The relative effects of left ventricular hypertrophy, coronary artery disease, and ventricular dysfunction on survival among black adults

OBJECTIVE

To evaluate the effect of echocardiographically determined left ventricular hypertrophy (LVH) on survival in comparison with number of stenosed vessels and left ventricular systolic dysfunction.

DESIGN

Cohort study based on a consecutive sample from a hospital registry, with a mean follow-up of 5 years.

SETTING

An inner-city public hospital in Chicago, Ill.

PATIENTS

The study included 1089 consecutive black patients who underwent both coronary angiography and M-mode echocardiography as part of a diagnostic evaluation.

RESULTS

Nonstenosed coronary arteries, single-vessel disease, and multivessel disease were found in 48%, 16%, and 36% of patients, respectively; LVH (left ventricular mass index > 131 g/m2 in men and > 100 g/m2 in women) was detected in 50% of patients. Hypertrophy without coexistent obstructive coronary disease was associated with a lower survival rate than that observed for single-vessel disease and was similar to multivessel disease. When LVH, number of diseases vessels, and left ventricular dysfunction were subjected to multivariate analysis, hypertrophy conferred a relative risk (RR) of 2.4 (95% confidence interval [CI], 1.7 to 3.2). By comparison, the presence of a single stenosed vessel did not increase the risk of death. Multivessel disease and ejection fraction less than 45% were associated with an RR of 1.6 (95% CI, 1.1 to 2.2) and 2.0 (95% CI, 1.4 to 2.7), respectively. Calculation of the attributable risk fraction demonstrated that for every 100 deaths in this cohort, LVH independently accounted for 37. The corresponding attributable risk fractions were 1%, 22%, and 9% for single-vessel disease, multivessel disease, and ventricular dysfunction, respectively.

CONCLUSIONS

Left ventricular hypertrophy was associated with a greater RR and attributable risk than the traditional measures of coronary disease severity. The high prevalence and powerful risk of LVH make an important contribution to the adverse survival rates among black patients with heart disease and may account for much of the black-white differential.

Continued adverse trends in coronary heart disease mortality among blacks, 1980-91

An abrupt downturn in mortality rates from coronary heart disease occurred in the United States in the mid-1960s, and for the next decade all four major sex-race groups experienced virtually identical rates of decline. Beginning around the mid-1970s, however, trends for blacks and whites began to diverge, with a deceleration in the annual fall in rates for blacks. The recent release of mortality data extending through 1991, with correction of the denominator estimates in the 1980s using the 1990 census, demonstrate a striking linearity of this trend over the entire decade. In 1989, for the first time since the category of coronary heart disease has been recorded in vital statistics, the age-adjusted death rate for it among black men exceeded that of whites. As a result of the divergent trends among men, an excess of 4,000 deaths of blacks were recorded in 1991 alone. Among women, coronary heart disease mortality was higher among blacks at the beginning of this period, and the average annual percent decline was only two-thirds that of whites. As a result, the absolute mortality gap between blacks and whites steadily increased from 19 to 33 percent (1980 to 1991). This study indicates that the factors that have led to the decline in coronary heart disease have not influenced all demographic groups equally over the last decade.

Ambulatory blood pressure monitoring in normotensive children

OBJECTIVE

To assess reference values of ambulatory blood pressure in normotensive children.

SUBJECTS AND DESIGN

Twenty-four-hour non-invasive ambulatory blood pressure monitoring (ABPM) was carried out in 241 healthy normotensive children aged from 6 to 16 years (126 boys, mean +/- SD age 11.2 +/- 2.7 years; 115 girls, mean +/- SD age 10.9 +/- 2.9 years). The subjects were subdivided into three age-sex groups: 6-9, 10-12 and 13-16 years.

SETTING

Primary care.

MAIN OUTCOME MEASURES

ABPM was performed using an oscillometric device (SpaceLabs model 90207) and appropriate cuff size during a regular school day. Blood pressure was measured every 20 min from 0600 to 2400 h, and thereafter every 30 min. At each monitoring session the following parameters were calculated for both systolic (SBP) and diastolic blood pressure (DBP): means and centiles for 24-h, daytime (0800-2200 h) and night-time (2400-0600 h); circadian variability, estimated as the blood pressure fall between the day and the night periods and the day: night ratio; and load, as the percentage of measurements above the age- and sex-specific 95th centile (P95).

RESULTS

The upper limits of 'normality' for the mean of 24-h SBP and DBP estimated as the P95 in each age subgroup were 121/71 and 119/71 mmHg, 123/78 and 120/74 mmHg, and 124/78 and 125/75 mmHg, for boys and girls, respectively. A progressive increase in SBP with age was observed in both sexes, in contrast, DBP was similar throughout the age range. A nocturnal blood pressure fall of approximately 11 mmHg was observed for both SBP and DBP in all subgroups. The day:night ratio was 1.12 and 1.22 for SBP and DBP, respectively. The upper limit of blood pressure load, estimated as the P95 in all children, was 39% for SBP and 26% for DBP. A significant positive correlation was observed between casual blood pressure and 24-h ambulatory blood pressure (SBP: r = 0.61, P < 0.0001; DBP: r = 0.31, P < 0.0001). In general, mean ambulatory blood pressure, during the 24-h or the daytime period, was higher than casual blood pressure for both SBP and DBP.

CONCLUSION

ABPM is feasible in children, and the values obtained are useful as a departure point in establishing reference values.

Does heart transplantation confer additional benefit over medical therapy to patients who have waited > 6 months for heart transplantation?

OBJECTIVES

This study compared the survival of patients with heart failure who have waited > 6 months for heart transplantation with that patients who undergo heart transplantation after a similarly prolonged waiting period.

BACKGROUND

There are little data describing outcome in patients with severe heart failure who have waited for extended periods of time on the heart transplant waiting list.

METHODS

Sixty-three consecutive patients who spent > 6 months on the heart transplant waiting list were examined. Mean (+/- SD) age was 53 +/- 9 years, mean left ventricular ejection fraction was 19 +/- 6%, and all were taking digoxin and diuretic and vasodilator agents. Patients who underwent transplantation during the follow-up period were censored from the pretransplantation analysis, and their survival was examined as part of the posttransplantation phase of the study.

RESULTS

Of the 63 original patients examined, 25 underwent transplantation, 10 during inotropic or mechanical circulatory support. The pretransplantation mortality rate was 6% at 6 months after the 6-month milestone on the waiting list, 12% at 12 months and 22% at 18 months. The posttransplantation mortality rate was 5% at 6 months, 10% at 12 months and 24% at 18 months. There were no differences in survival at any time between the two phases of the study.

CONCLUSIONS

Survival of patients who have survived > 6 months on the heart transplant waiting list is generally good. Although heart transplantation did not appear to confer additional survival advantage over medical therapy, a large proportion of the patients who underwent transplantation were critically ill at the time of transplantation and would undoubtedly have died of progressive heart failure had they not undergone transplantation. We conclude that heart transplantation should still be considered a therapeutic alternative in patients with heart failure even after a prolonged waiting period on the heart transplant waiting list.

Factors related to the presence of microalbuminuria in essential hypertension

The objective of the present study was to assess factors related to the presence of microalbuminuria in essential hypertension. Ninety-five patients with essential hypertension (58 males and 37 females, mean age 38.6 +/- 6.1 years) who had never been treated previously for hypertension were included in the study. Patients with nephropathy or diabetes mellitus, hyperglycemia > 120 mg/dL, glomerular filtration rate < 80 mL/min/1.73 m2, urinary tract infection, or positive dipstick for albumin or glucose were excluded. Blood pressure, echocardiographically determined left ventricular mass, serum biochemistry, and lipid profile were obtained. Twenty-four-hour urinary albumin excretion (UAE) was measured on two separate days using an immunonephelometric assay. Microalbuminuria (UAE 30 to 300 mg/24 h) occurred in 26% of patients and was associated with higher diastolic blood pressure (DBP), left ventricular mass index (LVMI), and a higher prevalence of hypertriglyceridemia and hyperapolipoproteinemia B (apo-B). Logistic regression analysis showed that the risk of microalbuminuria was independently related to diastolic blood pressure and hypertriglyceridemia when controlling for age, sex, body mass index, LVMI, and apo-B. Multiple regression analysis likewise confirmed that both DBP and LVMI were linearly related to UAE independent of age, sex, body mass index, total cholesterol, triglycerides, and apo-B. In conclusion, our study indicates that among hypertensive patients with elevated excretion rates of urinary albumin, even at the subclinical level, an increased cardiovascular risk exists compared to normoalbuminuric patients with a similar blood pressure. Assessment of the presence of microalbuminuria may be useful in the evaluation and management of hypertension.

A north-south comparison of blood pressure and factors related to blood pressure in the People's Republic of China: a report from the PRC-USA Collaborative Study of Cardiovascular Epidemiology

OBJECTIVES

To compare blood pressures in northern (Beijing) and southern (Guangzhou) Chinese population samples aged 35-54 years, males and females, urban and rural, and to assess the role of blood pressure-related traits in explaining north-south differences.

DESIGN

Cross-sectional surveys were conducted in 1983-1984 of northern and southern populations employed in industry (urban) or farming (rural).

METHODS

In the north samples were selected from the Capital Iron and Steel Complex (urban) and Shijingshan district (rural); in the south samples from the Guangzhou Shipyard (urban) and Panyu County (rural) were used.

RESULTS

The number of subjects surveyed in north and south were 4706 and 4179, respectively: 1500 and 1052 urban males, and 717 and 914 rural males; and 1300 and 1061 urban females, and 1189 and 1152 rural females, respectively. Average systolic (SBP) and diastolic (DBP) blood pressures, were consistently higher in the north than in the south. SBP and DBP were significantly and independently related to age, body mass index, heart rate, use of antihypertensive drugs, serum triglycerides level, alcohol use (males only) and inversely to cigarette smoking. Northerners were older, taller, heavier and had higher body mass index and triglycerides level than southerners. With adjustment of SBP and DBP for blood pressure-related traits, north-south blood pressure differences decreased, but remained significant for urban males, rural males and rural females, with sizeable differences for rural samples in particular.

CONCLUSIONS

North-south differences in blood pressure in these samples are accounted for only partly by north-south differences in the cited blood pressure-related traits. The role of other traits requires assessment.

beta-Carotene supplementation results in an increased serum and colonic mucosal concentration of beta-carotene and a decrease in alpha-tocopherol concentration in patients with colonic neoplasia

The aim of this study was to evaluate the colonic mucosal beta-carotene (BC) concentration following supplementation with BC and to determine if an increase in BC concentration influences vitamin E (alpha-tocopherol) status. The concentration of BC and alpha-tocopherol was assessed in serum and colonic tissue obtained from subjects with a history of colonic polyps or resected cancer (Dukes A, B1, or B2). Serum and mucosal biopsy samples were obtained prior to and following 3 months daily p.o. supplementation with 30 mg of BC or placebo. The concentration of BC was significantly increased in serum and colonic mucosa from both polyp and cancer subjects following supplementation as compared to presupplementation values and values from subjects receiving a placebo. The concentration of alpha-tocopherol in serum from cancer subjects was significantly decreased in samples obtained at the end of 3 months of BC supplementation as compared to placebo-matched controls. In BC-supplemented polyp subjects the tissue concentration of alpha-tocopherol was also significantly decreased relative to presupplementation values. The results indicate that BC supplementation does result in a significant accumulation of BC in the colonic mucosa but that the alpha-tocopherol concentration in both serum and colonic tissue may be compromised by an increased intake of BC. The mechanism for the decrease in alpha-tocopherol in conjunction with the increase in BC will require further study in order to develop strategies which will prevent vitamin E deficiency in BC-supplemented individuals.

Ambulatory blood pressure and microalbuminuria in essential hypertension: role of circadian variability

OBJECTIVE

To assess the relationship of subclinical urinary albumin excretion with ambulatory and circadian variability of blood pressure.

DESIGN AND METHODS

Patients with essential hypertension (82 males and 59 females, mean +/- SD age 38.9 +/- 7.3 years) who had never been previously treated for hypertension were included in the study. Patients with nephropathy or diabetes mellitus, hyperglycemia > 120 mg/dl, glomerular filtration rate < 80 ml/min per 1.73 m2, urinary tract infection and positive dipstick for albumin or glucose were excluded. Twenty-four-hour ambulatory blood pressure monitoring on a regular working day using an oscillometric device was performed. Twenty-four-hour urinary albumin excretion was measured on two separate days using an immunonephelometric assay.

RESULTS

Microalbuminuric patients (urinary albumin excretion 30-300 mg/24 h, n = 31) had significantly higher mean ambulatory systolic blood pressure (SBP) and diastolic blood pressure (DBP) than those with normoalbuminuria (urinary albumin excretion < 30 mg/24 h, n = 96) during the 24-h, daytime (0800-2200 h) and night (2400-0600 h) periods, whereas for office blood pressure only DBP was significantly higher. Urinary albumin excretion was positively correlated with the means of SBP and DBP. Multiple regression analysis similarly confirmed that DBP during daytime was positively and day:night ratio of DBP inversely associated with urinary albumin excretion independent of age, sex and other parameters of ambulatory blood pressure.

CONCLUSIONS

In conclusion, the present study indicates that, in middle-aged essential hypertensive patients, the presence of microalbuminuria is a marker for the presence of higher values of blood pressure throughout a 24-h period.

Assessment of the intestinal retention of beta-carotene in humans

OBJECTIVE

Assessment of the intestinal absorption of beta-carotene (BC) in humans as well as plasma clearance of BC has been difficult. We have used the total gut washout method (TGWM) to assess BC retention during transit through the intestine, as well as the effect that different diets and age have on BC retention.

METHODS

HPLC was used to quantitate fecal and serum BC concentrations from young and elderly subjects who had undergone the TGWM to remove all intestinal contents prior to ingesting BC or placebo with or without a meal. Meals contained different combinations of calories and fat.

RESULTS

In subjects receiving no meal, 83% of ingested BC was recovered in rectal effluent collected within 24 hours post-BC administration. The quantity of BC in feces of individuals receiving meals was 49-71%. There was no significant change in serum concentrations of other carotenoids or retinoids following consumption of BC with any of the different meals. Interestingly, both diet and age influenced the efficiency of BC absorption. An increase in dietary fat content resulted in an higher serum BC concentration in young subjects within 8 and at 24 hours post BC administration, whereas a higher caloric content resulted in a decrease in serum BC concentration in older subjects within 8 hours of BC administration.

CONCLUSION

Results indicate that the TGWM provides an accurate means for assessing the intestinal retention of BC in humans.

Risk/benefit ratio of perioperative OKT3 in cardiac transplantation

To evaluate the risk/benefit ratio of perioperative OKT3 in cardiac transplant patients receiving triple-drug immunosuppression, patients who underwent cardiac transplantation between July 1, 1988 and December 31, 1989 (n = 33) and who received perioperative OKT3 were retrospectively compared with patients who underwent transplantation between January 1, 1990 and June 30, 1991 (n = 46), and who received no perioperative anti-T cell therapy. To allow similar follow-up, data were analyzed through June 30, 1990 for the OKT3 group and through December 31, 1991 for the no anti-T cell therapy group. Patients in the no anti-T cell therapy group waited longer for a donor organ; other pretransplant characteristics did not differ. The azathioprine dose 1 month after transplant was higher in the no anti-T cell therapy group (144 +/- 63 mg vs 109 +/- 55 mg, p = 0.016); other post-transplant immunosuppression was similar. The incidence of total and treated rejection and the time to the first rejection did not differ between the groups. The OKT3 group had a higher number of infections (0.8 +/- 0.9 vs 0.3 +/- 0.3, p = 0.006) and intravenously treated infections (0.5 +/- 0.6 vs 0.1 +/- 0.2, p = 0.004) per patient per month. Cytomegalovirus infection developed in 46% of the OKT3 group versus 22% of the no anti-T cell therapy group (p = 0.025). Patient survival did not differ between the groups. Thus, an immunosuppressive regimen that includes perioperative OKT3 increases infections, especially cytomegalovirus infections, without decreasing or delaying rejection or increasing survival.

Iron status and coronary heart disease: negative findings from the NHANES I epidemiologic follow-up study

The potential association between iron status and coronary heart disease has received increased attention recently. The authors examine this hypothesis in the First National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study. The study consisted of 4,237 respondents (1,827 men, 2,410 women) aged 40-74 years at baseline. During the average 13-year follow-up, 489 persons (289 men, 200 women) had an acute myocardial infarction, and 1,151 persons (633 men, 518 women) developed coronary heart disease (included myocardial infarction and other forms of chronic ischemic heart disease). In logistic regression analyses, adjusting for baseline age, systolic blood pressure, serum cholesterol, smoking status, and education, serum iron was inversely associated with the risk of myocardial infarction in women (relative risk = 0.82 for an increase of 5.4 mumol/liter (equivalent to about 1 standard deviation), 95% confidence interval (CI) 0.70-0.95), but not in men. Total iron-binding capacity and transferrin saturation were not related to myocardial infarction in either sex, while serum iron and transferrin saturation were inversely associated with coronary heart disease in both sexes. Among men, the relative risk was 0.92 (95% CI 0.85-1.00) for a 5.4-mumol/liter increase in serum iron, while a relative risk of 0.91 (95% CI 0.83-1.00) was observed for a 10% increase in transferrin saturation. For women, the corresponding relative risks were 0.86 (95% CI 0.77-0.95) and 0.88 (95% CI 0.79-0.98), respectively. Dietary iron intake based on 24-hour recall was not associated with the two disease end points. These findings from a large national sample do not support the hypothesis of a positive iron-coronary heart disease relation.

Intracoronary ultrasound assessment of morphological and functional abnormalities associated with cardiac allograft vasculopathy

BACKGROUND

The diffuse nature of cardiac allograft vasculopathy makes early detection of the disease by traditional noninvasive methods or coronary angiography difficult. The aim of this study was to determine if there is a relation between abnormalities in vessel wall morphology, as assessed by intracoronary ultrasound, and a decreased vasodilatory response to the endothelium-dependent vasodilator papaverine hydrochloride and if cardiac allograft vasculopathy detected by coronary angiography is associated with specific intracoronary ultrasound findings.

METHODS AND RESULTS

Twenty-three heart transplant recipients underwent 25 intracoronary ultrasound studies and 24 studies of coronary vasomotor tone 10 days to 8.3 years after surgery using a 20-mHz intracoronary ultrasound catheter. The studies were divided in two groups according to the presence (n = 7, group 1) or absence (n = 18, group 2) of angiographically evident cardiac allograft vasculopathy. Qualitative assessment of vessel wall morphology and quantitative analysis of the vasodilator response to the injection of papaverine hydrochloride into the coronary artery distal to the imaging site were performed off-line, and results for the two study groups were compared. A significantly higher percentage of patients with than without angiographic evidence of cardiac allograft vasculopathy had a three-interface vessel wall morphology by intracoronary ultrasound (100% versus 11%, P < .001). In two recipients who underwent two serial studies, the appearance of three interfaces in the vessel wall or a progressive thickening of the inner interface of the vessel wall occurred in conjunction with the appearance of angiographic cardiac allograft vasculopathy. The vasodilator response to papaverine was less in patients with than in those without angiographically evident cardiac allograft vasculopathy both in terms of absolute and relative increases in lumen diameter (+0.1 +/- 0.12 mm versus +0.3 +/- 0.17 mm, P < .05, and +5.1 +/- 5.3% versus +8.2 +/- 5.3%, P = NS) and lumen cross-sectional area (+0.5 +/- 0.6 mm2 versus +1.7 +/- 1.1 mm2, P < .02, and +7.1 +/- 8.8% versus 16.6 +/- 11.0%, P = .055), respectively.

CONCLUSIONS

Intracoronary ultrasound assessment of vessel wall morphology and evaluation of vascular response to endothelium-dependent vasodilators are useful techniques for detecting cardiac allograft vasculopathy.

Determinants of incident non-insulin-dependent diabetes mellitus among blacks and whites in a national sample. The NHANES I Epidemiologic Follow-up Study

The excess incidence of non-insulin-dependent diabetes mellitus noted among African Americans in the past two decades may be attributable to variations in the distribution of specific risk factors, or the impact of these risk factors may differ by ethnicity or sex. Over the 16 years (1971-1987) of the First National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study, 880 incident cases of diabetes mellitus developed among 11,097 white and black participants who were between the ages of 25 and 70 years at baseline. There were substantial differences among the four race/sex groups with respect to age at baseline, as well as marked differences in the distribution of several major risk factors for diabetes, including obesity, subscapular and triceps skinfold thickness, blood pressure, income, activity, and educational level. The age-adjusted incidence of diabetes over the course of the study was 15.0% among black women, while it was 10.9% among black men. White women and men experienced similar, more moderate risks of 7.0% and 6.9%, respectively. The 100% excess risk among black women and the 50% excess among black men can in large measure explain the recent marked increase in diabetes rates in the black community. Furthermore, at nearly every level of obesity, blacks had a higher risk of diabetes than whites, suggesting that other factors contributed to risk. A significant interaction between race and body mass index (weight (kg)/height(m)2) was likewise demonstrated in multivariate analysis. Baseline age, race, body mass index, and ratio of subscapular skinfold to triceps skinfold were significantly related to incident diabetes, both overall and in separate models for men and women; in the entire cohort and in women alone, blood pressure, activity level, and education also contributed to risk. Other interactions were tested but were not found to be important. Despite sampling difficulties and inconsistencies in the data, the NHANES I Epidemiologic Follow-up Study provides evidence that the associations of anthropometric and sociodemographic variables with diabetes may vary among subgroups which have different mean levels and distributions of these risk factors.

Heart transplantation as a treatment option for end-stage heart disease in patients older than 65 years of age

Because of the critical donor organ shortage for heart transplantation, selection of recipients should be based on the potential for maximum benefit. To evaluate the effects of advancing age on outcome after heart transplantation, we compared the clinical variables of 12 recipients aged 65 years or older (66.1 +/- 0.9 years [x +/- standard deviation]; range, 65 to 67 years) with those of 57 patients aged 55 to 64 years (59.3 +/- 2.7 years) at the time of the procedure. The two study groups were similar in sex, race, pretransplantation heart disease, immunocompatibility, maintenance immunosuppression, and length of first hospitalization at the time of the procedure. Groups were also similar regarding the incidence of malignancies, fractures, diabetes, neurologic complications, and renal dysfunction occurring over the follow-up period. Patients 65 years of age or older had a significantly higher number of hospital days (36 +/- 29 versus 15 +/- 18 days; p < 0.02) and increased frequency of infections/month (0.7 +/- 0.3 versus 0.3 +/- 0.4 infections/month; p < 0.03) during the first postoperative year. Older patients had a higher incidence of cytomegalovirus infections (50% versus 19%; p < 0.06), lower rates of rejection at 1 and 6 months after operation (p < 0.03), and more severe functional limitation (p < 0.002) than patients aged 55 to 64 years. One-year actuarial survival was not significantly different in the two groups. The results of our study suggest that, because of lower rejection and higher infection rates, heart transplantation recipients older than 65 years of age should receive less intense immunosuppression.(ABSTRACT TRUNCATED AT 250 WORDS)

Sex differences in the impact of coexistent diabetes on survival in patients with coronary heart disease

OBJECTIVE

To evaluate the sex difference in the impact of diabetes on survival in patients with coronary heart disease.

RESEARCH DESIGN AND METHODS

Cohort study based on a sample from a hospital registry in Chicago, IL. A total of 974 consecutive patients (585 men and 389 women) with angiographically confirmed coronary artery disease were followed for 4.6 yr.

RESULTS

At baseline, 160 men and 155 women had diabetes. The age-adjusted relative risk of death from all causes for patients with diabetes versus patients without diabetes was 0.93 (95% confidence interval 0.65-1.34) in men and 1.99 (95% CI 1.30-3.05) in women. For cardiac death, the corresponding relative risk was 1.00 (95% CI 0.64-1.56) and 1.96 (95% CI 1.19-3.24) in men and women, respectively. Baseline differences in age, hypertension, body mass index, number of diseased vessels, and ejection fraction did not fully explain the excess mortality risk in diabetic women. Excess risk was apparent in both cardiac and noncardiovascular categories. Among nondiabetic patients, the risk of death was significantly lower in women compared with men (multivariate-adjusted relative risk = 0.61, 95% CI 0.41-0.89). However, the mortality risk of diabetic women became similar to men as a whole (relative risk = 1.13, 95% CI 0.80-1.60).

CONCLUSIONS

Diabetes confers a substantially higher risk of mortality in women than in men when it occurs in the presence of coronary heart disease.

Delay between onset of chest pain and arrival to the coronary care unit among minority and disadvantaged patients

Prehospital delay is an important cause of out-of-hospital coronary mortality. To determine the effects of decision time delay in a patient population comprised mainly of blacks and the underprivileged, 74 consecutive patients with acute chest pain necessitating admission to the coronary care unit in a large urban hospital were studied. Delay time from onset of chest pain to the decision to seek medical care was markedly prolonged in patients with myocardial infarction (n = 24; mean time: 11.3 +/- 18 hours) as well as in patients with chest pain who did not develop myocardial infarction (n = 50; mean time: 20.5 +/- 26 hours). In addition, transfer time from the emergency room to the coronary care unit was likewise unduly long (mean time: 4 +/- 3.8 and 4.1 +/- 6 hours for patients with and without myocardial infarction, respectively). This study documents a significant delay in the decision time among patients with low socioeconomic status, mostly inner-city blacks, and in the transfer time from emergency room to the critical care unit in a large public hospital. These findings must be taken into consideration when planning strategies to improve the health-care delivery system to blacks and the underprivileged and further lend support to the practice of initiating thrombolytic therapy in the emergency room.

Risk/benefit ratio of perioperative OKT3 in cardiac transplantation

This study shows that perioperative OKT3 provides no benefit in terms of the time of onset or frequency of rejection or patient survival. However, it does result in an increased incidence of infection, particularly CMV infection. Thus, the risk/benefit ratio of perioperative OKT3 does not appear favorable. However, a multicenter, randomized trial including a larger number of patients and longer patient follow-up will be required to definitively answer the question.

The prognostic role of left ventricular hypertrophy in patients with or without coronary artery disease

OBJECTIVE

To examine the association between echocardiographically determined left ventricular hypertrophy and mortality in patients with and without coronary artery disease.

DESIGN

Cohort study with a mean follow-up period of 4 years.

SETTING

An inner-city public hospital in Chicago.

PATIENTS

A cohort of 785 patients, most of whom were black and had hypertension.

INTERVENTIONS

Coronary arteriography for presumed coronary artery disease and echocardiography.

MAIN OUTCOME MEASURE

All-cause and cardiac mortality.

RESULTS

Left ventricular hypertrophy, based on left ventricular mass corrected for body surface area, was present in 194 of 381 patients (51%) with coronary artery disease and in 162 of 404 patients (40%) without coronary artery disease. Patients with left ventricular hypertrophy had worse survival than those without hypertrophy in both the group with coronary artery disease and the group without coronary artery disease. After adjustment was made for age at baseline, sex, and hypertension, the relative risk for death from any cause in patients with hypertrophy compared with patients without hypertrophy was 2.14 (95% CI, 1.24 to 3.68) among those with coronary artery disease and 4.14 (CI, 1.77 to 9.71) among those without coronary artery disease.

CONCLUSIONS

Echocardiographically determined left ventricular hypertrophy is an important prognostic marker in patients with or without coronary artery disease. The effect of reversing ventricular hypertrophy in patients with and without coronary disease deserves further study.