Eve Weinblatt

Psychosocial Influences on Mortality after Myocardial Infarction

Psychosocial interviews with 2320 male survivors of acute myocardial infarction, participants in the beta-Blocker Heart Attack Trial, permitted the definition of two variables strongly associated with an increased three-year mortality risk. With other important prognostic factors controlled for, the patients classified as being socially isolated and having a high degree of life stress had more than four times the risk of death of the men with low levels of both stress and isolation. An inverse association of education with mortality in this population reflected the gradient in the prevalence of the defined psychosocial characteristics. High levels of stress and social isolation were most prevalent among the least-educated men and least prevalent among the best-educated. The increase in risk associated with stress and social isolation applied both to total deaths and to sudden cardiac deaths and was noted among men with both high and low levels of ventricular ectopy during hospitalization for the acute infarction.

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.

THE H.I.P. STUDY OF INCIDENCE AND PROGNOSIS OF CORONARY HEART DISEASE; PRELIMINARY FINDINGS ON INCIDENCE OF MYOCARDIAL INFARCTION AND ANGINA.

Abstract Preliminary findings in the H.I.P. study of incidence and prognosis of CHD have been presented. The data shown are restricted to incidence of MI and angina as related to age and sex, smoking practices, and physical activities on the job and off the job. Comparisons are made between the results of the H.I.P. study and those of other studies, principally the Framingham and Albany studies, when data are available. Age-sex differentials in MI rates obtained in the H.I.P. study are similar to those observed in other studies except for a comparatively small increase between ages 45–54 and 55–64 years in the MI rates for men. Age-sex rates for angina are lower in the H.I.P. study than in the other investigations. The association between cigarette smoking and MI among men reported by the Framingham and Albany investigators was observed in the current study. A similar association was detected for women. The H.I.P. study also found an association among men between cigarette smoking and angina. In the other studies no such association was detected. Physical activities off the job and on the job have been combined to form a three class gradient of ‘light’, ‘intermediate’ and ‘heavy’ activities. Men with ‘light’ physical Activities have an elevated risk for MI; men with ‘heavy’ physical activities seem to have a comparatively high risk for angina. No directly comparable data are available from other studies.

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.

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.

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.

Prognostic factors in angina pectoris—A prospective study

Abstract In a population of men under age 65, employed in a broad range of occupations, men with angina becoming clinically manifest have 4 times the risk of dying and 7 times the risk of a first myocardial infarction in comparison with other men over a period of two and one half years. Striking differences in prognosis are demonstrable among men shortly after angina has become manifest in relation to other observations on cardiovascular status. Information on electrocardiographic findings, blood pressure level, and congestive heart failure identifies clearly those men with newly diagnosed angina who have the least and the most favorable prognosis. Smaller differences in prognosis are observed in relation to age, cigarette smoking and physical activity level prior to the diagnosis of angina, and to serum cholesterol levels. Although at this stage of analysis these differences cannot be demonstrated as statistically significant they are in the direction shown by incidence rates for first myocardial infarction.

The H.I.P. study of incidence and prognosis of coronary heart disease: Criteria for diagnosis

Abstract Criteria for the diagnosis of 8 manifestations of CHD have been developed for particular application to the H.I.P. study of the incidence and prognosis of CHD. The diagnosis of angina is based solely upon a detailed medical history obtained by a study internist and reported on a highly structured form. These histories are evaluated by the study medical director, utilizing a scoring system which has been described. Two manifestations (angina and possible angina) have been defined. The classification of MI as highly probable, probable or possible is determined by specific combinations of ECG, clinical, and ‘acute phase’ findings. Definitions of abnormality have been made for each of these components of the diagnosis. Criteria have also been developed to define the circumstances under which deaths occurring without suitable medical and ECG observations are to be considered as ‘new coronary events’. Particular types of conduction defects and congestive cardiac failure occurring in the absence of other identifiable cause have also been defined as separate manifestations. Two years of experience in applying these criteria to the H.I.P. study records indicate that a highly reproducible classification is achieved. These specific criteria provide a basis for determining the comparability of diagnostic categories with other epidemiologic studies.