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Hong Kong was occupied by the British during the Opium War in 1841 and was ceded to Britain as a colony under the Treaty of Nanking in 1843. The Kowloon peninsula and the New Territories were added to the colony in 1860 and 1897 respectively under the Conventions of Peking, increasing the size of the colony from 78 sq. km. to a total of 2,060 sq. km. From a fishing village and a pirates' haunt of 6,000 inhabitants, Hong Kong has transformed into a thriving city of 7.1 million people in 170 years. The sovereignty of Hong Kong was returned to China in 1997 in accordance with the 1984 Joint Sino-British Declaration.

Disease patterns have also undergone significant changes. In the first hundred odd years, infectious diseases were the major causes of death in the colony. As medical science developed and socioeconomic conditions and sanitation improved, infectious diseases were brought under control. Since the 1960s, cancer, heart disease and strokes have taken over as the three leading causes of death in Hong Kong.

Much progress has been made in the management of heart disease in Hong Kong. The development of cardiovascular medicine in Hong Kong will be chronicled against the background of local and world events from 1841 to 1992.

The First 50 Years (1841-1890)

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Western medicine was introduced into Hong Kong following the arrival of the British in 1841. The first report on population in 1845 gave a total of 23,817, of whom 595 were Europeans and 362 Indians. Living conditions for the majority were squalid and infectious diseases were rampant, such as malaria, cholera, dysentery, smallpox, tuberculosis and syphilis. Beri-beri was recorded in 1852 as being responsible for a number of deaths, and opium addiction was prevalent. 1

The first hospital was established in 1843. Known as the Seaman's Hospital, it was founded by the Church Mission Society of Canton and Macau. With 50 beds, it admitted only European patients. The-Government Civil Hospital was opened in 1859 but few Chinese patients would avail themselves of treatment there by the colonial surgeons, unless they were jailed and became ill while in prison. They would rather go to the traditional Chinese herbalists. The Tung Wah Hospital was established in 1872, providing Chinese traditional medicine in a hospital setting for the local residents. The Alice Memorial Hospital, founded by the London Missionary Society, was opened in 1887 and conditions were deemed favourable for the introduction of western medical education to Hong Kong. 2-3

Up to the seventeenth century, physicians in the West largely retained the view of the ancient Greeks that illnesses were due to imbalance of the four "humors": blood, mucus, black bile and yellow bile, and symptoms of disease depended on the individual's humoral constitution. Therapy was directed towards restoring harmony to the patient's body function. To determine the nature of illness, the physician mainly relied on the patient's descriptions of his symptoms, the patient's appearance, the appearance of his body fluids and the feel of his body temperature and pulse. It was Galen in the second century A.D. who observed the different characters of the pulse : swift or slow, strong or feeble, regular or irregular, hard or soft, etc. He also described unique characteristics given to the pulse by the body's organs, which allowed deductions about the state of each organ. 4 Physicians of traditional Chinese medicine inherited a very similar approach to the ancient Greeks, believing that illnesses were due to an imbalance of "Yin" and "Yang" and the five elements of metal : wood, water, fire and earth. They also paid great attention to the qualitative alterations of the pulse and believed that organ failure could be detected from the pulse as Galen did. Therapy was directed towards the restoration of harmony of "Yin" and "Yang" and the five elements.

Another school of thought in Greek medicine believed that specific disease entities have different patterns of symptoms, which had nothing to do with the "humors ". This school of thought was revived by Paracelsus in the sixteen century during the Renaissance 5 and elaborated by Sydenham in the seventeenth century. 6 The study of anatomy through dissection by Vesalius (1543) paved the way for Harvey's discovery of the circulation (1628). 7-8 The work of Morgagni (1761) established the understanding of disease through morbid anatomy. 9 The use of percussion as a clinical examination procedure was introduced by Auenbrugger in 1761. 10 Indirect auscultation by means of a stethoscope was developed by Laennec (1819) who went on to correlate stethoscopic signs with underlying pathology in the chest. 11 Sphygmographic analysis of the pulse by Marey (1860) dispelled many myths about the interpretation of the quality of the pulse by Galen's disciples. 12 The art of bed-side examination had attained a high level of sophistication in the late nineteenth century, as shown by Corrigan's classic description of the signs of aortic regurgitation (1832), Potain's observation on the internal jugular pulse (1867) and gallop rhythm (1875), Austin Flint's mitral murmur in aortic regurgitation (1862) and Graham Steell's pulmonary diastolic murmur in mitral stenosis (1887). 13-17 It was in this setting of western medical development that the Hong Kong College of Medicine came into being.

The Hong Kong College of Medicine for the Chinese was inaugurated within the premises of the Alice Memorial Hospital in October 1887. Patrick Manson, father of Tropical Medicine, was its first Dean and Sun Yat Sen, founder of the Chinese Republic, was one of its first graduates.

The teaching staff of the college in those early days gave their services freely in addition to working as private practitioners, government servants or military medical officers. Many of the key figures in the faculty, such as Manson, Cantlie, Gibson, Jordan and Ho Kai, were graduates from Aberdeen University and Edinburgh University. The five-year medical curriculum included chemistry, physics, botany, Latin, anatomy, physiology, pathology, medicine, surgery, midwifery and diseases of women, materia medica and therapeutics and medical jurisprudence. Bacteriology, public health and tropical diseases were among the later additions to the curriculum. 18 The lectures probably covered Heberden's description of angina pectoris (1768), Hale's direct measurement of blood pressure (1773), Withering's account of the Foxglove (1785), the use of amyl nitrite in angina pectoris (1867), Cheadle's treatise on the manifestations of the rheumatic state (1886), tetralogy of Fallot (1888) and the use of sodium salicylate in rheumatic fever (1895). 19-22 The foundation for the local development of cardiovascular medicine was laid.

The Second 50 Years (1891-1940)

At the turn of the century, the health authorities in Hong Kong had their hands full dealing with bubonic plague, the most dreaded horseman of the apocalypse. The battle lasted 30 years from 1894 to 1923 and about 21,000 fell victim to the pestilence, which had a mortality rate of 94%. Pasteurella pestis was identified as the causative bacteria for bubonic plague during the Hong Kong epidemic. 23

Meanwhile in Europe, the development of cardiovascular medicine took a gigantic leap forward following the invention of Roentgen's X-ray (1895), Riva-Rocci's sphygmomanometer (1896) and Einthoven's electrocardiograph (1901). 24-26 Those discoveries led to Korotkow's auscultatory method of measuring blood pressure (1905), the study of hypertension as a cardiovascular disease by Janeway (1913), the electrocardiographic method of diagnosing acute coronary occlusion by Herrick (1918), the electrocardiographic study of cardiac arrhythmias by Lewis (1925) and the self-catheterization of his own right atrium under fluoroscopy by Forssman (1929). 27-31

In the United States, the American Heart Association was founded in 1924. In 1931, congenital heart disease was classified by Abott. 32 In the same year, rheumatic fever was linked to streptococcal infection by Collis and Coburn, and the first modern textbook on heart disease was written by White. 33-35 The work of Wilson on the unipolar leads (1930-1944) enhanced the clinical application of electrocardiography. 36 Cardiology was getting too complicated for the general physicians and began to emerge as a specialty of internal medicine.

Therapeutic advances during this period included the introduction of mercurial diuretic (1924) and sulphonamide (1938). 37-38 Surgical ligation of patent ductus arteriosus was performed by Gross and Hubbard in 1938. 39

It is not known when exactly did the sphygmomanometer, the X-ray machine or the electrocardiograph first arrived in Hong Kong. The sphygmomanometer probably arrived first, in time to witness the inauguration of the University of Hong Kong and its new Faculty of Medicine.

The University of Hong Kong was founded in 1911 and the Hong Kong College of Medicine was incorporated into its Faculty of Medicine. Its medical degree was accorded full recognition by the General Medical Council in Britain. The University came about largely through the effort of Frederick Lugard, then Governor of Hong Kong, who conceived the idea of a university in Hong Kong serving not only Hong Kong, but China as well. The same vision was shared by the Rockefeller Foundation when it endowed to the University the Chairs of Medicine and Surgery in 1922 and the Chair of Obstetrics in 1923. 40-41

The X-ray machine was probably installed in the new Lai Chi Kok Hospital when it was opened in 1924, and in the new Kowloon Hospital which was operational in 1928. A part-time lecturer in Radiology and Radio-therapeutics was appointed by the University in 1927. The position of Government Radiologist was established in 1932. 42 The electrocardiograph, capable of recording three leads, was available when Queen Mary Hospital was opened in 1937. The hospital replaced the old Government Civil Hospital as the teaching hospital for the University. The stage was set for the next phase of development of cardiovascular medicine in Hong Kong, but progress was soon delayed by the onset of Second World War.

Cardiology in the 1940s

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The Japanese invaded Hong Kong in December 1941 and occupied the territory until August 1945. The University was closed and many of the medical undergraduates went to the medical schools in the hinterland of China to continue their medical education. The Faculty of Medicine was functional again : in 1948 the Phoenix had arisen from the Ashes. 43

The leading causes of death recorded in Hong Kong after the war in 1946 are listed in Table 1. 44

Table 1.
Leading Causes of Death in Hong Kong in 1946
1. Pneumonia 24.8%
2. Tuberculosis 10.9%
3. Beri-beri 7.9%
4. Smallpox 7.8%
5. Enteritis 7.4%
6. Infant Death 5.8%
7. Bronchitis/Emphysema 5.0%
8. Malaria 4.5%
9 Violence/Accidents 3.7%
10. Heart Disease 2.2%
11. Cancer 1.6%
12. Stroke 1.1%

In the meantime, important advances were made in the field of cardiology, such as the development of cardiac catheterization by Cournand and his associates in 1941, the establishment of Jones' criteria for rheumatic fever in 1944, and the initiation of the Framingham study on the risk factors of cardiovascular disease in 1948. 45-47 In therapeutics, the most significant advance was the production of penicillin by Florey and Chain in 1943. 48 Kempner's rice diet (1944) is mentioned to indicate the lack of effective drug therapy for hypertension in those days. 49 Some patients went through thoraco-lumbar sympathectomy to save their lives. Palliative surgery for tetralogy of Fallot was performed by Blalock in 1945 and by Pott in 1948. 50-51 Closed mitral valvotomy, successfully performed by Souttar in 1925 was revived by Baily, Harken and Ellis in 1948. 52-53

Cardiology in the 1950s

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Development of cardiovascular medicine as a specialty in Hong Kong truly began in the 1950s when Joseph Pan and Robert Barnes, graduates of 1951 and 1952, went to Boston and Dundee respectively for training in cardiology. Upon their return, in-service training in cardiology were organized and cardiac catheterization developed at Queen Mary Hospital and Queen Elizabeth Hospital. The latter was opened in 1963 to replace Kowloon Hospital. The first cardiac catheterization was performed in the Lewis Laboratory of Queen Mary Hospital in 1956. The first closed mitral valvotomy was performed in Kowloon Hospital in 1955. Soon, other general surgeons and thoracic surgeons joined in and performed closed-heart operations for mitral stenosis, patent ductus arteriosus, and Blalock's or Pott's shunts for tetralogy of Fallot. 54

On the world scene, the era of open-heart surgery had begun with the development of hypothermia technique (Lewis, 1953) and the pumpoxygenator (Gibbon, 1954). 55-56 Other therapeutic advances included the introduction of thiazides (1957), external cardiac pacing (Zoll, 1954), A.C. defibrillation (Zoll, 1956) and transvenous cardiac pacing (Furman, 1958). 57-59 The importance of echocardiography (Edler, 1954) and coronary angiography (Sones, 1958) were probably not fully realized in those early days. 60-61

Cardiology in the 1960s

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Advances in cardiac surgery continued to dominate the scene of cardiology in the 1960s. The milestones were prosthetic valve replacement (Harken, 1960), coronary bypass surgery (Sabiston, 1962) and heart transplantation (Barnard, 1967). 62-64 The other prominent events were permanent cardiac pacing (Chardack, 1960), external cardiac massage (Kouvenhover, 1960), D.C. defibrillation (Lown, 1962) and the birth of the coronary care unit (Day, 1962). 65-68

Locally the first case of open-heart surgery under hypothermia for congenital heart disease was performed at Queen Mary Hospital in 1964. A permanent cardiac pacemaker was implanted with epicardial leads at Queen Mary Hospital in 1965. Five cases of atrial septal defect were closed under hypothermia at Kowloon Hospital in 1967. 69 The new Lewis Laboratory was opened at Queen Mary Hospital in 1967. The three leading causes of death in Hong Kong in 1966 were cancer (17.4%), heart disease (23.6%) and strokes (9.8%). 70

The highlight of the decade in cardiologic development was the establishment of the open heart surgery unit with cardiopulmonary bypass facility at the Grantham Hospital in 1968. The surgical team was led by K.H. Kwong and John Leung, who went to the United States and New Zealand respectively for their training. K.H. Wai was the first paediatric cardiologist and was trained in Canada. 71 Others went to Britain and Australia for their specialty training and returned to serve the community. Transvenous permanent cardiac pacing was first performed in 1969 at queen Elizabeth Hospital.

The Hong Kong Cardiological Society was founded in 1967 and played an active role in continuing medical education and international scientific exchange. It became a member of the Asian Pacific Society of Cardiology and the International Society and Federation of Cardiology. Its foundation President was K.F. Woo, a former Professor of Medicine at the Lingnan University in Canton. The ten Presidents of the Society who held office are listed in Table 2.

Table 2.
Presidents of the Hong Kong Cardiological Society
K.F. Woo 1967-1968
K.F. Woo 1969-1970
Robert J. Barnes 1971-1972
Robert J. Barnes 1973-1974
Joseph Y.C. Pan 1975-1976
Peter C.Y. Wong 1977-1978
Raymond W.Y. Wu 1979-1980
S.M. Kong 1981-1982
Patrick W.I. Pau 1983-1984
C.K. Mok 1985-1986
Patrick W.I. Pau 1987-1988
S.P. Wong 1989-1990
C.H. Cheng 1991-1992

Cardiology in the 1970s

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Coronary bypass surgery reached its zenith on the world scene in the 1970s. The annual national cost in the United States for coronary angiography was $500 million while the cost for coronary bypass surgery reached a staggering two billion dollars (1970 dollars). Several large scale randomized prospective studies were undertaken to evaluate the role of surgical versus medical treatment in chronic stable angina pectoris, such as the Veterans Administration Cooperative Study (1972), the European Coronary Surgery Study Group (1973) and the Coronary Artery Surgery Study (CASS)(1975). The cumulative survival after 7-10 years showed no significant difference as a whole between the two groups, except in the subset of patients who had main-stem disease, three-vessel disease, two vessel disease with significant proximal left anterior descending coronary artery lesions, or significant left ventricular dysfunction with ejection fraction less than 0.50. 72-74

On the other hand, a decline in mortality from coronary artery disease by about 20% was observed in the United States from 1968 to 1980. 75 The decline was attributed to better control of the risk factors of coronary artery disease through health education and life-style changes, and more effective treatment for hypertension and acute myocardial infarction. A similar trend was observed in other developed countries such as Canada, Australia, New Zealand and Finland. The mortality rate from heart disease per 100,000 population in Hong Kong was 58.9 in 1961, 90.2 in 1977 and 80.4 in 1987. 76

The development of space-age technology was responsible for new methods of cardiovascular investigation such as echocardiography, radionuclide scintigraphy, ambulatory ECG monitoring, stress exercise tests, and electro-physiologic studies. 77-81 Technological advances were also responsible for the introduction of dual-chamber cardiac pacing and percutaneous transluminal coronary angioplasty (Gruentzig 1977). 82 Interest in thrombolytic therapy for acute myocardial infarction was revived in the 1970s and led to the European Cooperative Group Study on intravenous streptokinase in acute myocardial infarction (1979), which revolutionalized treatment of acute myocardial infarction in the 1980s and beyond. 83

In Hong Kong, mortality from heart disease was rising to a peak in the 1970s. The first heart health campaign was organized by the Hong Kong Cardiological Society in 1972. The eruption of the Middle East "Oil Crisis" in 1973 forced the Government to cancel the "B" Block extension project at Queen Elizabeth Hospital for economic reasons, and delayed the establishment of a new cardiac catheterization laboratory for two decades. The promotional effort of the Hong Kong Cardiological Society led to the incorporation of the Hong Kong Heart Foundation in 1975. Chaired by Q.W. Lee, a prominent local banker and community leader, the Heart Foundation played a significant role in the promotion of public health education and the provision of new diagnostic and therapeutic facilities for the management of heart disease. A notable venture undertaken by the Heart Foundation in conjunction with the Government and the Grantham Hospital Board was the construction of a new heart centre at the Grantham Hospital, which was opened in 1982.

Coronary angiography was started at the Lewis Laboratory, Queen Mary Hospital in 1976 and the first coronary bypass surgery was performed in Grantham Hospital in 1977.

The variety of cardiovascular investigations performed in the Lewis Laboratory from 1976 to 1979 are listed in Table 3.

The number of cardiac catheterizations performed at Queen Elizabeth Hospital in 1979 was 187, comprising 71 cases of adult congenital heart disease, 63 cases of acquired heart disease and 53 paediatric cases. 401 patients received cardiac surgery in Grantham Hospital in 1979, of which 306 cases were open-heart surgery and 95 cases were closed-heart surgery.

Table 3.
Work of the Lewis Laboratory,
Queen Mary Hospital, 1976-1979
1976 1977 1978 1979
Cardiac Catheterization 150 350 355 360
Coronary Angiography 1 18 22 54
Permanent Cardiac Pacing 35 40 40 55
Treadmill Exercise Test - 200 450 500
24 Hr Ambulatory ECG - - 6 47
Echocardiography (m-mode) 350 400 1080 1252

Cardiology in the 1980s

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Development of cardiology moved ahead at an unprecedented pace in the 1980s, from gross imaging of the living heart to minute study of the heart and blood vessels at the molecular level. New imaging devices in echocardiography included two dimensional (2-D) echocardiography, Doppler echocardiograph, colour Doppler, transoesophageal echocardiography, stress echocardiography and intravascular echocardiography. 84-90 In nuclear medicine, thallium-201 imaging was combined with stress testing for the evaluation myocardial perfusion, new technetium-99m labeled compounds were developed for better imaging and positron-emission tomography provided a non-invasive method of assessing myocardial viability. 91-93 In radiology, digital coronary angiography provided more accurate measurement of coronary stenosis, 94 and the roles of fast computed tomography and magnetic resonance imaging were being evaluated.

Therapeutic advances were equally impressive. Percutaneous transluminal coronary angioplasty (PTCA) overtook coronary bypass surgery as the treatment of choice for chronic stable angina pectoris unresponsive to medical therapy and unstable angina, where the site and characteristics of the stenotic lesions were suitable. As one third of the cases restenosed within six months after PTCA, stenting, laser therapy, and atherectomy were developed to tackle the problem. 95 Balloon valvuloplasty was used selectively in the treatment of stenotic valvular lesions.

Multicentre trials such as ISIS-2 established the beneficial role of thrombolytic therapy for acute myocardial infarction when given early after its onset. 96 Other pharmacological advances included the use of ACE inhibitors in the management of hypertension, heart failure and myocardial infarction, new calcium channel blockers and new lipid-lowering agents such as HMG-CoA reductase inhibitors. The introduction of cyclosporin A for immunosuppression therapy gave a new breath of life to heart transplantation, which became fully established as an accepted treatment for end-stage heart disease. More than 13,000 heart transplants were performed in over 230 transplant centres worldwide in the 1980s and a mean 1-year survival of 83% and 5-year survival of 75% were achieved. 97

In the treatment of cardiac arrhythmias, transcutaneous ventricular pacing was revived for temporary emergency pacing, and new technology in permanent pacing included programmability and rate-adaptive pacemakers. 98-100 Implantable cardioverter-defibrillators were used for pacing induction and termination of ventricular tachycardia and fibrillation. 101 Multipolar catheter electrodes and programmed stimulation were used invasively for the study of arrhythmias and the selection of antiarrhythmic agents, while radiofrequency catheter ablation therapy provided an alternative to surgical ablation in the treatment of AV reentrant and ventricular tachyarrhythmias. 102-103 Signal-averaged ECG provided measurement of late potentials, which may help to predict the risk of ventricular arrhythmias and sudden death. 104

Development of cardiovascular medicine in Hong Kong also gathered pace in the 1980s. The new heart centre in Grantham Hospital was opened in 1982 and was named after its benefactor, Kwok Tak Seng, who donated eleven million Hong Kong dollars to the Hong Kong Heart Foundation to build the centre. The rest of the capital cost and recurrent costs were born by the Government. Its opening shortened the waiting period of cardiac catheterization and open-heart surgery for paediatric patients from two years to a few weeks or none at all for emergency cases.

With the opening of a second medical school for Hong Kong at the Chinese University of Hong Kong in the New Territories, a new cardiac unit was established at the newly-opened Prince of Wales Hospital in Shatin in 1984. Meanwhile the expansion project at Queen Elizabeth Hospital was approved and scheduled for completion in the early 1990s.

Increased demand for cardiac care among the more affluent in Hong Kong also led to the establishment of new cardiac centres in the private hospitals, equipped with cardiac catheterization laboratories, coronary and intensive care units and open-heart surgery facilities. The first of the private cardiac centres was established at the Hong Kong Adventist Hospital in 1984. A team of experts with missionary zeal from the Loma Linda University of California came to assist the opening of the centre. A second cardiac centre was established at the Hong Kong Sanatorium and Hospital in 1987 and a third was planned for opening in Kowloon in the early 1990s at St, Teresa's Hospital.

Acquisition of technological skill in new diagnostic and therapeutic procedures continued, such as 2-D echocardiography, Doppler echocardiography, colour Doppler, radionuclide scintigraphy, electrophysiology studies, dual-chamber and rate-adaptive pacing, PTCA and balloon valvuloplasty, led by the University team at Queen Mary Hospital and Grantham Hospital. Electrophysiology study was first performed in 1980, dual-chamber pacing in 1982, PTCA in 1984, balloon valvuloplasty in 1988, catheter ablation of the atrioventricular node in 1988, and rate adaptive pacing in 1988. The work of the cardiac unit at Queen Mary Hospital, Grantham Hospital, Queen Elizabeth Hospital and Prince of Wales Hospital, Hong Kong Adventist Hospital, St. Teresa's Hospital, and Hong Kong Sanatorium & Hospital in 1989 are listed in Table 4.

Table 4.
Work of the Cardiac Units at Queen Mary Hospital (QMH), The Grantham Hospital (TGH),
Queen Elizabeth Hospital (QEH), Prince of Wales Hospital (PWH),
Hong Kong Adventist Hospital (HKAH), St. Tersea's Hospital (STH),
and Hong Kong Sanatorium & Hospital (HKSH), 1989
QMH TGH QEH PWH HKAH STH HKSH
Permanent pacing 105 25 53 85 - - 73
Electrophysiology study 106 - 6 48 - - -
Cardiac catheterization 476 920 264 319 479 88 283
PTCA 20* 91 11* 19 124 - 41
Balloon valvuloplasty 2* 8 - - - - -
ECG 26280 10141 84241 - - 5321 4000
24 hr ambulatory ECG 1435 355 644 843 - 122 172
Ambulatory blood pressure 189 - - - - - -
Treadmill exercise test 753 370 581 793 - 386 711
Exercise thallium 80 - 70 136 - - -
Echocardiogram 3402 6268 4231 2193 - 540 449
* Performed in TGH
- Data not available

The first Biennial Scientific Congress of the Hong Kong Cardiological Society was held in 1988. It was meant as a venue for local cardiologists to present their work pertinent to the local scene. Special invitations were extended to cardiologists from China to attend local Congress and prominent speakers were invited from overseas to give keynote addresses. Over 50 local papers were presented in the first Congress in 1988, and over 70 local papers were presented in the second Congress in 1990.

Cardiology for the 1990s

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Progress in the development of cardiovascular medicine continued with the establishment of a new cardiac centre at St. Teresa's Hospital in 1991 and the completion of the extension project with a new cardiac catheterization laboratory and a new coronary care unit at Queen Elizabeth Hospital in 1992. Radiofrequency ablation of accessory atrioventricular pathway was first performed in 1990 and radiofrequency ablation of ventricular tachycardia in 1991. The first two cardioverter-defibrillators were implanted in 1992. A week before Christmas Day, 1992, the first heart transplant in Hong Kong was successfully performed at the Grantham Hospital.

The work of the various cardiac units in 1991 are listed in Table 5 and serve to illustrate the progress that has been made since western medicine was introduced into Hong Kong 150 years ago.

Table 5.
Work of the Cardiac Units at Queen Mary Hospital (QMH), The Grantham Hospital (TGH),
Queen Elizabeth Hospital (QEH), Prince of Wales Hospital (PWH),
Hong Kong Adventist Hospital (HKAH), St. Tersea's Hospital (STH),
and Hong Kong Sanatorium & Hospital (HKSH), 1991
QMH + TGH QEH PWH HKAH STH HKSH
Permanent pacing 124 25 98 131 - 11 74
Radiofrequency ablation 41 - - - - - -
Electrophysiology study 158 - 12 10 - - -
Cardiac catheterization 428 1243 277 642 434 411 297
PTCA 40* 207 17 141 203 70 64
Balloon valvuloplasty 3* 91 - - - 3 10
ECG 27996 12283 76043 - - 7714 3900
24 hr ambulatory ECG 1404 418 923 1290 - 145 126
Ambulatory blood pressure 107 - 23 - - - -
Treadmill exercise test 916 467 742 785 - 630 1112
Exercise thallium 150 - 159 147 - - -
Echocardiogram 4025 7797 5247 2398 - 795 625
* Performed in TGH
+ Lewis Laboratory underwent renovation in October 1991
- Data not available

Eight years have passed since the Joint Sino-British Declaration on the question of Hong Kong was signed in Beijing on 19 December 1984. In another four and half years, the sovereignty of Hong Kong will be returned to China. Under the principle of "one country, two systems", the capitalist system of Hong Kong will remain unchanged for fifty years. Provisions were made in the Joint Declaration and in the Basic Law of the Hong Kong Special Administrative Region (HKSAR) promulgated in 1989, which will enable the medical profession in Hong Kong to continue to govern itself through registration, examination, licensing and disciplinary action, and to set a high standard of medical training for undergraduates and postgraduates that will be unique for Hong Kong. The medical profession, as represented by the Hong Kong Medical Association, accepted the challenge and emphasized the important role of the medical profession in maintaining the health and welfare of the people in the future HKSAR. 105 The outcome of eight years of discussion and preparation was the formation of the Hong Kong Academy of Medicine, which was established by statute in August 1992, to govern postgraduate specialist medical training and accreditation, and to promote continuing medical education in Hong Kong. The Academy has recommended that there should be three years of basic specialty training (in medicine, surgery, etc.) followed by three years of higher specialist (or subspecialty) training. The trainees will be closely monitored in approved training programs, and there will be interim and exit examinations where appropriate, which will be administered by the component colleges (such as the College of Physicians, Surgeons, etc.) that constitute the Academy. 106

The formation of the Hong Kong College of Cardiology in January 1992 was a cooperative effort by the Council of the Hong Kong Cardiological Society to support the Academy of Medicine in the area of higher specialty training and continuing medical education. The College aims to promote the standard of training and practice of cardiology through the function of four Standing Committees, the Examination Committee, the Accreditation and Education Committee, the Scientific Committee and the Publication Committee. The inaugural scientific congress of the College will be held in February 1993.

The criteria for admission as Fellows of the College were successful completion of 3 years of basic specialist training with MRCP or FRCS diploma or their equivalents plus 3 years of higher specialist training in cardiology, cardiovascular surgery or related fields (or 2 years if the training was completed before 1980). 73 applicants so qualified were admitted as Fellows in November 1992, including 59 adult cardiologists, 7 paediatric cardiologists, 6 cardiovascular surgeons and one cardiac anaesthetist. 11 trainees were admitted as Members.

Contemporary practice of cardiology is more than an exercise of technological skill. It demands the correlation of clinical history and physical findings and judicious selection of a vast choice of diagnostic and therapeutic procedures. Fundamental to the training is the provision of the best possible care for the patients in a compassionate manner.

The subject of Adult Cardiology Training for the 1990s was first discussed at a meeting organized by the Hong Kong Cardiological Society in June 1990, when a teaching faculty from the American College of Cardiology led by Eliot Corday and Robert Frye visited Hong Kong. The outcome was the establishment and publication of the "Guidelines for Adult Cardiology Training in Hong Kong" in April 1992 by the Hong Kong College of Cardiology, 107 which was based on the proceedings of the 17th Bethesda Conference on Adult Cardiology Training published by the Journal of the American College of Cardiology in June 1986, with updates on newer procedures such as colour Doppler, stress and transoesophageal echocardiography, signal average electrocardiography, rate-adaptive pacing, implantable cardioverter-defibrillator, catheter ablation technique for cardiac arrhythmias, etc. Our existing cardiac training centres can provide the 24 months of core training in clinical cardiology and offer specialized training (level 2) in certain areas such as cardiac catheterization, electrocardiography, cardiac pacing and electrophysiologic studies to suit the individual programs. Certification of competence by the program directors and recording of training experience in the form of log-books will be undertaken. A third year of advanced training will be devoted to enhancing the clinical skills of the trainees in patient managements, cardiac consultations, specialized training (level 2) or advanced specialized training (level 3) in certain diagnostic and/or therapeutic procedures, cardiovascular research and cost benefit analysis. A selected number of trainees will be given the opportunity to undertake a third year or a fourth year of advanced training in overseas cardiac centres under the Hong Kong Heart Foundation Fellowship Scheme which was recently established and will be available in July 1993 for the qualified and selected trainees. The Cardiology Departments of the Cleveland Clinic, the Mayo Clinic, University of Michigan and Stanford University have indicated their willingness to accept the Hong Kong Heart Foundation Fellow for advanced training in clinical cardiology. Guidelines on Paediatric Cardiology Training and Cardiovascular Surgery Training are under preparation.

The University of Hong Kong was founded in 1911 with the purpose of serving not only Hong Kong, but China as well. The prospect is good that Hong Kong will become an important training centre in cardiology for China after 1997, if the momentum generated in the 1950s to the 1990s is carried forward.

The Hong Kong Heart Foundation Fellowship Program
 
The establishment of the Hong Kong Heart Foundation Fellowship Program was possible due to the strong support from the Hong Kong Heart Foundation, the Hong Kong College of Cardiology, The Hong Kong Hospital Authority, the Hong Kong Academy of Medicine, as well as the designated training centers for the program in America.
 
Since its inception in 1993 to the year 2007, over 50 cardiology trainees have completed their one-year advanced subspecialty training in America, such as interventional cardiology, electrophysiology study and arrhythmias, echocardiography, heart failure and heart transplant, nuclear cardiology, cardiac MRI, adult congenital heart disease, vascular medicine, intensive coronary care, pediatric cardiology, and cardiovascular surgery.
 
From the original four designated training centers at Cleveland Clinic, Mayo Clinic, University of Michigan and Stanford University, other centers have been added to the list over the past 15 years, including University of California San Francisco, Brigham and Women's Hospital, Massachusetts General Hospital and Columbia University Medical Center. Some of our fellows have been rated as outstanding by US standard and have received Young Investigators' Awards in international meetings in Asia and Europe after their return to Hong Kong. The goal of improving the standard of cardiology service in Hong Kong and bringing it up-to-date through the fellowship program has been achieved.


Author: Dr. Patrick Pau

Acknowledgement

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A major portion of this article was based on my Presidential Address delivered to the Hong Kong Cardiological Society in June 1983. I would like to thank Dr. Rebecca Wang, Dr. S.M. Kong and Prof. C.K. Mok for supplying the information on the work done at queen Mary Hospital, queen Elizabeth Hospital and the Grantham Hospital in 1979. I wish to thank Dr. C.P. Lau, Dr. Y.T. Tai, Dr. K.L. Cheung, Dr. S.P. Wong, Dr. C.O. Pun, Dr. Gary Mak, Dr. Patrick Ko, Dr. T.F. Tse and Dr. C.M. Wong for their contributions in Tables 4 and 5, and to Miss Dora Ho of the Hong Kong Medical Association for typing the manuscript. I am also indebted to Dr. H.C. Ho and Dr. Joseph Pan for their accounts of the local scene in the late 1930s to the 1950s.

The title of my second Presidential Address in 1987 was "Cardiology for the Future". I am encouraged by the events that have taken place since then, such as the formation of the Hong Kong Academy of Medicine and the Hong Kong College of Cardiology, the establishment of the Hong Kong Heart Foundation Fellowship and the adoption of the Guidelines for Adult Cardiology Training in Hong Kong. By constancy of purpose, they are dreams that have come true.

Special articles and books that I consulted in preparing this review included the following:

  1. The University of Hong Kong - The First Fifty Years. Hong Kong University Press 1960.
  2. Choa GH. A history of medicine in Hong Kong. Medical Directory of Hong Kong, 3rd ed. The Federation of Medical Societies of Hong Kong 1985; 13-29.
  3. Endacott GB. History (of Hong Kong). The Hong Kong Annual Report 1962. Hong Kong Government Publications 1962; 24:333-46.
  4. Evans DE. Constancy of Purpose, An account of the foundation and history of the Hong Kong College of Medicine and the Faculty of Medicine of the University of Hong Kong, 1887-1987. Hong Kong University Press 1978.
  5. Reiser ST. Medicine and the reign of technology. Cambridge University Press 1978.
  6. Mok CK. Cardiac surgery at the Grantham Hospital: A Presidential Address delivered to the Hong Kong Cardiological Society in 1985. Proceedings of the Hong Kong Cardiol Soc 1985-87; 19:7-14.
  7. Departmental Reports of the Director of Medical and Health Science. The Government Printer, Hong Kong.
  8. Hurst JW. The heart, arteries and veins. 4th ed. MacGraw-Hill-Inc. 1978.
  9. Braunwald E. Heart disease: a textbook of cardiovascular medicine. 4th ed. WB Saunders 1992.
    "Anyone who knows the Chinese even but slightly is well aware that steadiness of purpose is perhaps their most constant characteristic. In their national history ... their constancy of purpose has always prevailed." Tames Cantlie, KBE, MA, MB (Aberdeen), LLD, FRCS, DPH. Dean of the Hong Kong College of Medicine for the Chinese, 1889-1896.

References

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The First 50 Years (1841-1890)

  1. Choa GH. A history of medicine in Hong Kong: medical and health problems in the early day. In: Medical Directory of Hong Kong. 3rd ed. The Federation of Medical Societies of Hong Kong 1985; 16-20.
  2. Ibid. The non-government hospitals, 22-3.
  3. Ibid. The government hospitals, 20-1.
  4. Bedford DE. The ancient art of feeling the pulse. Br Heart J 1951; 13:423.
  5. Pagel W. Paracelsus: an introduction to philosophical medicine in the era of the Renaissance. Basel: S Karger 1958; 128.
  6. Sydenham T. Medical observation concerning the history and cure of acute diseases. In: The works of Thomas Sydenham, MD trans Latham RC. London: Sydenham Society 1948-50; 1:19
  7. Vesalius A. De humani corporis fabrica (1543) trans O'Malley CD. In: Andreas Vesalius of Brussels: 1514- 64. Berkely: University of California Press 1965.
  8. Harvey W. Exercitatio Anatomica de Motu Cordis et Sanguenis in Animalibus (1628) trans Leake CD. Springfield: Thomas 1928.
  9. Morgagni JB. The seats and causes of diseases investigated by anatomy (1961) trans Alexanda B. New York: Macmillan (Hafner Press) 1960.
  10. Auenbrugger L. Inventum Novum (1761) trans Forbes J. On percussion of the chest. Bull Hist Med 1936; 4:373.
  11. Laennec RTH. On mediate auscultation (1819) and a treatise on the disease of the chest (1821) trans Forbes J. London: T&G Underwood, 1827.
  12. Marey EJ. Researches sur le pouls au moyen d'un nouvel appareil enregistreur, Le sphygmographe. Paris: E Thunot et cil 1860. The graphic method in the experimental sciences and on its special application to medicine. Br Med J 1876; 1:1-3, 65.
  13. Corrigan DJ. On permanent patency of the mouth of the aorta or inadequacy of the aortic valve. Edinburgh Med Surg J 1832; 37:225.
  14. Potain PCE. On the movements and sounds that take place in the jugular veins. Bull Mem Soc Med Hop Paris 1867; 4:3.
  15. Potain PCE. Du rhythme cardiaque appete bruit de galop (1875). In: Ruskin A ed. Classics in arterial hypertension. Springfield Charles C. Thomas 1956.
  16. Flint A. On cardiac murmurs. Am J Med Sci 1862; 44:29.
  17. Steell G. Physical signs of cardiac diseases. 2nd ed. 1881; 43.
  18. Evans DE. The Alice Memorial Hospital and the vision of a medical school. In: Constancy of purpose. An account of the foundation and history of the Hong Kong College of Medicine and the Faculty of Medicine of the University of Hong Kong 1887-1987. Hong Kong University Press 1987; 27-32, 137-42.
  19. Heberden W. Some account of a disorder of the breast. Med Trans R Cell Physicians London 1786; 11:59. (The original mention of angina pectoris was made by Heberden in a lecture before the Royal College of Physicians in London in July 1768.)
  20. Withering W. An account of the Foxglove, and some of its medical uses: with practical remarks on dropsy, and other diseases. London: CGJ & J Robinson, 1785.
  21. Cheadle WB. The various manifestations of the rheumatic state. London: Smith, Elder & Co. 1889.
  22. Fallot A. Contribution a' l'anatomie pathologique de la maladie bleue (cyanose cardiaque). Marseille Med 1888; 25:77.

The Second 50 Years

  1. Choa GH. A history of medicine in Hong Kong. Bubonic plague. In: Medical Directory of Hong Kong. 3rd ed. The Federation of Medical Societies of Hong Kong 1985; 20.
  2. Roentgen WC. On a new kind of rays. Nature 1895-96; 53:274.
  3. Lewis WH. The evolution of clinical sphygmomanometry. Bull NY Acad Med 1941; 17:871.
  4. Einthoven W. The different forms of the human electrocardiogram and their significance. Lancet 1912; 1:853-61.
  5. Segall HN. Dr. NC Korotkoff discovery of the auscultatory method for measuring arterial pressure. Ann Intern Med 1965; 63:147.
  6. Janeway TC. The clinical study of blood pressure. New York: D Appleton & Co. 1907.
  7. Herrick JB. Thrombosis of the coronary arteries. JAMA 1919; 72:387.
  8. Lewis T. The mechanism and graphic registration of the heart beat. 3rd ed. London, Shaw & Sons 1925.
  9. Forssman W. Die Sondierung des rechten Herzens Klin Wochengchr 1929; 8:2085.
  10. Abott ME. Statistics of congenital cardiac disease (1,000 cases analysed) 1931. Reprinted in Disorders of the heart and circulation, ed. Levy RL. New York: Thomas Nelson & Sons 1951.
  11. Colles WRF. Acute rheumation and haemolytic streptococci. Lancet 1931; 1:1341.
  12. Coburn AF. Factor of infection in the rheumatic state. Baltimore: Williams & Wilkins Co. 1931.
  13. White PD. Heart disease. New York: The MacMillan Co. 1931.
  14. Johnston FD, Lepeschkin FDE (eds). Selected papers of Dr. Frank N Wilson. Ann Arbor: JW Edwards, 1955.
  15. Bernheim E. Uber das neues Ouecksilberpraparat Salyrgan, ab Diuretikum Therd Gegenu 1924; 65:538.
  16. Domagk G. Ein Beitrag zur chemotherapie der bakteriellen infektionen. Dt Med Wschr 1935; 61:250.
  17. Gross RE and Hubbard JP, Surgical ligation of the patent ductus arteriosus. Report of First Successful Case. JAMA 1939; 112:729.
  18. Evans DE, Frederick Lugard. In: Constancy of purpose. Hong Kong University Press 1978; 38.
  19. Ibid. Rockefeller Foundation; 51-60.
  20. Ibid. Lecturers in Radiology; 266 & 268.

Cardiology in the 1940s

  1. Evans DE, The Phoenix arises from the Ashes, In: Constancy of purpose. Hong Kong University Press 1978; 83-86.
  2. Annual Report. Medical & Health Department, Hong Kong 1946.
  3. Cournand AF, Ranges HS. Catheterization of the right auricle in man. Proc Soc Exp Bio Med 1941; 46:462.
  4. Jones TD. The diagnosis of rheumatic fever. JAMA 1944; 126:481.
  5. Schiffman T. The Framingham Study. An epidemiological investigation of cardiovascular disease. US Government Printing Office 1970.
  6. Florey HW. The use of micro-organisms for therapeutic purposes. Yale J Biol Med 1946; 19:101.
  7. Kempner W. Treatment of kidney disease and hypertensive vascular disease with rice diet. North Carolina Med J 1944; 5:125.
  8. Blalock A, Taussig HB. The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia. JAMA 1945; 128:189.
  9. Potts WJ, Gibson S. Aorto-pulmonary anastomosis in congenital pulmonary steniosis. JAMA 1948; 137:343.
  10. Baily CP. The surgical treatment of mitral stenosis (mitral commissiurotomy) Dis Chest 1949.
  11. Harken DE, Ellis LB, Ware PF, et al. The surgical treatment of mitral stenosis by valvuloplasty. N Engl J Med 1948; 239:801.

Cardiology in the 1950s

  1. Mok CK. Cardiac surgery at the Grantham Hospital (abstract). Proceedings of the Hong Kong Cardiol Soc 1987; 19:7.
  2. Lewis FJ, Tauffie M. Repair of atrial septal defects in men under direct vision with the aid of hypothermia. Surgery 1954; 36:538.
  3. Gibbon JH. Application of mechanical heart and lung apparatus to cardiac surgery. Minn J Med 1954; 37:171.
  4. Zoll PM, Linanthal AJ, Norman LM, et al. Treatment of Stokes-Adams disease by external stimulation of the heart. Circulation 1954; 9:482.
  5. Zoll PM, Linanthal AT, Gibson W, et al. Termination of ventricular fibrillation in man by externally applied electric countershock. N Engl J Med 1956; 254:727.
  6. Furman S, Robinson G. The use of an intracardiac pacemaker in the correction of total heart block. Surg Forum 1958; 9:245.
  7. Edler I. Ultrasound cardiogram in mitral valve disease. Acta Chir Scand 1956; 111:230.
  8. Sones FM Jr, Shirley EK. Cine coronary arteriography. Mod Concepts Cardiovasc Dis 1962; 31:735.

Cardiology in the 1960s

  1. Harken DE, Sorrff HS, Taylor WJ, et al. Partial and complete prosthesis in aortic insufficiency. J Thorac Cardiovasc Surg 1960; 40:744.
  2. Sabiston DC Jr. The coronary circulation. Johns Hopkins Med J 1974; 134:314.
  3. Barnard CN. A human cardiac transplant. An interim report of a successful operation performed at Groote Shuur Hospital Capetown. S Afr Med J 1967; 41:1271.
  4. Chardack WM, Gage AA, Schimert G, et al. Three years clinical experience with an implantable pace- maker. Circulation 1963; 28:701.
  5. Kouwenhoven WB, Jude JR, Korickerbock GG. Closed chest cardiac massage. JAMA 1960; 178:1064.67. Lown B, Amarasingham R and Neuman J. New method for terminating cardiac arrhythmias. Use of synchronized capacity discharge. JAMA 1962; 182:548.
  6. Lown B, Amarasingham R, Neuman T. New method for terminating cardiac arrhythmias. Use of synchronized capacity discharge. JAMA 1962; 182:548.
  7. Day HW. Preliminary studies of an acute coronary area. Lancet 1963: 83:53.
  8. Barnes RJ, Grigg L, Wu RWY. Some aspects of atrial septial defect. Far East Med J 1968; 4:180-4.
  9. Annual Report. Medical and Health Department, Hong Kong 1966.
  10. Mok CK. Cardiac surgery at the Grantham Hospital (abstract). Proceedings of the HK Cardiol Soc 1987; 9:7-14.

Cardiology in the 1970s

  1. The Veterans Administration Coronary Artery By pass Surgery Cooperative Study Group: Eleven-year survival in the veterans administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med 1984; 311:1333.
  2. Varnauskas E, the European Coronary Study Group. Twelve-year follow-up of survival in the randomized European coronary surgery study. N Engl I Med 1988; 319.
  3. Alderman EL, Bourassa MG, Cohen LS, et al. Ten year follow-up of survival and myocardial infarction in the randomized coronary artery surgery study (CASS). Circulation 1990; 82:1629.
  4. Goldman L, Cork EF. The decline in ischaemic heart disease mortality rates: an analysis of the comparative effects of medical interventions and charges in lifestyle. Ann Intern Med 1984; 101:825.
  5. Annual Report. Medical and Health Department, Hong Kong 1987.
  6. Feigenbaum H. Echocardiography. 2nd ed. Philadelphia Lea & Febrgei 1976.
  7. Strauss HW, Pitt B, Tames A, et al (eds). Cardiovascular nuclear medicine. St. Louis: the CV Mosby Company 1975.
  8. Harrison DC, Fitzgerald JM, Winkle RA. Ambulatory electrocardiography for diagnosis and treatment of cardiac arrhythmias. N Engl J Med 1976; 294:373.
  9. Ellestad M. Stress testing. Philadelphia FA Davis Co. 1975.
  10. Josephson ME, Seides SF. Clinical cardiac electro physiology, techniques and interpretation. Philadelphia, Lea & Febiger 1979.
  11. Gruentzig AR, Senning A, Siezen Hraler WE. Non operative dilatation of coronary artery stenosis. N Engl J Med 1979; 301:61.
  12. European Cooperative Study Group for straptokinase treatment in acute myocardial infarction. N Engl Med 1979; 301:797.

Cardiology in the 1980s

  1. Feigenbaum H. Echocardiography 4th ed. Philadelphia: Lea and Febiger 1986.
  2. Hatle L, Angelsen P. Doppler ultrasound in cardiology. Physical principles and clinical application. 2nd ed. Philadelphia: Lea and Febiger 1984.
  3. Nanda NC. Textbook of colour doppler echocardiography. Philadelphia, Lea & Febiger 1989.
  4. Seward JB, Khandheria BK, Oh JK, et al. Transoesophageal echocardiography. A multicenter survey of 10,419 examinations. Circulation 1991; 83:817.
  5. Presti CF, Armstiong WF, Feigenbaum H. Comparison of echocardiography at peak exercise and after bicycle exercise in evaluation of patients with known or suspected heart disease. J Am Soc Echo 1988; 1:119
  6. Picano E, Severi S, Michalassi C, et al. Prognostic importance of dipyridamole echocardiography test in coronary artery disease. Circulation 1989; 80:450.
  7. Guessenhoven EJ, Essed CE, Lancee CJ, et al. Arterial wall characteristics determined by intravascular ultrasound imaging. An in-vitro study. J Am Cell Cardiol 1989; 14:947-52.
  8. Berger BC, Watson DD, Taylor GJ, et al. Quantitative thallium-201 exercise. Scintigraphy for detection of coronary artery disease. J Nucl Med 1981; 22:585.
  9. Taillefer R, DuPras G, Sporn V, et al. Myocardial perfusion imaging with a new radiotracer, technetium-99 m-hexamibi (methoxyl isobutyl isonitrate) comparison with thallium-201 imaging. Clinical Nuclear Medicine 1989; 14:89.
  10. Chan SY, Brunken RC, Buxton DB. Cardiac positron emission tomography: the foundations and clinical applications. J Thorac Imaging 1990; 5:9.
  11. Vas R, Diamond GA, Levisman JA, et al. Computer enhanced digital angiography. Clin Cardiol 1982; 5:318.
  12. Ryan TJ, Faxon DP, Gunnar RM. Guidelines for percutaneous transluminal coronary angioplasty: a report of the ACC/AHA Task Force. J Am Cell Cardiol 1988; 12:529-45.
  13. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomized trial of intravenous streptokinase, and aspirin, both or neither, among 17,187 cases of suspected acute myocardial infarction- ISIS-2. Lancet 1988; 2:349.
  14. Kriett JM, Kaye MP. The Registry of the International Society for Heart Transplant: Seventh Official Report 1990. 1 Heart Transplant 1990; 9:323.
  15. Klein LS, Miles WM, Hegar JJ, et al. Transcutaneous pacing: patient tolerance, strength, interval relations and feasibility for programmed electrical stimulation. Am J Cardiol 1988; 62:126.
  16. Pless P, Simonsin E, Arnsbo P, et al. Superiority of multiprogrammable VVI pacing. A comparative study with special reference to management of pacing system malfunction. PACE 1986; 9:739.
  17. Benditt DG, Milslein S, Buetikofer J, et al. Sensor triggered, rate-variable cardiac pacing. Current technologies and clinical application. Ann Intern Med 1987; 107:714.
  18. Troup PT. Implantable cardioverters and defibrillators. Curr Probl Cardiol 1989; 14:679.
  19. Zipes DP, Akhtar M, Denis P, et al. ACC/AHA guide lines for clinical intracardiac electrophysiologic studies. J Am Cell Cardiol 1989; 14:1827 and Circulation 1989; 80:1925.
  20. Borggrefe M, Hindudes G, Havekamp W, et al. Radiofrequency ablation. In: Zipes DP and Jalife J (eds). Cardiac electrophysiology: from cell to bed-side. Philadelphia: WB Saunders Co. 1990; 997.
  21. Turitto G, Caref EB, Macina G, et al. Time course of ventricular arrhythmias and the signal-averaged electrocardiogram in the post-infarction period: a pro spective study of correlation. Br Heart J 1988; 60:17.

Cardiology in the 1990s

  1. Annual Report of the Hong Kong Medical Association 1984-85.
  2. Halnan KE. The Hong Kong Academy of Medicine. J Royal Cell Physicians (London) 1992; 26:442.
  3. Guidelines for adult cardiology training in Hong Kong. Hong Kong College of Cardiology 1992; 1-43.