Daniel C. Connolly

Diabetes Mellitus: Incidence, Prevalence, Survivorship, and Causes of Death in Rochester, Minnesota, 1945–1970

The incidence and prevalence of diabetes mellitus in residents of Rochester, Minnesota, for 25 years (1945 to 1970) were determined from available medical records. The over-all incidence rate for diabetes is 133 new cases per 100,000 population per year (age-adjusted to 1970 U.S. white population). The rate increased with age for both men and women and was higher among men over 30 years of age. The average annual incidence rates per five-year period for juvenile-onset diabetes mellitus were low and variable and showed little change. Polyuria, polydipsia, glycosuria, lean habitus, loss of weight, and high levels of fasting hyperglycemia at initial diagnosis occurred more frequently in younger than in older patients. The peak incidence in 1960 through 1964 and the decrease in the following five years may be a reflection of the introduction of the AutoAnalyzer method for blood glucose in 1958. The average annual incidence rates for 1955 through 1959 and 1965 through 1969 were essentially the same. The over-all prevalence for diabetes mellitus is 1.6 per cent, with a higher rate among men than among women over 40 years of age; among school children the rate is 0.1 per cent. Survivorship in the diabetic population is lower than that in the general population. The leading cause of death was coronary heart disease, the death rate from it being higher than for the general population.

Long-term follow-up of isolated replacement of the aortic or mitral valve with the Starr-Edwards prosthesis.

Review of 1,684 cases of isolated aortic or mitral valve replacement with a Starr-Edwards prosthesis demonstrated that the procedure provides improved life expectancy over that found in the natural history of valvular heart disease. Further improvement in results depends on continued reduction in operative and late mortality and in the incidence of thromboembolism. Advanced preoperative functional class, atrial or ventricular enlargement, a history of prior heart surgery, advanced age at operation and untreated valvular disease were among the factors related to increased early or late mortality. The data suggest that adequate anticoagulation, earlier performance of valve replacement and more complete repair of valvular dysfunction may increase survival rates.

The Relationship between Pulmonary Artery Wedge Pressure and Left Atrial Pressure in Man

In 17 patients with atrial septal defect, in 12 patients with mitral stenosis and in four patients with unilateral lung tumor but without evidence of mitral valve disease, a similarity in pressure pulse contours in the left atrium and pulmonary artery wedge position was obtained at cardiac catheterization. It is concluded that the pulmonary artery wedge pressure pulse is a reasonably accurate reflection both in magnitude and in contour of the left atrial pressure pulse in man during normal respiration and also during assisted respiration at operation.

Coronary heart disease in residents of Rochester, Minnesota. VII. Incidence, 1950 through 1982

An epidemiologic study of coronary heart disease in residents of Rochester, Minnesota, has been updated through 1982. Between the time that mortality rates began to decline in the late 1960s and now, the age-adjusted incidence of all types of coronary heart disease in residents of Rochester decreased 11% in men but increased 9% in women. This difference was due mainly to changes in the incidence of myocardial infarction as the initial manifestation of coronary heart disease-in men, the rates declined by 20%, whereas the rates for women increased by 17%. The greatest changes were in the age group 50 to 69 years. From the 1965 through 1969 period to the 1979 through 1982 period, the age-adjusted incidence of sudden unexpected death as the initial manifestation of coronary heart disease decreased in both sexes, but the incidence of angina pectoris increased in both men and women. The 24-hour and 30-day case fatality rates for myocardial infarction and the incidence rates for sudden unexpected death have stabilized. Additional studies are needed to identify the reasons for the striking divergence in secular trends in coronary heart disease for men as compared with those for women.

The role of collateral circulation in the various coronary syndromes.

Coronary collaterals were evaluated at arteriography within 1 year of the onset of symptoms of coronary disease in 73 patients with transmural myocardial infarction (TMI), 63 patients with subendocardial myocardial infarction (SMI), and 164 patients with angina pectoris (AP) alone. An occluded artery was present in 79% of patients with TMI, 70% of patients with SMI and elevated serum enzymes, and 42% of patients with AP. Collateral vessels supplied the occluded artery in 91% of patients with AP, 93% of patients with SMI all had postinfarction AP - and 78% of patients with TMI and postinfarction AP, but in only 35% of patients with TMI and no postinfarction AP (p < 0.01). With the treadmill stress test in patients with AP alone and coronary lesions in the anterior wall coronary distribution, 97% had ischemia in leads V4 to V,. Only 25% of patients with coronary lesions in the inferior wall coronary distribution had ischemia in leads III and aVF (positive group) and 75% did not (false negative group). The affected artery was occluded and supplied by collaterals in only 9% of patients of the positive group, but in 57% of the false negative group (p < 0.01). These data and additional findings in the infarction syndromes suggest that in TMI and SMI the presence of collaterals maintains a peri-infarction ischemic zone with subsequent AP. In patients with AP alone, the treadmill stress test is highly predictive of coronary disease in the anterior but not in the inferior wall coronary distribution, in part because of the influence of collaterals.

Pericarditis: A ten year survey

Abstract Acute nonspecific pericarditis is a relatively common diagnosis, and probably represents a group of disease processes. The etiologic agent in many patients is a virus, and in a large group of patients the process is related to a hyper-sensitivity state or an autoimmune process. Acute nonspecific pericarditis is not always a benign disease, although in the majority of patients it runs a benign course. Among the complications that may result are pericardial effusion with tamponade, pericardial hemorrhage, acute relapses, the subsequent appearance of chronic constrictive pericarditis, and the occurrence of associated myocarditis. Adrenal steroid therapy may help dramatically in some patients, but steroid dependence and occasional hypercorticoadrenalism are disturbing complications of this treatment.

Coronary Heart Disease in Residents of Rochester, Minnesota. IV. Prognostic Value of the Resting Electrocardiogram at the Time of Initial Diagnosis of Angina Pectoris

The data in this study were based on the 1,154 Rochester residents in whom a resting electrocardiogram had been obtained at the time of diagnosis of angina pectoris as the initial manifestation of coronary heart disease during the 26-year period 1950 through 1975. The finding of a normal electrocardiogram at the time of the initial diagnosis of angina pectoris was associated with a good prognosis. Survival at 5 years was equal to that expected, for the given age and sex distribution, under a cohort life table for the Minnesota white population. In contrast, in those patients who had an abnormal electrocardiogram at the time of diagnosis, the observed survival rate was 86% of that expected at 5 years.

Paroxysmal ventricular tachycardia and fibrillation without complete heart block: Report of a case treated with a permanent internal cardiac pacemaker

Abstract Recurrent paroxysmal ventricular tachycardia and fibrillation in a patient without evidence of atrioventricular block were successfully controlled by a permanently implanted internal pacemaker with the pacing rate set at 100/min. The rationale for the choice of the pacemaker rate is discussed. It is suggested that, should other conventional forms of therapy such as cardiac depressant drugs be ineffective, implantation of a permanent cardiac pacemaker may be useful in the control of this serious tachyarrhythmia.

Relation of intraoperative or early postoperative transmural myocardial infarction to patency of aortocoronary bypass grafts and to diseased ungrafted coronary arteries

Serial preoperative and postoperative electrocardiograms and vectorcardiograms were obtained in 500 patients undergoing saphenous vein aortocoronary artery bypass graft surgery. Evidence of transmural myocardial infarction was found early postoperatively in 67 patients (13 percent). Age and sex distributions, number of vessels diseased or vessels grafted, and preoperative and postoperative New York Heart Association functional classification (mean follow-up, 26 months) did not differ in the groups with and without infarction. Increased duration of cardiopulmonary bypass time (more than 120 minutes) was slightly greater in the group with infarction (P smaller than 0.05). Multivariate analysis revealed that 60 percent of patients in the group with infarction were identified by a 1st day serum glutamic oxaloacetic transaminase value greater than 100 U/liter; however, for each such patient identified, there was approximately one false positive result. Use of other values (creatine phosphokinase, cardiopulmonary bypass time and total anoxic rest time) did not improve discrimination. Twenty-five percent of all transmural infarctions occurred within the zone of myocardium supplied by a diseased ungrafted artery. In 32 patients with early evidence of transmural mycardial infarction in a zone of myocardium supplied by a grafted artery, postoperative angiography showed as many with patent as with occluded grafts. Of 154 patients in the group without infarction who had early postoperative graft angiograms, 30 (19 percent) had one graft occluded and yet no evidence of transmural infarction by our criteria. Therefore, early postoperative evidence of transmural myocardial infarction as defined in this study is an unreliable indicator of the status of the graft supplying the zone of infarction.

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.