David Short

Earliest Symptoms of Coronary Heart Disease and their Recognition

We have reviewed the histories of 320 patients in whom a diagnosis of coronary heart disease was ultimately established and traced the symptoms back to their first appearance. In 51% the first symptom was effort angina. Difficulties in recognition arose when the symptom was localized to an unusual site, when its occurrence was dependent on a combination of exercise with cold or a recent meal, or when it was induced by excitement rather than by effort. In a quarter of the cases the onset of angina was abrupt, and in these there was usually evidence of acute infarction. In 43% of cases the first symptom was an attack of pain or discomfort in the torso occurring without any discernable precipitating factor. Again, diagnosis was difficult when the pain was in an atypical site and also when it was of brief duration associated with skeletal or abdominal disease which could cause pain at the same site, or if the patient was able to undertake strenuous exertion. In four patients cardiac pain was first experienced during a paroxysm of tachycardia. In 6% of cases the onset was marked by a symptom other than pain—most frequently dyspnoea, tiredness, faintness, or syncope. Clinical examination was of no direct value in diagnosis. Its importance lay in disclosing factors which had to be taken into account in interpreting the electrocardiogram. The electrocardiogram was invaluable, though by no means infallible. In over half of the patients the first tracing showed major abnormalities of coronary type, and nearly a quarter more showed minor S-T/T depression consistent with coronary disease. Ten per cent. showed miscellaneous abnormalities, such as left ventricular hypertrophy or bundle-branch block, and 15% no definite abnormality. There is as yet no completely reliable objective method of diagnosing early coronary heart disease, so that the recognition of symptoms remains of paramount importance.

Serious Mitral Stenosis with Slight Symptoms: Case for a Purely Objective Assessment for Operation

One of the established principles in the selection of patients for mitral valvotomy is that the symptoms must be disabling enough to warrant the risks of surgery. In practice this is generally taken to mean that there must be at least moderate dyspnoea before operation is recommended. In this paper we present evidence that mitral stenosis may become serious and potentially lethal without causing any definite symptoms.

Value and Limitations of Electrocardiogram in Diagnosis of Slight and Subacute Coronary Attacks

The electrocardiogram recorded at the initial consultation was compared with the final diagnosis in 211 consecutive suspected slight or sub-acute coronary attacks in 206 patients. In 77 (36%) of the 211 episodes, acute (or subacute) myocardial infarction was finally diagnosed. The initial E.C.G. showed a diagnostic pattern in only 19 (25%) of these 77 episodes; in 39 (50%) it was abnormal but not diagnostic of recent infarction; while in 19 (25%) the E.C.G. showed no abnormality classified under the Minnesota Code, though in 16 of these there were definite minor changes. In 61 (29%) of the 211 episodes acute myocardial infarction was excluded and an alternative diagnosis was made. The E.C.G. was strictly normal in only 23 (38%) of these 61 episodes; in 15 (25%) it showed minor abnormalities, and in 23 (38%) it was grossly abnormal.

Points: Must ethical committees inhibit research?

referring hospital. Paraquat was detected in the urine by the alkaline dithionite screening tests and confirmed by derivative ultraviolet spectrophotometry as paraquat ion. At this stage we tested the blue-green fluid by diluting it 1/1000, and obtained a positive reaction for paraquat. If we had not been led astray and had used our usual drug screening procedures we would have detected the paraquat sooner. The local suppliers of Gramoxone confirmed the colouring had been changed from brownish-purple to blue-green to make it less attractive to children. When we compared some authentic Gramoxone with our sample of fluid they were found to be identical. The change in appearance was not known to us, nor to the poisons unit consulted, and nor to the patient, who subsequently died.

Millions of mild hypertensives

It is important that plasma low-density lipoprotein and, ideally, high-density lipoprotein-cholesterol concentrations should be measured in all hypertensives in order that progress can be measured, because the risks of combined hypertension and hyperlipidaemia are so great. The dietary recommendations, however, are for whole populations and are in effect of a prophylactic nature against the commonest complications of hypertension.