Sudden death in Auckland

Components of the Anger-Hostility Complex and Symptom Reporting in Patients with Coronary Artery Disease: A Multi-Measure Study

Multiple anger and hostility variables were investigated for associations with coronary artery disease (CAD) symptoms and to examine if those relationships were different for disease severity.Atwo year follow-up study of97 men with stenosed coronary arteries was undertaken. Questionnaires measured: nine forms of anger and hostility; Type A behaviour; anxiety; depression; social support; and ninesymptom measures. CAD severity was derived from clinicians’ ratings of coronary angiograms. Results are four fold: anger-hostility variables are relatively unimportant predictors of symptoms compared with anxiety and depression; psychosocial measures (except for expressed anger) are uncorrelated with CAD severity, though correlate numerously with CAD symptoms; symptoms are not distinguishable empirically in terms of frequency, intensity and duration with regard to type (‘angina pain’, ‘tiredness’ and ‘breathlessness and restricted mobility’); finally, CADsymptoms are unrelated to CAD severity. In conclusion, components of the angerhostility complex are of limited use for predicting CAD symptoms. However, anger expression is of utility for differentiating between CAD symptoms and disease severity.

Behavioral risk factors of sudden cardiac arrest

OBJECTIVE

The purpose of this study was to investigate the association between sudden cardiac arrest (SCA) and the behavioral factors exhaustion and nonexpression of emotions.

METHODS

Case-control study of 99 victims of SCA and 119 coronary controls, matched for gender and age.

RESULTS

Victims of SCA were more often assessed as exhausted and as closed by their family members than controls. A significant interaction between exhaustion and closeness on the risk of SCA was observed. Those who were exhausted and did not express their emotions had a sevenfold greater risk of SCA.

CONCLUSION

The behavioral factor of exhaustion and nonexpression of emotions may contribute to the identification of persons at elevated risk for SCA.

Relationship of blood coagulation and fibrinolysis to vital exhaustion

OBJECTIVE

Acute physical and psychological stressors affect blood coagulation and fibrinolysis, but little is known about hemostatic factors associated with chronic psychological stress. Prolonged psychological stress may end in a state of vital exhaustion, which has been shown to be a risk factor for first myocardial infarction and recurrent events after coronary angioplasty. The present study tested the hypothesis that vital exhaustion resulting from chronic psychological stress is associated with impaired fibrinolytic capacity and increased coagulation factors.

METHODS

On the basis of a validated questionnaire and subsequent structured interview, a well-defined group of otherwise healthy exhausted men was recruited (N = 15) and compared with age-matched not-exhausted controls (N = 15). Fibrinolytic measures included tissue plasminogen activator (TPA) antigen and plasminogen activator inhibitor (PAI-1) activity, and as coagulation factors we examined factors VIIc, factor VIIIc, and fibrinogen. Control variables were: blood pressure, smoking status, triglycerides, cholesterol, and standard hematological measures. Samples were collected twice to correct for intraindividual fluctuations. Statistical analyses were performed using 2 x 2 mixed model analysis of variance with subsequent univariate testing.

RESULTS

Vital exhaustion was associated with significantly elevated levels of PAI-1 activity (p = .023). The higher PAI-1 activity in exhausted subjects (median = 13.0 U/ml vs. 6.0 U/ml) was not accounted for by smoking status or serum lipids. No significant differences were observed in TPA antigen, factor VIIc, factor VIIIc, and fibrinogen. The groups did not differ in blood pressure, smoking status, triglycerides, cholesterol, or standard hematological measures.

CONCLUSION

These data suggest a reduced fibrinolytic capacity in exhausted individuals. Therefore, the relationship between vital exhaustion and risk of myocardial infarction may be mediated in part by an imbalance between blood coagulation and fibrinolysis.

The relationship between severity of coronary artery disease and vital exhaustion

The present study investigates the association between the severity of coronary artery disease (CAD) and feelings of exhaustion. Vital exhaustion consists of three major components: lack of energy, increased irritability, and demoralization. Previous studies showed that exhaustion is of predictive value for first myocardial infarction (MI). However, these studies could not rule out that the state of exhaustion prior to MI was the result of underlying CAD. To examine this issue, severity of CAD and cardiac pump function were related to feelings of exhaustion in 307 patients who underwent coronary angiography. It was found that exhaustion, as assessed by means of the Maastricht Questionnaire (MQ), was not related to the severity of CAD (F = 1.17; p = 1.05). Furthermore, a poor left ventricular function did not relate to MQ scores (N = 138; F < 1; NS). On the other hand, clinical variables (duration of complaints, exercise performance, peripheral vascular disease, and dyspnea), use of medication (nitrates, beta-blocking agents, calcium antagonists, and diuretics), and demographic characteristics (gender and education) were associated with MQ scores. Multiple regression analysis showed that demographic variables (lower education, younger age, and female gender) were the predominant predictors of exhaustion. In addition, dyspnea, peripheral vascular disease, and the use of medication related significantly to exhaustion scores (R2 = 0.13; F = 4.8; p < 0.001). We conclude that neither the extent of CAD nor impaired cardiac pump function is related to feelings of exhaustion in patients referred for coronary angiography. Therefore, the previously reported association between exhaustion and future MI is not likely to be caused by underlying coronary disease.

Incidence and other epidemiological characteristics of sudden cardiac death in northwest Greece

Sudden cardiac death (SCD) has not been investigated separately in Greece. The aim of this study is to describe the epidemiological characteristics of people dying suddenly out of hospital in an area of Greece. In 1990, a population based study was started to detect the cases of people dying suddenly out of hospital (< 1 h after onset of acute symptoms or < 6 h after being seen alive) in a closed population in Northwest Greece (Ioannina area: 160,000 inhabitants). During a 3.5 year period, 283 potential cases aged 30-70 years were identified by monitoring the mortality in the emergency rooms of the two hospitals of the area, the coroner's office and the death certificates from the Government Department of Statistics. The diagnosis of SCD was established in 223 (183 men, 40 women; mean ages 59 and 61 years respectively) after visiting and interviewing the relatives and/or the family doctors within 12 days (range 1-28) after the death. SCD in the study accounts for 50% of all cardiovascular deaths and is the most common cause of death after neoplasia. The most common place of death was home (151 cases, 68%), and in 174 cases (78%) deaths occurred while the patients were relaxing or during routine activities. Prodromal symptoms were reported in 57 cases (26%). The time of day of death showed a circadian variation, with a peak in the late morning from 9:00 to 12:00. Ninety four (42%) had a prior history of heart disease. One hundred and ninety one cases (86%) occurred in the subgroup of age 50-70 years.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of successful coronary angioplasty on feelings of exhaustion

Excess fatigue and exhaustion are among the most prevalent premonitory complaints of myocardial infarction and sudden cardiac death. These feelings may reflect subclinical heart disease, prolonged psychological tension, or both. The present study investigates to what extent coronary artery disease explains exhaustion. For this purpose, the relationship between the severity of coronary artery disease and exhaustion, and the relief of exhaustion after successful percutaneous transluminal coronary angioplasty (PTCA) is investigated. Patients who had a successful elective PTCA (N = 120) were evaluated on feelings of exhaustion on admission, 2 weeks after discharge and 6 months after discharge, making use of the Maastricht Questionnaire. Multiple regression analyses were used to investigate to what degree exhaustion on admission and after PTCA was determined by the extent of coronary artery disease and other patient characteristics. Severity of coronary artery disease before PTCA was positively associated with exhaustion and successful PTCA resulted in a significant decrease of exhaustion scores (P < 0.001). However, less than 5% of the variance of the exhaustion scores before PTCA could be explained by severity of coronary artery disease (R2 = 0.04, F = 5.1, P = 0.03). The majority of patients who were exhausted before PTCA remained exhausted after PTCA. Exhaustion was present in 75% of the patients before PTCA and in 65% 2 weeks after PTCA, which indicates that restoration of coronary perfusion by successful PTCA does not substantially reduce the number of exhausted patients. At 6 months, exhaustion was present in 60% of the patients, and there was no difference between patients with and without typical anginal complaints at that time.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in life-style in men under sixty years of age before and after acute myocardial infarction: a case-control study

A case-control study was conducted to examine the presence of psychosocial factors before, during, and after acute myocardial infarction (AMI) in Dutch men under sixty years of age. The study included 42 AMI patients and 48 individuals in an age-adjusted sampled control group. The psychological factors included high level of psychological stress, of social isolation, type A1 and A2 behavior, and mental depression. They were assessed by means of the Health Insurance Questionnaire of Greater New York. Univariate analysis indicated that the presence of psychological factors was common at the onset of the myocardial infarction (MI). It clearly diminished, however, after the MI had taken place. In a stepwise logistic regression analysis after adjustment for the independent variables hypertension, cholesterol, and smoking, the following three characteristics were independently related to the risk of MI: no talking (item of social isolation, P = 0.008), need to excel (item of type A1 behavior, P = 0.04), and blue feeling (item of mental depression, P = 0.09). The authors conclude that in men under 60 with AMI, the presence of psychosocial characteristics is common and that this group is going to change its life-style soon after the MI, even without any psychosocial rehabilitation therapy. Follow-up studies investigating the influence of psychological factors on survival and reinfarction should be adjusted for these changes in life-style.

Burnout as a risk factor for coronary heart disease

During the preparation of a prospective study of exhaustion as a precursor of myocardial infarction (MI), the authors found that many coronary patients said that they had been burned out at some time in their lives. Therefore, the question, "Have you ever been burned out?" was included in the study. The cohort was formed by 3,877 men, aged 39 to 65, and was followed up on for 4.2 years. Among the men who were free of coronary heart disease (CHD) at screening, 59 subjects experienced a fatal or nonfatal myocardial infarction during follow-up. Those who endorsed the above question when they entered the study were found to be at increased risk for myocardial infarction when the authors controlled for age, blood pressure, smoking, and cholesterol; RR (relative risk) = 2.13; p less than .01. About one third of those who were exhausted before myocardial infarction had been burned out at some time in their lives, chi 2 = 7.09, p less than .01. The data indicate that a state of exhaustion before myocardial infarction is often a reactivation of earlier periods of breakdown in adaptation to stress.

Mental precursors of myocardial infarction

Both cardiologists and psychiatrists have observed that the onset of myocardial infarction is often preceded by feelings of decreasing energy, general malaise, and minor depression. This paper describes these observations and tries to integrate the findings. It is proposed that the mental state preceding myocardial infarction can be best described as 'vital exhaustion'.

Fatigue and heart disease. The association between 'vital exhaustion' and past, present and future coronary heart disease

In order to study the association between vital exhaustion and different manifestations of coronary heart disease, a prospective study was conducted among 3877 males, aged 39-65. This group was studied during a mean period of 4.2 years. Vital exhaustion, a mental state characterized by unusual fatigue, a feeling of being dejected or defeated, and increased irritability, were assessed by means of the Maastricht Questionnaire. Subjects who scored in the upper third were labelled as exhausted and were compared with those who scored in the lower or middle third. The age-adjusted relative risk of angina pectoris at screening that was associated with vital exhaustion was 4.17 (p less than 0.01); that of unstable angina pectoris at screening was 17.21 (p less than 0.001). No association was observed between vital exhaustion and past myocardial infarction, except in the youngest age group (OR = 3.76; p = 0.05). Among the subjects free from coronary heart disease at screening, 54 cases of angina pectoris, 38 cases of non-fatal myocardial infarction, and 21 cases of fatal myocardial infarction were observed during follow-up. The age-adjusted relative risk of angina pectoris at follow-up was found to be 1.86 (p less than 0.03) and that of non-fatal myocardial infarction was found to be 2.28 (p less than 0.001). No association was found between vital exhaustion and fatal events.

Circadian variation in the frequency of sudden cardiac death

To determine whether sudden cardiac death exhibits a circadian rhythm similar to that recently demonstrated for nonfatal myocardial infarction, we analyzed the time of day of sudden cardiac death as indicated by death certificates of 2203 individuals dying out of the hospital in Massachusetts in 1983. The data reveal a prominent circadian variation of sudden cardiac death, with a low incidence during the night and an increased incidence from 7 to 11 A.M. The pattern is remarkably similar to that reported for nonfatal myocardial infarction and episodes of myocardial ischemia. The finding that the frequency of sudden cardiac death is increased in the morning is compatible with hypotheses that sudden cardiac death results from ischemia or from a primary arrhythmic event. Further study of the physiologic changes occurring in the morning may provide new information supporting or refuting these hypotheses, thereby leading to increased understanding and possible prevention of sudden cardiac death.

Comparisons between different syndromes of heart attack--a multivariate analysis

A register of acute coronary events in Auckland, New Zealand enabled characterization of cases of the following different coronary syndromes: definite myocardial infarction (MI) (divided to Type I with typical ECG findings and Type II with new symmetrical T wave inversion only), nonhypotensive definite infarction with and without ventricular fibrillation, possible myocardial infarction and sudden death. Comparisons between these syndromes were analyzed. ECG type II (as compared to ECG type I) definite infarction was a more chronic, repeated syndrome, with more myocardial fibrosis in fatal cases, and more previous prolonged anginal pain without documented infarction. Cases of possible (as compared to definite) myocardial infarction were also more likely to report previous prolonged aningal pain, to use beta blockers, furosemide and less likely to die within 30 days. They consumed significantly more alcohol and were more likely to be female, than cases of definite infarction. Patients with nonhypotensive definite infarction complicated by ventricular fibrillation had higher acute phase pulse rates and more pallor and sweating than similar patients not experiencing ventricular fibrillation. Some possible explanations for the above findings were discussed.