Prevalence of ischaemic heart disease in middle aged British men

ABO blood group and ischaemic heart disease in British men

OBJECTIVE

To establish whether ABO blood group is related to ischaemic heart disease on an individual and geographic basis in Britain.

DESIGN

Prospective study of 7662 men with known ABO blood group selected from age-sex registers in general practices in 24 British towns.

MEASUREMENTS

ABO blood group, standard cardiovascular risk factors, social class, and presence or absence of ischaemic heart disease determined at entry to study.

END POINTS

Eight year follow up of fatal and nonfatal ischaemic heart disease events achieved for 99% of study population.

RESULTS

Towns with a higher prevalence of blood group O had higher incidences of ischaemic heart disease. In individual subjects, however, the incidence of ischaemic heart disease was higher in those with group A than in those with other blood groups (relative risk 1.21, 95% confidence limits 1.01 to 1.46). Total serum cholesterol concentration was slightly higher in subjects of blood group A. No other cardiovascular risk factor (including social class) was related to blood group.

CONCLUSIONS

Blood group A is related to the incidence of ischaemic heart disease in individual subjects. Geographic differences in the distribution of ABO blood groups do not explain geographic variation in rates of ischaemic heart disease in Britain. The findings do not support the view that ABO blood group and social class are related.

Guidelines for the detection of high-risk lipoprotein profiles and the treatment of dyslipoproteinemias. Canadian Lipoprotein Conference Ad Hoc Committee on Guidelines for Dyslipoproteinemias

Elevated plasma levels of cholesterol and triglycerides, low levels of high-density lipoproteins, hypertension, diabetes mellitus, smoking and abdominal obesity are risk factors for coronary heart disease (CHD) and stroke. Because of the preventable threat to life, well-being and productivity from perturbations of plasma lipoproteins (which affect about 60% of adults), we recommend a population-based strategy with public education on diet, exercise and the hazards of smoking and legislation for better food labelling. This should be combined with the medical guidelines we describe to detect and treat those at highest risk for CHD (including about 15% of adults), who merit priority for the medical, dietetic and laboratory services required. Among people aged 40 years or more this includes those with plasma total cholesterol levels greater than 7 mmol/L, fasting triglyceride levels greater than 3 mmol/L or cholesterol level greater than 6 mmol/L when associated with CHD or other risk factors for CHD. For younger people the criteria for highest risk include cholesterol levels greater than 6.5 mmol/L for those aged 30 to 39 years, greater than 6 mmol/L for those aged 20 to 29 and greater than 5 mmol/L for those under age 20.

Prevalence of cardiovascular disease and diabetes mellitus in residents of Rochester, Minnesota

To determine the prevalence of cardiac disorders as risk factors for stroke, we conducted a survey in 1986 in a stratified random sample of the population of Rochester, Minnesota, 35 years of age or older. The medical records of the 2,122 subjects in the sample were retrieved with use of the Rochester Epidemiology Project medical records linkage system. The data were used to estimate (1) the reliability of self-reported information about cardiac and cerebrovascular disorders and (2) the age- and sex-specific prevalence of diabetes mellitus and various cardiac and cerebrovascular conditions. The estimated prevalence for selected risk factors in the population 35 years of age or older was 5.8% for diabetes mellitus, 3.3% for myocardial infarction, 1.2% for mitral valve disease, 4.2% for left ventricular hypertrophy, and 2.8% for atrial fibrillation or flutter. These data can be used to estimate resources required for evaluation and management of the disorders. When the prevalence and the relative risk for stroke are known for a particular cardiac disorder, the proportion of stroke attributable to that disorder can be estimated.

DNA restriction fragment length polymorphisms as markers of familial coronary heart disease

246 of 713 men aged 30 to 59 years had first-degree relatives who had had coronary heart disease (CHD) by the age of 60; men with a family history of CHD were twice as likely to have CHD themselves, compared with those without such a family history. At least 75% of the difference was accounted for by CHD in men with minor alleles of 4 restriction fragment length polymorphisms (RFLPs) in the region of the apolipoprotein (apo) AI and apo CIII genes. The RFLPs were identified with the restriction enzymes XmnI, PstI, MspI, and SacI. Each polymorphism has two alleles (major and minor), designated X1 and X2, P1 and P2, M1 and M2, and S1 and S2, respectively. In men with any one of the minor alleles, a family history of CHD was associated with a 234% increase in CHD prevalence. In men with major alleles only, a family history of CHD was not associated with any significant increase in CHD. The effect of the minor alleles was not significantly altered when plasma lipids and other variables except for age were taken into account. The association between the minor RFLP alleles and polymorphic gene variants (probably the apo AI, apo CIII, or both genes) which enhance liability to CHD accounted for almost 20% of total CHD in this population.

Relative weight and major ischaemic heart disease events in hypertensive men

Some studies have suggested that lean hypertensive men may be at greater risk of major ischaemic heart disease (IHD) events than obese hypertensive men. The issue was examined on data from the British Regional Heart Study for 7735 middle-aged men followed up for an average of 7.5 years; during this time 443 men experienced a major IHD event. Hypertension was defined as systolic blood pressure of 160 mm Hg or above, diastolic blood pressure of 95 mm Hg or above, or receiving treatment for hypertension. For both hypertensive and normotensive men the rate of major IHD events, standardised for age and cigarette smoking, rose with increasing body mass index (BMI). The relative odds associated with a 5 kg/m2 difference in BMI (ie, a 15 kg difference in weight in men of average height [1.73 m]) were 1.30 (p = 0.02) and 1.43 (p = 0.0004) for hypertensive and normotensive men, respectively. A review of eleven prospective studies, including the British Regional Heart Study, presented in standard form for comparative purposes, suggests that lean hypertensive men are not at higher risk of major IHD events than overweight/obese hypertensive men. There seems to be no justification for the suggestion that a policy of weight reduction to lower blood pressure might be inappropriate.

Breathlessness, angina pectoris and coronary artery disease

The relation of breathlessness to angina was examined in 7,735 middle-aged British men. Among men who did not report breathlessness, the age-standardized prevalence rate of angina was 4%. In men with mild, moderate or severe breathlessness, the prevalence rates of angina were 16, 29 and 41%, respectively. The association between breathlessness and angina was independent of age or cigarette smoking, with similar relations observed in men who had never smoked. The prevalence of electrocardiograms revealing ischemia increased with the severity of breathlessness, even in men without angina or other evidence of coronary artery disease (CAD) at screening. In men with a low forced expiratory volume in 1 second, the prevalence of angina was also increased, but the association was much weaker than that observed between angina and breathlessness. After a 5-year follow-up, 25% of men severely breathless at screening but without any initial evidence of CAD had developed angina, 5% had had a heart attack (half of these were fatal) and 7% were dead from causes other than CAD. The corresponding rates for men not breathless at screening and without evidence of CAD were: 4% angina, 2.5% heart attack and 2% dead from causes other than CAD. Breathlessness appears to be an early indicator of CAD in the absence of either angina or electrocardiographic evidence of ischemia.

Occupation, type A behavior and self-reported angina pectoris

The utility of the Type A Behavior Pattern (TABP) as an explanatory concept in psychosomatic medicine has recently been challenged by the appearance of data casting doubt on associations between the TABP and coronary disease. The present study examined an interactive view of the relationship between the TABP and self-reported angina pectoris by suggesting that the TABP exerts a pathogenic influence only under certain occupational conditions. The data gave broad support to this view, and while the results are as yet preliminary, they point to a means of extending the usefulness of the TABP as a variable in epidemiological studies of cardiovascular disease.

Comparison of a supplemented Rose Questionnaire to exercise thallium testing in men and women

The Rose Questionnaire has had high specificity and variable sensitivity when compared to physician identification of the symptom complex of angina pectoris. We assessed the accuracy of a supplemented Rose Questionnaire in a series of 198 patients by comparing the Questionnaire to exercise thallium test evidence of coronary artery disease. The Rose diagnosis of angina had 26% sensitivity, 79% specificity, 42% positive predictive value, and 65% negative predictive value. The Rose diagnosis of myocardial infarction had 26% sensitivity and 90% specificity. The Rose diagnosis of angina or infarction yielded a sensitivity of 44%, specificity of 72%, positive predictive value of 67%, and negative predictive value of 50%. Supplemental questions designed to identify atypical ischemic pain led to increased sensitivity of up to 68% that was offset by decreased specificity. While the Questionnaire's sensitivity for coronary disease was greater for women than men (57 vs 40%), the overall accuracy was the same because specificity was lower (63 vs 80%).

The role of risk factors in heart attacks occurring in men with pre-existing ischaemic heart disease

The importance of three risk factors--serum total cholesterol, systolic blood pressure, and cigarette smoking--on the risk of new major ischaemic heart disease events in men who already have evidence of ischaemic heart disease was assessed. Data from the initial examination in a large prospective study of cardiovascular disease in middle aged men (the British Regional Heart Study) were used to separate 7710 men into three groups on the basis of a resting electrocardiogram, a standardised chest pain questionnaire, and recall of a doctor's diagnosis of angina or of a previous heart attack: (group 1) no evidence of ischaemic heart disease (75%), (group 2) evidence of ischaemic heart disease short of a definite myocardial infarction (20%), (group 3) definite myocardial infarction (6%). In the average follow up period of 7.5 years, 443 men suffered a new major event caused by ischaemic heart disease (fatal or non-fatal myocardial infarction or sudden cardiac death). Age standardised event rates were determined for each of the three groups for varying levels of the established risk factors. Cigarette smoking is strongly associated with the event rate in group 1 but in men with existing heart disease, especially group 3, differences in risk between the smoking categories were smaller. The strong relation between systolic blood pressure and event rate persisted in groups 1 and 2 but not in group 3. The positive association between serum concentration of total cholesterol and the event rate was strongest in group 1 and weaker in groups 2 and 3, though it remained highly significant. These observations, taken together with the results of previous prospective studies and intervention trials, suggest that the important association between serum total cholesterol and the risk of heart attack persists in men with pre-existing ischaemic heart disease, including myocardial infarction. Therefore, in these men the reduction of serum total cholesterol concentration may be at least as important as it is in men without evidence of ischaemic heart disease.

Changes in drinking habits in middle-aged British men

The drinking behaviour of 7735 middle-aged men drawn from general practices in 24 British towns was determined in 1978-80 and five years later in 1983-85. Those with heavier initial drinking were more likely to have reduced consumption after five years. At every level of consumption manual workers showed a greater tendency to decrease drinking than non-manual workers. Of those who became non-drinkers over the five years, 12% had been moderate or heavy drinkers. Men who were told by a doctor that they had developed ischaemic heart disease during the five years were more likely to reduce their alcohol consumption than men who remained free of ischaemic heart disease. Similarly, men who were put on regular medical treatment of any kind or who acquired two or more diagnoses of illness (including ischaemic heart disease) were more likely to become occasional or non-drinkers. Nondrinkers at both reviews had higher rates of diagnosed illness than drinkers. In particular, the ex-drinkers, who comprised 70% of non-drinkers at follow up, had higher rates of ischaemic heart disease and cardiovascular-related problems, such as high blood pressure and diabetes, than drinkers.It is essential to be aware of the tendency for moderate or heavy drinkers to reduce or stop drinking over time, particularly if illness has been diagnosed. Non-drinkers and exdrinkers should not be used as a baseline in studies relating alcohol to disease.

Identification and treatment of risk factors for coronary heart disease in general practice: a possible screening model

A screening programme for the identification of risk factors for coronary heart disease in all patients aged 25-55 years in a general practice population was studied. The identification of risk factors included measurement of obesity, blood pressure, hypercholesterolaemia, and urinalysis, together with questions about family history, cigarette smoking, alcohol intake, and lifestyle. The patients with identified risk factors were invited to attend a lifestyle intervention clinic organised by the practice nurses and run by the health visitors, with the help of the local authority dietitian. Of 2646 (62%) patients who attended for screening, 78 (64%) of the 121 shown to have a high cholesterol concentration experienced a drop in cholesterol concentration. The mean fall in cholesterol concentration in the 78 patients who showed a positive response to intervention was 1.1 mmol/l. The study was intended as a possible flexible model for screening for coronary heart disease in general practice that could be complemented rather than replaced by opportunistic screening. The issues of organisation, cost, manpower, nonattendance, and effectiveness in a busy general practice environment are discussed.

Prevalence of angina as assessed by a survey of prescriptions for nitrates

Prescriptions for nitrates issued during a 6-month period in the Nottingham Health District were used to estimate the prevalence of patients thought to have angina who might potentially require specialist investigation and treatment. The 15,451 prescriptions issued were for 6856 patients. Of these, only 435 were known to hospitals. The general practitioner records of 499 patients identified from a 10% sample of general practitioners showed that in 96% the general practitioner had prescribed a nitrate for the treatment of angina. The records of five large practices with some form of diagnostic register suggested, however, that the survey detected only 73% of patients thought to have angina. With these estimates of specificity and sensitivity the prevalence of angina in Nottingham was calculated to be 1.5%. Few of the patients identified had been investigated in detail, and only 26% had attended hospital in the 3 years before the survey. There is clearly a very large potential demand for hospital resources for the investigation and treatment of angina.

Prevalence of ischaemic heart disease: the Caerphilly and Speedwell surveys

Mortality from ischaemic heart disease remains high in the United Kingdom, and the present report describes the prevalence of the various epidemiological manifestations of the disease in two recent community studies with a common core protocol, each containing samples of over 2000 men, carried out in South Wales (Caerphilly) and the West of England (Speedwell, Bristol). The prevalence of electrocardiographic evidence of ischaemia was similar in the two communities--8.7% of men aged 45-49 years rising to 18.6% in men aged 55-59 years in the samples from South Wales, and 8.0% and 17.2% respectively in the Bristol population. The overall prevalence of angina was 7.7% in Caerphilly and 7.8% in Speedwell in men aged 45-59 years, but symptoms of severe chest pain were more commonly reported in South Wales than in Speedwell (10.1% compared with 6.3%). The data, however, suggested that the overall prevalence of ischaemic heart disease was very similar in the two areas. The prevalence of ischaemic heart disease was compared with that found in other population studies carried out in the United Kingdom and was higher than that found when employed men only were studied. There were substantial differences in mortality between the two areas; possible reasons for this are differences in community or medical services, smoking habit, or unemployment rates.

The extrinsic fibrinolytic system in survivors of myocardial infarction

The extrinsic fibrinolytic system was assessed among 124 consecutive survivors of acute myocardial infarction below 70 years of age. In samples drawn 3 months after discharge from hospital, the PAI-1 levels were higher and the tPA activities were lower than among elderly healthy controls. In contrast, the AMI survivors had higher tPA antigen levels at rest and after venous occlusion, and higher tPA activities after venous occlusion. Among patients having PAI-1 levels greater than 10 IU/ml, there was a positive correlation between PAI-1 and serum triglycerides, and a negative correlation between PAI-1 and age; this group was also significantly younger than the subgroup having less than or equal to 10 IU/ml of PAI-1. There were thus multiple disturbances of the extrinsic fibrinolytic system among these patients. As cardiovascular risk factors, these disturbances appear to be relatively more important the younger the patients are.

Social class differences in ischaemic heart disease in British men

To examine why ischaemic heart disease (IHD) mortality rates in Britain are higher in manual than in non-manual workers 7735 middle-aged men in the British Regional Heart Study were followed up for 6 years, during which time 336 men experienced a major IHD event (fatal or non-fatal myocardial infarction or sudden cardiac death). The prevalence rates of IHD at screening, were higher in manual workers. Also, the attack rate of major IHD events during follow-up was 44% higher in manual workers. Marked differences in cigarette smoking contributed substantially to the increased risk of IHD in manual workers, who also had higher levels of blood pressure, were more obese, and took much less physical activity in leisure time. Adjustment for differences in these risk factors narrowed the gap between manual and non-manual workers in attack rates of IHD. Since the risk of IHD in Great Britain is high in all social classes, there would seem to be little justification for any overall policy for prevention of IHD to focus on social class. However, anti-smoking strategies might well take into account the social class differences described.

Type A behaviour and ischaemic heart disease in middle aged British men

The Bortner questionnaire, which measures aspects of type A (coronary prone) behaviour was completed by 5936 men aged 40-59 selected at random from one general practice in each of 19 British towns. The presence of ischaemic heart disease was determined at initial examination and the men were followed up for an average of 6.2 years for morbidity and mortality from myocardial infarction and for sudden cardiac death. Non-manual workers had significantly higher scores (more type A) than manual workers and the score decreased (less type A) with increasing age. After adjustment for social class and age men with higher scores had higher prevalences of ischaemic heart disease less marked for electrocardiographic evidence and more marked for response to a chest pain questionnaire (angina or possible myocardial infarction). A man's recall of a doctor's diagnosis of ischaemic heart disease, however, did not relate to his Bortner score. There was no significant relation between the Bortner score and the attack rate or incidence of major ischaemic heart disease events. In this study type A behaviour, as measured by the Bortner questionnaire, did not predict major ischaemic heart disease events in British middle aged men.

Sudden coronary death in Glasgow: nature and frequency of acute coronary lesions

A detailed pathological study of the coronary arteries was carried out on 130 random white subjects (91 male and 39 female) who died suddenly in the Glasgow area. In 30 there was a clearly defined cause of death that was not due to ischaemic heart disease. In eight subjects the cause of death was in doubt. Ninety two of the 130 showed coronary stenosis resulting in a loss of more than 75% of coronary artery cross sectional area and/or acute coronary events with no other cause of death. Of these 92 subjects considered to have died suddenly of ischaemic heart disease, 64% showed plaque rupture and thrombosis which occurred at sites of previous high grades of stenosis. Twenty two subjects had intraluminal thrombosis unrelated to plaque fissuring. Thirty eight (41%) showed histological evidence of recent myocardial necrosis; acute coronary events occurred in 34 of these. There was no correlation between the duration of symptoms before death and the occurrence of acute coronary events. Acute coronary events, mainly in the form of plaque rupture, are a common finding in sudden coronary death when a careful study is made of the whole coronary arterial tree.

Alcohol and ischaemic heart disease in middle aged British men

The relation between alcohol intake and ischaemic heart disease was examined in a large scale prospective study of middle aged men drawn from general practices in 24 British towns. After an average follow up of 6.2 years 335 of the 7729 men had experienced a myocardial infarction (fatal or non-fatal) or sudden cardiac death. No significant relation was found between reported alcohol intake and the incidence of such events. Though the group of light daily drinkers had the lowest incidence of ischaemic heart disease events, it also contained the lowest proportion of current smokers, had the lowest mean blood pressure, had the lowest mean body mass index, and contained the lowest proportion of manual workers. These characteristics are more likely to account for the apparent protective effect of alcohol against ischaemic heart disease than a direct effect of alcohol. Compared with the effects of established risk factors alcohol seems to be quite unimportant in the development of ischaemic heart disease.

Giving up smoking and the risk of heart attacks. A report from The British Regional Heart Study

In a prospective study of 7735 middle-aged men, both current and ex-cigarette-smokers had a risk of a major IHD event, within an average 6.2 years of screening, more than twice that in men who had never smoked cigarettes; men who had given up smoking more than 20 years ago still had an increased risk. This excess risk among ex-smokers is only to a small extent explained by their higher blood pressure, serum total cholesterol, and body-mass index. An increased prevalence of IHD in men who had recently given up smoking also made a small contribution to excess risk. In both current and former cigarette smokers, the number of years a man had smoked cigarettes ("smoking-years") was the clearest indicator of IHD risk due to cigarettes. The major benefit of giving up smoking may lie in halting the accumulation of smoking years.

Identifying men at high risk of heart attacks: strategy for use in general practice

A strategy was devised for identifying men at high risk of acute myocardial infarction or sudden ischaemic death. A risk score was devised using cigarette smoking, mean blood pressure, recall of ischaemic heart disease or diabetes mellitus diagnosed by a doctor, history of parental death from "heart trouble," and the presence of angina reported on a questionnaire. The top fifth of the score distribution identified 53% of ischaemic heart disease cases--that is, men who subsequently experienced major ischaemic heart disease over the next five years. The addition of serum total cholesterol concentration and electrocardiographic evidence only slightly improved prediction (to 59%) and would have considerably increased the cost and effort of screening. Using this risk score on an opportunistic basis could be particularly valuable in general practice. Management of this high risk group is regarded as appropriate medical care and is complementary to the population approach to preventing ischaemic heart disease. Such a strategy for reducing the incidence of and mortality from ischaemic heart disease in men at high risk would also increase professional and public awareness of the need for preventive action.

High density lipoprotein cholesterol is not a major risk factor for ischaemic heart disease in British men

The concentration of high density lipoprotein cholesterol (HDL cholesterol) in serum was measured at initial examination in a large prospective study of men aged 40-59 drawn from general practices in 24 British towns. After an average follow up of 4.2 years 193 cases of major ischaemic heart disease had been registered in 7415 men in whom both HDL cholesterol and total cholesterol values had been measured. The mean HDL cholesterol concentration was lower in the men with ischaemic heart disease ("cases") compared with other men, but the difference became small and non-significant after adjustment for age, body mass index, blood pressure, cigarette smoking, and concentration of non-HDL cholesterol. The higher mean concentration of non-HDL cholesterol in "cases" remained highly significant after adjustment for other factors. Men in the highest fifth of non-HDL cholesterol values had over three times the risk of major ischaemic heart disease compared with men in the lowest fifth. Multivariate analysis showed that non-HDL cholesterol was a more powerful predictor of risk than the HDL to total cholesterol ratio. These British findings were compared with six other prospective studies. All the larger studies showed similar results, suggesting that HDL cholesterol is not a major risk factor in the aetiology of ischaemic heart disease.

Risk factors for ischaemic heart disease: the prospective phase of the British Regional Heart Study

Risk factors for major ischaemic heart disease (acute myocardial infarction or sudden death) have been investigated in a prospective study of 7735 men aged 40-59 years drawn from general practices in 24 British towns. After a mean follow-up of 4.2 years, there have been 202 cases of major ischaemic heart disease. Univariate estimates of the risk of ischaemic heart disease show that serum total cholesterol, HDL-cholesterol and triglyceride concentrations, systolic and diastolic blood pressures, cigarette smoking, and body mass index are all associated with increased risk of ischaemic heart disease. Evidence of ischaemic heart disease at initial examination is also strongly associated with increased risk of subsequent ischaemic heart disease. All these factors were then considered simultaneously using multiple logistic models. Definite myocardial infarction on electrocardiogram and recall of a doctor diagnosis of ischaemic heart disease remained predictive of subsequent major ischaemic heart disease, after allowance for all other risk factors. Serum total cholesterol, blood pressure, and cigarette smoking each remained as highly significant independent risk factors whereas overweight, above average levels of HDL-cholesterol and serum triglyceride were not predictive of risk after allowance for the above factors. Men with and without pre-existing ischaemic heart disease were examined separately in the same way (using multiple logistic models). The strength of association between the principal risk factors and subsequent major ischaemic heart disease was reduced in the men with pre-existing ischaemic heart disease, only age and serum total cholesterol remaining highly significant. Overall the levels of the major risk factors commonly encountered in British men have a marked effect on the risk of ischaemic heart disease. Modification of these risk factors in the general population constitutes an important national priority.

Provision of services for the diagnosis and treatment of heart disease in England and Wales. Third report of a Joint Cardiology Committee. Royal College of Physicians of London and the Royal College of Surgeons of England

The principal conclusions of the report are as follows. Cardiology continues to change rapidly. In the five years since the issue of the Second Report of the Joint Cardiology Committee in 1980 the specialty has been affected principally by the increase in coronary artery surgery and the increasing importance of non-invasive techniques of diagnosis, particularly echocardiography. The burden of heart disease in Britain shows some decline recently, but this falls short of that which has occurred in other countries. The vital role of the initial assessment of patients to ensure the efficient use of limited resources falls upon physicians and paediatricians in district general hospitals. Each district general hospital should have at least one physician, practising general medicine but having a special expertise and training in cardiology. He should undertake echocardiography, stress testing, ambulatory monitoring, emergency pacing, rehabilitation, and cardiac intensive care, with the necessary facilities and staff. He will also play an important part in the follow up of patients assessed and treated at cardiac centres. Paediatricians should continue to evaluate children with heart disease and their training should include periods at cardiac centres. Cardiac centres currently undertaking invasive investigations and cardiac surgery need to expand to cope with demand. A target figure of 750-1000 coronary artery bypass operations annually is suggested. This implies three or four surgeons and six cardiologists per centre. Other staffing should be based on these figures. Smaller centres are not necessarily non-viable but should be encouraged to expand or merge. Funding should be clarified so that regional contributions to regional services are identified and not lost in district budgets. Expensive capital equipment should be regionally funded whether sited in cardiac centres of district general hospitals. (7) Supraregional centres for the cardiac problems of infants under the age of one year have been identified ans should receive supraregional funding. Their staffing and equipment should be appropriate to the exceptional demands of this work. If such a centre is sited within an existing cardiac centre the staff will be additional to those needed for the adult work. Facilities for older children should continue to be provided, as at present, at all cardiac centres. (8) Cardiac transplantation should be funded supraregionally. (9) The medical audit of cardiac work should be supported by the Department of Health and Social Security (DHSS). (10) Research remains a high priority, and cardiac centres should be provided with the facilities, and staff with the contracts and time, to undertake it. (11) A revision of this report is recommended within five years.

Recall of diagnosis by men with ischaemic heart disease

In a study of the prevalence of ischaemic heart disease in middle aged men in 24 British towns, the subjects were asked whether a doctor had ever told them that they had any form of cardiovascular disease. Their recall of various diagnoses was related to evidence of ischaemic heart disease obtained by an administered questionnaire on chest pain and electrocardiography. Twenty one per cent of men recalled a diagnosis of cardiovascular disease, in one quarter of whom it was ischaemic heart disease. There was a sixfold increase in the prevalence of recall of a diagnosis of ischaemic heart disease over the age range studied. Only one third of the men with possible myocardial infarction on questionnaire recalled such a diagnosis having been made by a doctor. Only half of those with a definite myocardial infarction on an electrocardiogram could recall a diagnosis of ischaemic heart disease. Even in severe (grade 2) angina 40% could not recall being told that they had heart disease. Overall, only one in five of those regarded as having ischaemic heart disease was able to recall such a diagnosis having been made by a doctor, and these were likely to be those most severely affected. Ischaemic heart disease is common in middle aged British men, but most of those affected are apparently not aware of their condition. This low level of awareness among patients and doctors may contribute to a lack of public concern regarding the need for action to reduce the incidence of ischaemic heart disease in Great Britain.