martes, 10 de noviembre de 2009


Libro publicado en 1997 por Hultgren


Tuvimos la oportunidad de conocer al Dr. Hultgren, de la Escuela de Medicina de Stanford, en algunas de sus ocasionales visitas al Hospital de Chulec de La Oroya, cuando en la década de los ochentas coordinaba con nuestro jefe el Dr. Emilio Marticorena. Ya desde 1964 ambos habían trabajado intensamente en el Edema Agudo Pulmonar de Altura en pacientes en el Hospital de Chulec, habiendo realizado en varias series cateterismos encontrando que el edema pulmonar estaba asociado a hipertensión pulmonar con baja o normal presión de cuña de la arteria pulmonar, publicando sus conclusiones en Circulation y otras revistas.

Tenía mucho afecto por La Oroya y el Hospital de Chulec y en los últimos años de su vida terminó de escribir el Libro High Altitude Medicine.

Publicamos un homenaje a su prestigiosa vida de investigador de la Medicina de la Altura.

Dr. Aquiles Monroy

In Memoriam
Herbert N. Hultgren, MD, 1917–1997
William H. Barry, MD, Salt Lake City, Utah

Herbert N. Hultgren, Professor of Medicine Emeritus at Stanford, died in October 1997 at age 80 of complications of acute myelogenous leukemia. Herb was a native of northern California and graduated from Stanford University in 1939 and from its School of Medicine in 1943. He completed residency training in medicine and pathology at Stanford and served in Europe in World War II with the US Army Medical Corps. He was a research fellow in cardiology at the Thorndike Memorial Laboratory in Boston, Mass, and then returned to Stanford in 1948, where he established the first cardiac catheterization laboratory in northern California and in 1955 became chief of cardiology at Stanford.

In 1968, after the Stanford Medical School had relocated from San Francisco to Palo Alto, Calif, Herb was appointed chief of cardiology at the Palo Alto Veterans Administration Hospital, a position he held until 1984. I worked with him at Stanford as a cardiology fellow and then as junior faculty member in the cardiology division from 1970 to 1977. I and numerous Stanford students, residents, and faculty benefited enormously from contact with Herb, as he was a superb teacher, clinical cardiologist, and clinical investigator. He was chairman of the American Board of Internal Medicine Subspecialty Board on Cardiovascular Disease from 1972 to 1975 and was a founding member of the Association of University Cardiologists, serving as its president in 1970.

Herb was recognized as a world authority on altitude sickness and was the first US investigator to define (in Medicine in 1961) the clinical characteristics of high-altitude pulmonary edema, although the pathophysiological basis of this condition was unknown. In 1962, while serving as chief of cardiology at the University of Utah, Hans Hecht published a case report of pulmonary hypertension with a normal left atrial pressure (measured at right heart catheterization via a patent foramen ovale) in a physician who had developed pulmonary edema while skiing at Alta, Utah. A pulmonary artery wedge pressure could not be recorded, and Hecht and associates concluded that hypoxia-induced spasm of the postcapillary pulmonary veins might be the cause of high-altitude pulmonary hypertension and edema. In 1964, Hultgren and associates published a remarkable study in Circulation in which they performed right heart catheterization in a series of patients with high-altitude pulmonary edema admitted to Chulec General Hospital in the city of La Oroya, at 12 300 feet in the Peruvian Andes. This study established that this form of pulmonary edema was consistently associated with very significant pulmonary hypertension and documented that it occurred with a normal or low wedge pressure. Herb subsequently advanced the still-accepted hypothesis that edema resulted from hypoxia-induced focal pulmonary artery constriction, with overperfusion of lesser-affected segments causing a pulmonary capillary leak.

Herb was an avid mountaineer and climbed many of the highest peaks in North and South America. He was chairman of the Medical Committee of the American Alpine Club from 1974 to 1980. When I was at the Palo Alto Veterans Administration Hospital, Herb was fond of taking junior faculty and fellows to the Barcroft high-altitude research laboratory on White Mountain Peak, at an altitude of 12 500 feet. Herb always took an echocardiogram machine to the laboratory on the chance that one of us would develop high-altitude pulmonary edema so that he could demonstrate that this occurred in the presence of normal echocardiographic ventricular function. Although none of us ever did develop this disorder, we were routinely embarrassed by Herb's endurance at high altitude on our climbs to the top of White Mountain Peak, at 14 246 feet. Herb's endurance was also demonstrated by his decision to undergo chemotherapy at age 79 so that he could complete work on his excellent book, High-Altitude Medicine, which was published last June.

Herb was also very interested in ischemic heart disease and was cochair (with T. Takaro) of the Veterans Administration cooperative study comparing the use of coronary artery bypass graft surgery with medical treatment in patients with ischemic heart disease. This was one of the first large, randomized, multicenter trials that assessed benefits of a specific treatment in cardiovascular disease. Analysis of data from this study clearly established the beneficial effects of surgery on survival in patients with left main disease and on exercise hemodynamics in patients with ischemic ventricular dysfunction. It had a major impact on practice and on subsequent design and application of clinical trials in cardiology. During his career, Herb was author of 176 papers and 34 book chapters. In 1990, his numerous clinical contributions were recognized when he received the prestigious Albion W. Hewlett Award at Stanford, which honors "the physician of care and skill who has committed to discovering and using biologic knowledge, wisdom, and compassion to return patients to productive lives."

Herb and I became close friends during the years I spent with him at the Veterans Administration Hospital and remained so subsequently. I was fortunate to be able to enjoy many backpacking and trout-fishing trips with Herb. In spite of his remarkable professional and personal achievements, Herb remained totally self-effacing and modest. He is survived by his wife, Barbara, three sons, and one grandson. His family and friends, as well as the cardiology and mountaineering communities, owe much to this remarkable man.

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