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Editorials |

Do No Harm

Robyn J. Barst, MD
Author and Funding Information

Affiliations: New York, NY 
 ,  Dr. Barst is Associate Professor of Pediatrics and Medicine at Columbia University College of Physicians and Surgeons, New York, NY.

Correspondence to: Robyn J. Barst, MD, 3959 Broadway BH262N, New York, NY 10032



Chest. 1999;116(5):1147-1148. doi:10.1378/chest.116.5.1147
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A cardinal rule in medicine is to “do no harm.” As physicians, we are constantly asking ourselves what the overall risk/benefit ratio is for every therapeutic intervention we consider for our patients. In addition, consideration of any therapeutic modality is based on our knowing the natural history of the condition untreated, with our weighing the advantages vs disadvantages of adding therapeutic interventions (whether medical or surgical). Ricciardi et al report in this issue of CHEST (see page 1218) using echocardiographic parameters to predict an adverse response with an acute trial of nifedipine in patients with primary pulmonary hypertension. Acute vasodilator testing for patients with primary pulmonary hypertension was first reported in the mid 1970s following favorable experiences with vasodilator therapy for systemic hypertension. With the advent of vasodilators (such as hydralazine), physicians looked to these vasodilators with potential promise for their patients with primary pulmonary hypertension. Unfortunately, several of the earliest experiences with acute vasodilator testing resulted in fatalities using agents with a relatively long half-life, eg, hydralazine, in whom minimal if any active pulmonary vasoreactivity existed, ie, postmortem histopathology revealed severe fixed pulmonary vascular disease with little medial hypertrophy in the pulmonary arterioles. The administration of a relatively long-acting vasodilator in patients with advanced disease resulted in significant systemic vasodilatation with little if any pulmonary vasodilatation and subsequently cardiogenic shock. Based on this early experience, we “stepped back” and readdressed the cardinal rule to “do no harm” in medicine.

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