Lewis Kuller

Natural History of Ischemic Heart Disease in Relation to Arteriographic Findings A Twelve Year Study of 224 Patients

The severity of the atherosclerotic disease of the coronary arteries is demonstrated to be an important predictor of survival in a group of 224 patients followed from 5 to 12 years after coronary arteriography. The group consisted of young patients (average age 41.8 years) without hypertension or congestive heart failure, who were studied during the stable phase of their disease. The current status of 218 or 97% of this group of patients is known.

Epidemiological Study of Sudden and Unexpected Deaths due to Arteriosclerotic Heart Disease

A study of sudden unexpected nontraumatic deaths was begun on June 1, 1964. A sample of all nontraumatic deaths in Baltimore residents between the ages of 20 and 64 from June 15, 1964, to June 14, 1965, was obtained. The deaths were then studied by reviewing all available medical information in order to determine: (1) whether the death was possibly sudden or not and (2) the accuracy of the diagnosis reported on the death certificate. The next of kin or other relative or friend of each deceased person who died suddenly was then interviewed.For comparison, information was obtained on (1) a probability sample of the Baltimore population, and (2) deaths due to arteriosclerotic heart disease (ASHD deaths) that were found to be “not-sudden.”There were 1,857 deaths in the original sample, of which 589 were sudden according to the definition of sudden death. After adjustment for sampling, it was estimated that 1,178 (32%) of the total 3,648 deaths in Baltimore were sudden. Arteriosclerotic heart disease (ASHD) accounted for 58% and the cardiovascular group together for 69% of the sudden deaths.Sixty per cent of all ASHD deaths were sudden. Of the 1,030 ASHD deaths in Baltimore City between the ages of 40 and 64, 20.6% occurred outside of a hospital and 46.2% represented deaths on arrival at a hospital. Only 18.9% of all ASHD deaths occurred after the first 24 hours of hospitalization.By use of data provided in several crosssectional and prospective studies, it was estimated that 22% of new coronary events were sudden deaths and that the case-fatality rate was 31%.In approximately half of the ASHD sudden deaths the deceased had a history of heart disease prior to death and in 24% the deceased had seen a physician within the week prior to death. Unfortunately we were not able to determine the reasons for these visits.In considering the implications of these findings with regard to the prevention of ASHD deaths, it would appear that prevention of only a comparatively small percentage (8.2%) of ASHD deaths is completely dependent on primary prevention. For the remaining ASHD deaths a combination of both primary and secondary prevention may be effective. Because of the rapidity of death and the high frequency of these deaths either occurring outside of a hospital or being called deaths on arrival, hospital treatment may well have little effect on reducing the ASHD mortality, while, on the other hand, the combination of better and earlier diagnosis and intensive treatment in a hospital could conceivably re- duce the mortality.

Sudden death in arteriosclerotic heart disease; the case for preventive medicine.

Abstract Arteriosclerotic heart disease is the leading cause of death among adults in the United States. The distribution of deaths due to arteriosclerotic heart disease in relation to demographic factors, time, space and medical care has been studied in several different ways. Data from cross-sectional and prospective studies disclose that the incidence of sudden death due to arteriosclerotic heart disease is higher in male than in female subjects and increases with age. Approximately 25 to 30 per cent of patients with incident cases of myocardial infarction die suddenly, and for a cohort of myocardial patients with myocardial infarction there are as many deaths within the first 24 hours as during the next 5 years. A variety of studies in the United States and England have shown that in about 70 per cent of all deaths due to arteriosclerotic heart disease the individuals died outside of a hospital or were dead on arrival. Relatively few of the deaths occur after 24 hours of hospitalization. Survivors of a myocardial infarction have a very high risk of dying suddenly. This risk also may exist for patients with angina pectoris. A retrospective study of sudden death in Baltimore has shown that 60 per cent of all deaths due to arteriosclerotic heart disease were sudden and that 61.4 per cent of all sudden deaths were due to arteriosclerotic heart disease. Sudden death due to arteriosclerotic heart disease was the single most important type of death in subjects aged 40 to 64 years, accounting for 20 per cent of the nontraumatic deaths. Approximately one half of the individuals with arteriosclerotic heart disease dying suddenly had a history of heart disease, and 23 per cent had seen a physician within a week before death. Finally, of the 585 white men who died of arteriosclerotic heart disease, only 52 (8.4 per cent) had died within two hours, had no history of heart disease and had not seen a physician within one month before death. A review of these studies, therefore, shows that either a program of primary prevention of myocardial infarction and sudden death or methods of early diagnosis and treatment outside of the hospital and in a coronary care facility will be necessary to reduce the death rates from arteriosclerotic heart disease in the community.

Sudden and unexpected non-traumatic deaths in adults: A review of epidemiological and clinical studies

Abstract The reported studies of sudden and unexpected non-traumatic deaths in adult populations have been reviewed. The percentage of deaths certified by a Coroner or Medical Examiner is the only available measure of the frequency of sudden death in a community. The problems associated with the use of only Medical Examiners certified deaths were discussed. The greater frequency of sudden deaths observed in certain ethnic, racial and economic groups may well be due to differences in the availability of medical care which influence the frequency of certification by the Medical Examiner. Although there are many possible causes of sudden death, cardiovascular disease, especially coronary artery disease, accounts for the majority of cases. Several prospective and cross-sectional studies of coronary artery disease were reviewed in order to obtain some measure of the incidence of sudden death as the first and only manifestation of coronary artery disease. Almost all of these studies have reported that about 20 per cent of new coronary events are sudden deaths. Furthermore, longitudinal studies of individuals who have survived the immediate period following a myocardial infarction have also reported a high risk of sudden death among the original survivors. Many of the studies have shown that the immediate mortality rate following a myocardial infarction is greater than the rate during the next 5 years among those who have survived the first 24 hr after their infarction. Whether or not individuals who die suddenly following a new coronary event differ in certain biological or social characteristics which affect their probability of survival is unknown. Very limited data have suggested that sudden death may be more common in the young and in men [20, 32]. Their blood pressure, cholesterol and body weight prior to death appear to be similar to those who have survived, but the available data are extremely limited [40]. The relationship of physical activity at the onset of a new coronary event and prior occupation to the likelihood of sudden death has not been studied adequately and no definite data are available. The pathophysiology of sudden and unexpected death has been difficult to study. The use of animals as models for the study of the various pathophysiological events in man has been questioned by several investigators. Because of the large number of deaths that occur outside of a hospital and are frequently medically unattended, the mechanisms of death have not been determined. Many studies are under way which are attempting to delineate the pathophysiology of various arrhythmias and the mechanisms of shock following a myocardial infarction. New techniques of monitoring the electrocardiogram have made it possible to measure the types and frequency of various cardiac arrhythmias following a myocardial infarction. It also appears possible to monitor the daily activities of normal men and obtain some estimate of the frequency and types of arrhythmias that occur during regular activities. A high risk group of individuals may exist who develop recurrent arrhythmias following a variety of activities, ultimately leading to ventricular fibrillation, asystole and death. Several other diseases which may cause sudden death were discussed. These diseases can be broadly classified into two groups: (1) rare diseases which are often associated with sudden death; and (2) relatively common diseases, in which a small proportion of all deaths are sudden. In the first group are several cardiovascular diseases such as ruptured and dissecting aneurysms, while in the second group are a variety of diseases such as rheumatic heart disease, cerebrovascular disease, and cirrhosis of the liver. Neither adequate cross-sectional studies nor longitudinal studies have been carried out on any of these diseases, so the frequency of sudden death and the characteristics of the victims are as yet undetermined. It is unfortunate that most studies of cardiovascular diseases are restricted either to cases admitted to a hospital, cases seen by a physician in consultation, or to deaths certified by the Medical Examiner. It is obvious that in order to obtain a true picture of cardiovascular mortality in a community, the deaths at home and those certified by the Medical Examiner must be studied as diligently as the hospital cases. The prospective and cross-sectional epidemiological studies of coronary artery disease are frequently limited to homogenous groups, most often middle class white males. They are further limited to a relatively small number of new cases. Only a few studies have attempted to analyse cardiovascular disease in negroes or in women. Because of the large number of deaths attributed to cardiovascular disease certified by the Medical Examiner or Coroner, variations in methods of certification can significantly affect death rates from some cardiovascular diseases. Whether variations in the frequency of attributing sudden death to ASHD accounts for observed geographical differences in mortality rates, needs to be determined. Studies of the relationship of sudden deaths to variables known to increase the risk of coronary artery disease should be analyzed. Finally, the place of occurrence, activity at onset, prior symptomology and medical care, and availability and utilization of emergency facilities in a community should be studied in order to adequately plan the development of intensive care and other facilities in communities.

Three-area epidemiological study of geographic differences in stroke mortality. II. Results.

An epidemiological study was conducted of geographic differences in stroke mortality between the following areas within the United States; Savannah, Georgia (high stroke rates), Hagerstown, Maryland (intermediate stroke rates) and Pueblo, Colorado (low stroke rates). Population samples 35--54 years of age of the three cities were drawn for interview and examination to determine medical conditions and living habits of these populations. The population samples were compared with emphasis on possible risk factors for stroke: serum cholesterol and glucose tolerance test determinations, weight and height measurements, blood pressure and cigarette smoking. The gradient of increasing prevalence of stroke-related risk factors from low to intermediate to high for the three cities was present for blood pressure in black females and white males and for glucose tolerance tests in whites and nonwhites. No other consistent pattern of increasing prevalence of risk factors for stroke was evident.

Cigarette Smoking and Strokes

Utilizing a defined general population, two investigations were conducted in Washington County, Maryland. In the eight-year mortality study, the relative risk of stroke among cigarette smokers was only 0.85 as compared to nonsmokers. In the two-year morbidity investigation, limited to stroke cases occurring after the age of 50, it appears that the association of cigarette smoking to strokes in the older age groups is at most very small. In atherosclerotic strokes, there may be an association with cigarette smoking, but only in the younger age groups, as suggested by two other studies. In order to investigate this possibility a retrospective case/control study of young cases is recommended. If there is no age dependency of atherosclerotic strokes, this implies that cigarette smoking may not be associated with the atherosclerotic process in cerebral and coronary arteries.

A follow-up study of the commission on chronic illness morbidity survey in baltimore —IV. Factors influencing mortality from stroke and arteriosclerotic heart disease (1954–1967)☆

Abstract The Commission on Chronic Illness Survey population has been followed from 1954 to 1967. Previous reports have described subsequent mortality in relation to demographic characteristics and population mobility to 1962. A recent study compared the survivorship of screenees and non-screenees. The present study extends the mortality follow-up to 1966–1967. Only 3.9 per cent of the population was lost to follow-up. Men had substantially higher all cause and arteriosclerotic heart disease mortality than women and blacks had higher all cause and stroke mortality than whites. A history of hypertension, heart disease, or diabetes was associated with a substantially increased risk of all cause, stroke and arteriosclerotic heart disease deaths. Individuals with abnormal screening tests also had a markedly increased mortality. A study of the married couples in the sample failed to reveal any evidence of spouse aggregation of either all cause or specific cause mortality.

Survey of Stroke Epidemiology Studies

The Committee on Criteria and Methods of the Epidemiological Council of the American Heart Association conducted a survey of epidemiological studies of stroke. A questionnaire was sent to investigators who were involved in stroke epidemiological research. Forty studies have been reviewed.nnStroke epidemiological studies include a wide range of populations and geographic areas of the United States. Of the 12 prospective studies only five were primarily stroke-oriented, while the remaining initially involved the study of coronary artery disease.nnRelatively few stroke studies identify cases by clinical examination at the time of the stroke; most depend on examination sometime after the stroke, review of hospital records, physicians reports and patient interviews. In relatively few of the studies are the cases being examined by a neurologist.nnThere is a need for better methods of stroke-case ascertainment, for standardized diagnostic techniques that can be used in field studies, and for the evaluation of specific disabilities following a stroke.

Analysis of the validity of cerebrovascular disease mortality statistics in maryland

Abstract A study of cerebrovascular disease mortality in the state of Maryland was conducted in order to determine the validity of the cerebrovascular disease diagnoses. A stratified sample of 1932 death certificates were reviewed by obtaininginformation from other medical sources. After adjusting for sampling, cerebrovascular disease was mentioned on 669 (15.8 %) of 4 230 certificates age 40 to 75. Cerebrovascular disease was the underlying cause in 361, or 54 %, of the 669 deaths. In 121 (18.1 %) of the 669 deaths no information to validate the cerebrovascular disease diagnosis was reported, while there were 265 deaths in which a cerebrovascular disease diagnosis was noted on a clinical record other than the death certificate. Among the 364 death certificates mentioning cerebrovascular disease in which the death occurred in the hospital, the medical reviewer did not believe that cerebrovascular disease was present in 19.8%, while of the 356 hospital deaths attributed to cerebrovascular disease by the reviewer, 260 (80.2%) also reported cerebrovascular disease on the death certificate. In 241, (74.1%) of the 324 death certificates listing cerebrovascular disease, the reviewer determined that the diagnosis was well supported by clinical and/or laboratory evidence. The sensitivity and specificity of the cerebrovascular disease diagnosis on the death certificate was similar in the city and counties. Approximately 73 % of all reported CVD diagnoses were listed on the death certificates. This percentage did not vary with age and no apparent race-sex bias was present.

Breast cancer treated at the Johns Hopkins hospital, 1951–1956: Review of international ten-year survival rates

Recent results of surgical treatment of breast cancer at the Johns Hopkins Hospital reveal that the crude 5‐year survival rate for radical mastectomy was 62.3% and that the crude 10‐year survival rate was 48.7%. These results were compared with 3 prior time periods. Progressive improvement was noted despite the paradox of a uniform and level trend in our national mortality rates. The prognosis for Negro women appeared to be comparatively poor. A collective study of international 10‐year survival rates was reviewed to compare the effectiveness of varying methods of treatment. The striking characteristic of these world‐wide survival rates is their remarkable similarity regardless of the difference in the type of treatment. This concordance is true despite the dissimilarity of country or clinic being compared. A controlled clinical trial to evaluate the relative merits of equivalent methods of treatment must be undertaken as soon as possible. Randomized studies are urgently needed to assess the value of adjuvant therapy including castration, pre‐ or postoperative radiation therapy and chemotherapy.