burch GE, DePasquale NP. Phlebotomy: use in patients with erythrocytosis and ischemic heart disease. Arch Intern Med 1963;111:687-95.
   
8. Burch GE. Of bloodletting. Am Heart J 1979;98:666.
   

This article has been cited by other articles:

				T. O. Cheng Is There an Optimal Hematocrit Value for Cardiac Patients? J. Am. Coll. Cardiol., May 3, 2005; 45(9): 1549 - 1549. [Full Text]

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