Charles W. Frank

Ventricular Premature Beats and Mortality after Myocardial Infarction

To assess the role of ventricular premature beats in influencing mortality of coronary patients, 1739 men with prior myocardial infarction were monitored for ectopic activity for one hour at a standard base-line examination, and followed for mortality for periods up to four years (average, 24.4 months). Analyses of survival taking into account other important prognostic variables establish that the presence of complex premature beats (R on T, runs of 2 or more, multiform or bigeminal premature beats) in the monitoring hour is associated with a risk of sudden coronary death three times that of the men free of complex ventricular premature beats. The corresponding risk of death from any cause is twice that of men without such complex beats in the hour. These arrhythmias make an independent contribution to increased risk of death that persists over the length of this observation period.

Ventricular premature complexes and sudden death after myocardial infarction.

Among 1739 male survivors of myocardial infarction, mortality over 5 years was examined in relation to presence of complex ventricular premature complexes (R on T, runs of two or more, multiform or bigeminal complexes) identified during 1 hour of monitoring. Such arrhythmia was associated with excess risk of death over the entire period. Men with R on T or runs during the hour show a 5-year sudden coronary death rate of 25%, compared with 6% of men free of premature complexes. Men with complex ventricular premature complexes are also at relatively higher risk for nonsudden cardiac death than the other men (5-year mortality 15% and 7%, respectively), but no additional disadvantage was associated with the presence of R on T or runs. Multivariate survival analyses, controlling simultaneously for other important clinical factors, identify complex ventricular premature complexes as the strongest influence on risk of sudden coronary death and congestive heart failure as the strongest influence on risk of other cardiac death.

Relation of Education to Sudden Death after Myocardial Infarction

We studied the influence of social and personal characteristics on prognosis among 1739 male survivors of myocardial infarction who had been monitored for one hour at a standard examination and subsequently followed for mortality. Over a three-year period men with little education (eight years of schooling or less) who had complex ventricular premature beats in the monitoring hour had over three times the risk of sudden coronary death found among better educated men with the same arrhythmia (cumulative mortality of 33 per cent and 9 per cent, respectively). No such differential appeared in the absence of complex ventricular premature beats. Neither risk factors for incidence of coronary heart disease nor clinical characteristics affecting prognosis accounted for the differences observed. There was no relation between education level and risk of recurrent infarction.

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.

An experimental study of the immediate hemodynamic adjustments to acute arteriovenous fistulae of various sizes.

In the past thirty years, numerous observations have been made on the hemodynamic effects of arteriovenous fistulae. Arteriovenous fistulae of variable size and location have been studied in patients as well as in animals. Such studies have consisted a) in observing the effect of suddenly opening and closing a fistula in acute experiments, b) in studying the effects of suddenly closing and opening a fistula in an animal or a patient who had had such a fistula for a relatively long time, and c) in recording the effect of complete surgical eradication of a long-standing fistula. While some agreement has been reached on many points, there persists some controversy about most of them (1). It is now generally agreed that an

Ventricular premature complexes in prognosis of angina.

We studied the prognostic role of ventricular premature complexes occurring during 1 hour of electrocardiographic monitoring of 416 men with effort angina who had never had myocardial infarction, and compared mortality over 5 years with that of 1739 men with infarction before first observation. Multivariate analyses of survival identified the presence of ventricular premature complexes in 1 hour of monitoring, the presence of ST-segment depression on the standard ECG, and age as the variables making the most important independent contributions to risk of death (all causes and sudden coronary deaths) among the men with angina. The relatively lower age-adjusted 5-year mortality among men with angina compared with those who had a prior myocardial infarction reflects the lower prevalence in the former group of indicators of myocardial dysfunction, such as ventricular ectopic activity and ST-segment depression.

The effect of atrial and ventricular tachycardia on cardiac output, coronary blood flow and mean arterial blood pressure.

The effect of electrically induced auricular and ventricular tachycardia of various rates was studied in the anesthetized dog. When, the control heart ranging between 140 and 190 per minute, atrial tachycardia of a rate only slightly higher than the control rate was induced, a very temporary initial decrease in arterial blood pressure, cardiac output and coronary blood flow occurred, then all three parameters essentially returned to control level. With atrial tachycardia of a higher rate, blood pressure, cardiac output and coronary flow fell more markedly, then blood pressure and cardiac output rose to or toward control level, remaining below control level with higher rates of tachycardia, whereas the coronary flow rose to or above control level and only exceptionally remained below control level. Ventricular tachycardia had essentially the same effects as atrial tachycardia, but a ventricular tachycardia of a given rate had the same quantitative effect as an atrial tachycardia of a higher rate.

Repeated 1 hour electrocardiographic monitoring of survivors of myocardial infarction at 6 month intervals: Arrhythmia detection and relation to prognosis

In a study of the relation between ventricular premature beats and sudden death among 1,739 male of myocardial infarction enrolled in the Health Insurance Plan of Greater New York (HIP), patients underwent 1 hour of electrocardiographic monitoring at a baseline examination. During follow-up periods of up to 5 1/2 years, survivors underwent repeated monitoring at 6 month intervals for a maximum of four monitorings. At each monitoring a constant proportion of the men--25 percent--showed complex ventricular premature beats (runs of two or more, R on T phenomenon, bigeminal or multiform beats) during the hour. In comparison with men free of such arrhythmia, those demonstrating these complex forms in a given hour were three times as likely to show such beats in a subsequent monitoring hour. The mortality risk over 3 1/2 years after each of the four monitoring observations was in all cases elevated among men with complex ventricular premature beats. The risk of sudden death over this period was 6 percent for men without and 13 to 17 percent for men with such complexes. A study of the 1,445 men who underwent monitoring both at baseline examination and 6 months later identified the presence of runs of ventricular premature betas in either observation as a particularly important harbinger of sudden death.

Return to work after first myocardial infarction.

Job outlook among men aged 25 to 64 years followed after first myocardial infarction (MI) is examined in a study of incidence and prognosis of coronary heart disease (CHD) conducted by the Health Insurance Plan of Greater New York, Employment status of 470 men with first MI is similar to that of men clinically free of CHD at the start of follow-up: 79% of men with Ml and 83% of CHD-free men are employed at the end of 4 1/2 fears of follow-up. Age and clinical severity of Ml influence rate of return to work and the proportions of men returning, but hypertension is not a significant factor. Blue-collar workers return to work more slowly than white-collar workers. Under age 55, blue-collar workers are more likely to return to changed jobs; among older men, retirement is more common in the blue-collar group.

A Study of the Usefulness and Limitations of Electrical Countershock, Cardiac Massage, Epinephrine and Procaine in Cardiac Resuscitation from Ventricular Fibrillation

The efficacy of electrical countershock, cardiac massage, epinephrine and procaine in stopping ventricular fibrillation and restoring a competent ventricular contraction was studied in anesthetized dogs. It was found that countershock is a reliable means of stopping fibrillation. However, it must be preceded by cardiac massage if not applied promptly after the initiation of fibrillation. Epinephrine helps restore a competent ventricular contraction once fibrillation has been stopped by countershock but it increases the incidence of recurrence of fibrillation. The doses of procaine which constitute a reliable means of stopping fibrillation depress the rhythmicity of the heart to such an extent that the cessation of fibrillation is followed by prolonged periods of cardiac standstill.