Prognostic factors in angina pectoris--a prospective study

The importance of mechanical performance for development of myocardial infarction in man

In studies using an experimental infarction as a model it has been shown that factors increasing myocardial oxygen consumption will increase the size of infarction, while factors reducing the oxygen consumption have the opposite effect. The presence of catecholamines might be most important. It is suggested that local release of noradrenaline from the sympathetic nerve endings in ischemic myocardium can induce vigorous contractions and deleterious ischemia and result in cellular necrosis. A retrospective study was performed in 81 patients hospitalized in Göteborg in 1964-1965 due to attacks of severe chest pain with no previous documented myocardial infarction. In 31 of these patients definite congestive heart failure was seen at hospitalization or developed later. During 10 years of follow up the mortality was 48 per cent and an acute myocardial infarction was found in 64 per cent of the patients without congestive heart failure. In patients with congestive heart failure the mortality was 42 per cent, and 6.4 per cent had an acute myocardial infarction. The poor mechanical performance and a lower myocardial content of noradrenaline of the failing heart might protect from the acute myocardial infarction and instead be predisposed to a slow degeneration, pump failure, and serious arrhythmias. Severe angina pectoris and congestive heart failure might represent opposite ends of the spectrum of ischemic heart disease with similar degrees of luminal narrowing of the coronary arteries.

Detecting acute coronary syndrome in the emergency department with cardiac magnetic resonance imaging

BACKGROUND

Managing chest pain in the emergency department remains a challenge with current diagnostic strategies. We hypothesized that cardiac MRI could accurately identify patients with possible or probable acute coronary syndrome.

METHODS AND RESULTS

The diagnostic performance of MRI was evaluated in a prospective study of 161 consecutive patients. Enrollment required 30 minutes of chest pain compatible with myocardial ischemia but an ECG not diagnostic of acute myocardial infarction. MRI was performed at rest within 12 hours of presentation and included perfusion, left ventricular function, and gadolinium-enhanced myocardial infarction detection. MRI was interpreted qualitatively but also analyzed quantitatively. The sensitivity and specificity, respectively, for detecting acute coronary syndrome were 84% and 85% by MRI, 80% and 61% by an abnormal ECG, 16% and 95% for strict ECG criteria for ischemia (ST depression or T-wave inversion), 40% and 97% for peak troponin-I, and 48% and 85% for a TIMI risk score > or =3. The MRI was more sensitive than strict ECG criteria for ischemia (P<0.001), peak troponin-I (P<0.001), and the TIMI risk score (P=0.004), and MRI was more specific than an abnormal ECG (P<0.001). Multivariate logistic regression analysis showed MRI was the strongest predictor of acute coronary syndrome and added diagnostic value over clinical parameters (P<0.001).

CONCLUSIONS

Resting cardiac MRI exhibited diagnostic operating characteristics suitable for triage of patients with chest pain in the emergency department. Performed urgently to evaluate chest pain, MRI accurately detected a high fraction of patients with acute coronary syndrome, including patients with enzyme-negative unstable angina.

An economic analysis of an aggressive diagnostic strategy with single photon emission computed tomography myocardial perfusion imaging and early exercise stress testing in emergency department patients who present with chest pain but nondiagnostic electrocardiograms: results from a randomized trial

STUDY OBJECTIVE

Conventional emergency department testing strategies for patients with chest pain often do not provide unequivocal diagnosis of acute coronary syndromes. This study was conducted to determine whether the routine use of single photon emission computed tomography (SPECT) imaging at rest and early exercise stress testing to assess intermediate-risk patients with chest pain and no ECG evidence of acute ischemia will lead to earlier discharges, more discriminate use of coronary angiography, and an overall reduction in average costs of care with no adverse clinical outcomes.

METHODS

All patients in this study had technetium 99m tetrofosmin SPECT imaging at rest and were randomly assigned to either a conventional (results of the imaging test blinded to the physician) or perfusion imaging-guided (results of the imaging test unblinded to the physician) strategy. Patients in the conventional arm were treated at their physician's discretion. Patients in the perfusion imaging-guided arm were treated according to a predefined protocol based on SPECT imaging test results: coronary angiography after a positive scan result and exercise treadmill testing after a negative scan result. Study endpoints consisted of total in-hospital costs and length of stay. Hospital costs were calculated using hospital department-specific Medicare cost/charge ratios. Length of stay was calculated as total hospital room days billed (regular and intensive care).

RESULTS

We enrolled 46 patients, 9 with acute myocardial infarctions. Patients randomly assigned to the perfusion imaging-guided arm had $1,843 (95% confidence interval [CI] $431 to $6,171) lower median in-hospital costs and 2.0-day (95% CI 1.0 to 3.0 days) shorter median lengths of stay but similar rates of in-hospital and 30-day follow up events as patients in the conventional arm.

CONCLUSION

An ED chest pain diagnostic strategy incorporating acute resting (99m)Tc tetrofosmin SPECT imaging and early exercise stress testing may lead to reduced in-hospital costs and decreased length of stay for patients with acute chest pain and nondiagnostic ECGs.

Potential cost effectiveness of initial myocardial perfusion imaging for assessment of emergency department patients with chest pain

Previous investigations have confirmed the diagnostic and predictive usefulness of initial single-photon emission computed tomography (SPECT) myocardial perfusion imaging using technetium-99m sestamibi in the evaluation of emergency department patients with chest pain. Patients with a normal SPECT perfusion scan performed during chest pain have an excellent short-term prognosis, and may be candidates for expeditious cardiac evaluation or outpatient management. However, there are limited data regarding the cost effectiveness of this technique. This analysis models the potential cost effectiveness of this procedure. In the current investigation we compared 2 model strategies for management of emergency department patients with typical chest pain and a normal or nondiagnostic electrocardiogram (ECG). In 1 model strategy, (the technetium-99m sestamibi SPECT myocardial perfusion imaging [SCAN] strategy), the decision whether to admit or discharge a patient from the emergency department is based on results of initial technetium-99m sestamibi SPECT myocardial imaging. Patients with normal scans are discharged; others are admitted. In the second model strategy, (the NO SCAN strategy), the decision whether or not to admit a patient is based on a combination of clinical and electrocardiographic variables. Patients with > or = 3 cardiac risk factors or an abnormal ECG are admitted; others are discharged. Adverse cardiac events were prospectively defined as cardiac death, nonfatal myocardial infarction, or the need for acute coronary intervention. Costs were assigned using data derived from 102 patients who underwent SPECT myocardial perfusion imaging and an additional 107 emergency department patients with ongoing chest pain who either underwent or were eligible for initial SPECT myocardial perfusion imaging. Mean (+/- SE) costs were highest among hospital admitted patients who experienced an adverse cardiac event ($21,375 +/- $2,733) and lowest in patients discharged from the emergency department ($715 +/- 71). Mean costs per patient of the SCAN strategy and NO SCAN strategy were $5,019 versus $6,051, respectively. These results were stable in a sensitivity analysis across a range of costs and predictive values. Thus, the SCAN model strategy for initial management of emergency department patients with typical ongoing angina and a normal or nondiagnostic ECG using initial myocardial perfusion imaging with technetium-99m sestamibi appears to be safe, accurate, and potentially cost effective. Validation of these preliminary retrospective observations will require further prospective investigation.

Technetium-99m sestamibi myocardial perfusion imaging in the emergency room evaluation of chest pain

OBJECTIVES

The purpose of this investigation was to evaluate the practicality and short-term predictive value of acute myocardial perfusion imaging with technetium-99m sestamibi in emergency room patients with typical angina and a normal or nondiagnostic electrocardiogram (ECG).

BACKGROUND

Accuracy of emergency room chest pain assessment may be improved when clinical and ECG variables are used in conjunction with acute thallium-201 myocardial perfusion imaging. Technetium-99m sestamibi is a new radioisotope that is taken up by the myocardium in proportion to blood flow, but unlike thallium-201, it redistributes minimally after injection. Technetium-99m sestamibi can thus be injected during chest pain, and images acquired 1 to 2 h later (when patients have been clinically stabilized) will confirm whether abnormalities of perfusion were present at the time of injection.

METHODS

One hundred two emergency room patients with typical angina (on the basis of a standardized angina questionnaire) and a normal or nondiagnostic ECG had a technetium-99m sestamibi injection during symptoms and were followed up for occurrence of adverse cardiac events (cardiac death, nonfatal myocardial infarction, coronary angioplasty, coronary surgery or coronary thrombolysis).

RESULTS

Univariate predictors of cardiac events included the presence of three or more coronary risk factors (p = 0.009, risk ratio 3.3) and an abnormal or equivocal acute technetium-99m sestamibi scan (p = 0.0001, risk ratio 13.9). Multivariate regression analysis identified an abnormal perfusion image as the only independent predictor of adverse cardiac events (p = 0.009). Of 70 patients with a normal perfusion scan, only 1 had a cardiac event compared with 15 patients with equivocal scans or 17 patients with abnormal scans, with a cardiac event rate of 13% and 71%, respectively (p = 0.0004).

CONCLUSIONS

Initial myocardial perfusion imaging with technetium-99m sestamibi when applied in emergency room patients with typical angina and a normal or nondiagnostic ECG appears to be highly accurate in distinguishing between low and high risk subjects.

Survival patterns in clinical and angiographic subsets of medically treated patients with combined proximal left anterior descending and proximal left circumflex coronary artery disease (CASS)

Baseline, clinical, and angiographic features of 1014 Coronary Artery Surgery Study (CASS) registry patients with combined proximal left anterior descending and proximal left circumflex coronary disease were examined to define determinants of prognosis in this clinical high-risk patient subset. A stepwise Cox regression analysis identified congestive heart failure score, left ventricular contraction score, mitral regurgitation, age, and digitalis usage as independent variables predictive of 8-year survival. When patients were stratified by left ventricular contraction score, the 8-year survival rate was 62%, 49%, and 19%, respectively, for patients with a left ventricular score of 5 to 9, 10 to 14, and greater than or equal to 15 (p less than 0.0001). The presence of a stenosis greater than or equal to 70% in the right coronary artery was associated with worse survival (47% versus 54% at 8 years; p = 0.051). In conclusion, the diagnosis of combined proximal left anterior descending and left circumflex coronary artery disease represents a large prognostic spectrum that needs to be considered when counselling individual patients.

Factors of importance for prognosis in men with angina pectoris derived from a random population sample. The Multifactor Primary Prevention Trial, Gothenburg, Sweden

A random population sample of middle-aged men from the Primary Prevention Trial was followed for 11.3 years from a first screening when different factors known to be associated with coronary artery disease (CAD) were analyzed. Men with uncomplicated angina pectoris (AP) (n = 167) derived from this population had an incidence of fatal and nonfatal CAD events 3 times higher than that of men without AP or myocardial infarction (n = 5,774). Men with myocardial infarction with or without AP had an incidence of CAD events 7 to 8 times higher than that of men without AP or myocardial infarction. Similar differences were found for new cases of uncomplicated AP (n = 128) and myocardial infarction detected at a second screening after 4 years and followed for 7.3 years. Pooled data from this series of men with uncomplicated AP showed the following factors to be associated in multivariate analysis with nonfatal or fatal CAD endpoints during follow-up: elevated serum cholesterol, elevated blood pressure, smoking and attack score. The risk increase associated with the first 3 factors was similar to the general population. These findings indicate that the same factors affecting prognosis after a first appearance of AP affect similarly patients with myocardial infarction and clinically healthy subjects. Preventive measures against these risk factors seem to be of similar importance among patients with AP, post-infarct patients and healthy subjects.

Coronary heart disease in residents of Rochester, Minnesota. V. Prognosis of patients with coronary heart disease based on initial manifestation

During the period 1960 through 1979, 1,014 residents of Rochester, Minnesota, had a diagnosis of classic angina pectoris as the first manifestation of coronary heart disease, and 1,013 had a myocardial infarction as the initial manifestation. In the angina cohort, about 50% were men, and of them, 20% were 70 years old or older. The female patients were an average of 6 years older than the men, and 43% were 70 years old or older. In this cohort, the 5-year survival rate increased from 77% in the 1960s to 87% in the 1970s (P less than 0.01). The 5-year net survivorship free of a myocardial infarction increased from 76% to 85% during that same time (P less than 0.01). In the myocardial infarction cohort, the 5-year death rate among the 30-day survivors of myocardial infarction was the same during both decades of the study. The age-adjusted reinfarction rate per 100 person-years at risk during teh first 5 years of follow-up decreased very slightly among men and increased among women; thus, it remained essentially unchanged overall. Although the case fatality rate in the myocardial infarction cohort declined sharply from the 1960s to the 1970s, the long-term prognosis of the 30-day survivors of a myocardial infarction did not improve.

Alpha- and beta-blockade in angina pectoris

Angina pectoris encompasses a clinically diverse group of syndromes in which the common factor is myocardial ischaemia resulting from an imbalance between oxygen requirement and delivery. Anginal pain is most frequently precipitated by exercise, but may occur without any apparent cause at rest. Fixed obstructions in the coronary vessels, often attended by thickening of the overlying coronary artery media, are the most frequent cause of ischaemic cardiac pain. The resulting myocardial fibrosis impairs efficient filling and emptying of the ventricles, further aggravating the functional embarrassment resulting from the reduced coronary blood flow. In stable coronary heart disease the increased energy demands during exercise are associated with the rapid development of a haemodynamic profile characteristic of acute left ventricular failure. This results in further substantial increases in pressure work, wall stress and oxygen consumption of the left ventricle. The reflex sympathoadrenal consequences of these primary haemodynamic changes lead to further mechanical and electrical embarrassment of the ischaemic heart. Increased stimulation of beta 1- and beta 2-receptors in the heart increases heart rate and contractility and thereby myocardial oxygen demand. Increased stimulation of alpha-receptors in the peripheral veins and arteries indirectly increases left ventricular oxygen demand still further by increasing preload and afterload, respectively. The reduced blood flow to the endocardium enhances its sensitivity to increased sympathoadrenal stimulation and facilitates initiation of arrhythmias. Blockade of all adrenergic activity, particularly in the myocardium, coronary arteries and peripheral blood vessels should, therefore, help alleviate the myocardial ischaemia. There is a rational argument for the use of alpha-blockade in coronary heart disease, particularly in conjunction with beta-blockade. Attenuation of the risk of coronary spasm and ventricular arrhythmias and reduction of pressure work and left ventricular afterload are amongst the potential attributes of alpha-blockade. Alone, however, their utility is severely limited by the risks of hypotension and reduction in coronary perfusion pressure and reflex oxygen-wasting tachycardia. Alone, alpha-adrenoceptor antagonists have no place in the treatment of angina pectoris. beta-Adrenoceptor blocking drugs competitively inhibit catecholamines at both cardiac and peripheral vascular beta-adrenergic receptors. Their main advantage is that they reduce many of the important determinants of myocardial oxygen consumption, particularly by reducing the heart rate during exercise.(ABSTRACT TRUNCATED AT 400 WORDS)

Importance of coronary risk factors in the presence or absence of myocardial ischemia

Smoking history, systolic blood pressure, and serum cholesterol concentration were studied for their value in predicting 5-year coronary mortality in middle-aged and older Finnish men. Total experience consisted of 188 deaths from ischemic heart disease during 20,245 person-years. Initially, the men were divided into 3 groups according to the degree of myocardial ischemia: (1) previous myocardial infarction; (2) ischemic heart disease without infarction; and (3) no myocardial ischemia. The 3 main risk factors were associated, independently of each other and of age, with the relative risk of coronary death similarly in the 3 groups, whereas their absolute impact on mortality was strong among men with ischemic heart disease and even stronger among those with a prior myocardial infarction. For example, the estimated excess coronary mortality attributable to smoking 10 to 19 cigarettes per day was 6.3 deaths per 1,000 person-years in the group with no ischemia, 14.6 in the ischemia group, and 43.1 in the infarction group. The results suggest that secondary prevention of ischemic heart disease may be important. Screening of coronary disease among middle-aged and older men also appears justified.

Clinical factors influencing survival and adequacy of revascularization after coronary bypass operation

We retrospectively analyzed the clinical data on 3479 consecutive patients having coronary bypass surgery. Patients with triple vessel and left main coronary disease had a greater frequency of inotropic requirements than did patients with single or double vessel disease (7.9% and 8.6% versus 3.8% and 4.2%; P less than 0.001). Presence of previous myocardial infarction, heart failure, or left ventricular contraction abnormalities significantly decreased the ability to achieve complete revascularization with bypass grafting. Hospital mortality since 1976 has been 0.8% (25/3040). Hospital mortality was significantly increased by history of myocardial infarction (P less than 0.001), hypertension (P less than 0.05), heart failure (P less than 0.01), extent of anatomic disease (P less than 0.005), presence of preoperative ST-T wave changes (P less than 0.001), and severe abnormalities of left ventricular function (P less than 0.001). Anginal pattern, history of hypertension, previous myocardial infarction, preoperative heart failure but not perioperative myocardial infarction significantly affected long-term survival. Patients with normal left ventricular function had excellent 42-month survival regardless of vessel disease. Inability to achieve complete revascularization did not adversely affect hospital mortality, but did significantly reduce late survival. Although bypass grafting improves survival in patients with multivessel disease and left ventricular dysfunction, the benefits appear to be significantly reduced when left ventricular damage has occurred.

Effect of bypass surgery on survival in patients in low- and high-risk subgroups delineated by the use of simple clinical variables

A multivariate risk function was developed on data from all 508 medical patients in the Veterans Administration (VA) randomized study of coronary bypass surgery. The variables, in order of importance, were ST-segment depression on resting ECG, history of myocardial infarction, history of hypertension and New York Heart Association functional classification III or IV. These noninvasive variables have been reported to be risk factors in natural-history studies of coronary heart disease (CHD). Applying the risk function to medical and surgical patients of the 1972-1974 cohort yielded a 5-year probability of dying for each patient. Investigation of treatment effects in approximate terciles obtained by collapsing the probability distribution into low-, middle- and high-risk groups showed that surgery was beneficial for patients in the high-risk tercile even after removal of patients with left main coronary artery disease (17% surgical vs 34% medical mortality at 5 years; p less than 0.01). This finding was accentuated when patients in the 10 hospitals with the lowest operative mortality (3.3%) were compared. Mortality results in the low-risk tercile favored medical treatment (medical vs surgical mortality 7% vs 17%; p less than 0.05). The risk function predicted mortality well not only for te VA medical group, but also for an independent symptomatic CHD population from the University of Alabama arteriography registry. This report further delineates the advantages and limitations of coronary bypass surgery in CHD patients with chronic stable angina.

Blood glucose and risk of coronary heart disease

Health status of 1877 Tecumseh Study subjects aged 35-64 years was ascertained in 1977. They represented 77% of the persons in this age range who were apparently healthy and had participated in comprehensive examinations of nearly the entire population of the community in 1959-1960 and 1962-1965. Subjects who developed coronary heart disease had a significantly higher mean blood glucose concentration than other members of the cohort, even after exclusion of diabetics. Similarly, when examined as single variables, age, sex, serum cholesterol, systolic blood pressure, number of cigarettes smoked per day, and relative weight were significantly related to incidence of coronary events. In the multiple logistic function, however, age, cigarette smoking, blood pressure, and blood glucose were the only significant variables. In a two-way interaction model, glucose and cholesterol were a highly predictive pair. After exclusion of diagnosed diabetics, glucose by itself or in interaction with other variables was not significant in the multiple logistic functions.

Nonfatal myocardial infarction in medically treated patients with coronary artery disease

The purpose of this study was to identify patient characteristics associated with nonfatal myocardial infarction as the first event after cardiac catheterization in medically treated patients with coronary artery disease. Multiple logistic risk analysis of 81 baseline characteristics in 354 patients who died or had nonfatal infarction identified 10 characteristics (5 clinical and 5 cardiac catheterization variables) as independently discriminating between the two events. Left ventricular function, specific coronary anatomy, previous myocardial infarction and age were the most important discriminators. Poor left ventricular function and left main coronary stenosis were associated with death. Subtotal left anterior descending and right coronary arterial stenosis, normal hemodynamics, absence of previous infarction and young age were associated with nonfatal infarction. Thus, in any subset of patients who have a uniform risk of ischemic events (nonfatal infarction or death), nonfatal infarction is most likely to occur in those who are young, have had no previous infarction, have subtotal left anterior descending and right coronary arterial stenosis and normal hemodynamics.

The incidence and economic costs of cancer, motor vehicle injuries, coronary heart disease, and stroke: a comparative analysis

The economic impact of disease and injury has most often been calculated by examining the costs associated with the prevalence of the impairments in the reference year. An alternative accounting approach is to assign all disease costs to the year of incidence, an approach which entails present-valuing to the year of incidence both health care expenditures and lost productivity. The incidence approach is the more appropriate for gauging the economic gains achievable through prevention, immediate rehabilitation, and arresting progression. Incidence-based costs have been estimated for the United States in 1975 for cancer, coronary heart disease, motor vehicle injuries, and stroke. A noteworthy finding is the relative economic importance of motor vehicle injuries, which frequently have been overlooked in the ordering of public health expenditure priorities. After cancer, which generated approximately $23.1 billion in present-valued costs in 1975 (discounted at 6 per cent), motor vehicle injuries and coronary heart disease constitute the next most expensive conditions--having generated estimated annual costs of $14.4 billion and $13.7 billion, respectively. Stroke, at $6.5 billion, follows in economic importance.

Outcome in medically treated coronary artery disease. Ischemic events: nonfatal infarction and death

In this study we extended the characterization of outcome in 1214 medically treated patients with coronary disease by considering nonfatal infarction and death together as ischemic events. At 7 years, the cumulative event rate was 47% (18% for nonfatal infarction as the initial event and 29% for death as the initial event). In multivariable analysis of 81 baseline descriptors, 11 (six clinical and five catheterization) were independent predictors of events. Progressive chest pain, number of diseased vessels, left main stenosis and left ventricular (LV) function were the most important predictors. Progrressive pain was a more important predictor of total events than of survival alone. In patients with one-, two- or three-vessel disease and normal LV function, nonfatal infarcation accounted for at least 50% of initial events. In patients with left main disease or severe LV dysfunction, death was the predominant event. These results have important implications for interpreting the natural history of coronary artery disease.

Clinical, anatomic and functional descriptors influencing morbidity, survival and adequacy of revascularization following coronary bypass

Clinical data on 3,479 consecutive patients having coronary bypass surgery were retrospectively analyzed. Perioperative complications, incomplete revascularization, and reduced long-term survival could frequently be correlated with manifestations of myocardial damage. Patients with triple vessel and left main coronary disease had a greater frequency of inotropic requirements than did patients with single or double vessel disease (7.9% and 8.6% vs. 3.8% and 4.2%). Inotropic requirements in the perioperative period were significantly increased for patients with preoperative left ventricular dysfunction; a history of heart failure or multiple infarctions did not significantly increase the incidence of inotropic requirements. Presence of previous myocardial infarction, heart failure, or left ventricular contraction abnormalities significantly decreased the ability to achieve complete revascularization with bypass grafting. Hospital mortality since 1976 has been 0.8% (25/3,040). Hospital mortality was significantly increased by history of myocardial infarction, hypertension, heart failure, extent of anatomic disease, presence of preoperative ST-T wave changes, and severe abnormalities of left ventricular function. Hospital mortality in patients with ejection fraction </=0.35 was 3.4% vs. 1.3% for those >0.35. Anginal pattern, history of hypertension, previous myocardial infarction, preoperative heart failure all significantly affected long-term survival. Occurrence of perioperative myocardial infarction did not adversely influence long-term survival. Patients with normal left ventricular function had excellent 42 month survival regardless of vessel disease (95%, 96%, and 94% for single, double, and triple vessel disease, respectively). Survival was significantly less for such patients with abnormal left ventricular function. Inability to achieve complete revascularization did not adversely affect hospital mortality, but did significantly reduce late survival. The important effect which complete revascularization had on long-term survival appeared to increase with increasing severity of coronary disease. Although bypass grafting improves survival in patients with multivessel disease and left ventricular dysfunction, the benefits appear to be significantly reduced once manifestations of left ventricular damage have occurred.

Progress study of 590 consecutive nonsurgical cases of coronary disease followed 5-9 years. II. Ventriculographic and other correlations

The clinical progress was studied in a series of 590 patients documented to have significant obstructive disease by coronary arteriography. Ventriculographic findings, age, history, cigarette smoking, hypertension, serum cholesterol, and diabetes were correlated with prognosis. In categories separated on the basis of left ventricular angiogram the 5-year cardiac mortality rates ranged from 25% among patients with normal left ventricles to 69% among patients with dilated and generally poorly contracting left ventricles. Combining the results of coronary and left ventricular angiography yielded a better prediction than either method separately. Most of the other parameters studied were related to a certain extent to mortality, but their predictive power was limited and could partly or entirely be explained by the associated obstructions of the coronary arteries or the condition of the left ventricle. The most significant clinical determinants were the history, the electrocardiogram, and the presence of diabetes mellitus. Particularly high mortality was found in patients with congestive heart failure or electrocardiographic conduction disturbances.

Angina pectoris in men. Prognostic significance of selected medical factors

Prognosis of men whose first manifestation of coronary heart disease was angina without antecedent infarction was found to resemble closely that of men followed after an initial MI. Overall mortality over a period of 4.5 years following a baseline examination was the same in the two cohorts: 17.5%.

In both groups of men electrocardiographic abnormalities and blood pressure elevation identified subsets of coronary patients with a relatively poor prognosis, but the course of disease was apparently not influenced by the serum cholesterol level. Among the men with angina no relationship emerged between symptomatic status at time of baseline and risk of mortality in the ensuing observation period.

The findings are from the HIP (Health Insurance Plan of Greater New York) study of the incidence and prognosis of coronary heart disease, a prospective study of a general population of 110,000 men and women aged 25-64 years.

Surgery for coronary artery disease

Direct distal aortocoronary vein-grafts have been used in 20 patients suffering form ischaemic heart disease. In 16 patients the indication for surgery was severe angina pectoris failing to respond to medical measures. Seven patients had angina decubitus and were Class IV according to the New York Heart Association classification and 9 patients were in Class III. Two patients had recurrent myocardial infarctions and 2 were in cardiac failure. There were 14 good results, 2 failures, and 4 deaths. Post-mortem studies of the hearts confirmed the accuracy of selective angiography in identifying the sites of major coronary obstruction. Findings at surgery showed that the absence r presence of extensive peripheral disease beyond a block could not be reliably assessed in all cases. Histological studies of the veno-arterial anastomoses suggested that rigid atherosclerotic arterial disease is a cause of graft thrombosis and that endarterectomy is a useful procedure though its longterm value is uncertain.