Peter C. Gazes

Preinfarctional (Unstable) Angina—A Prospective Study— Ten Year Follow-Up Prognostic Significance of Electrocardiographic Changes

One hundred and forty patients with preinfarctional (unstable) angina were followed for ten years for the purpose of determining the natural history and the prognostic significance of electrocardiographic findings. The cumulative survival rate for the 140 patients was as follows: 12 months: 82%; 24 months: 75%; 36 months: 69%; 60 months: 61%; and 120 months: 48%. Twentyone percent (29 of 140) of the patients developed an acute myocardial infarction within eight months of the onset of the diagnosis of preinfarctional angina with an associated mortality of 41.4% (12 of 29). A combination of high-risk factors in a patient, e.g., frequent angina in the hospital, prior stable angina, and ischemic ST change during pain, identified his as a high-risk case. The high-risk subgroup (54) had a cumulative survival rate as follows: 12 months: 57%; 24 months: 47%; 36 months: 37%; 60 months: 27%; and 120 months: 19%. Thirty-five percent (19 of 54 patients) of this subgroup developed a myocardial infarction within three months of the onset of preinfarctional angina with an associated mortality rate of 63% (12 of 19 patients). At the first year follow-up, 18% (25 of 140) of the patients died; 74% (104 of 140) had less angina; and 8% (11 of 140) did not show a change in their anginal pattern. These data can be used as a basis for a controlled trial of surgical treatment for preinfarctional angina.

Mortality Rates and Risk Factors for Coronary Disease in Black as Compared with White Men and Women

BACKGROUND Currently recognized risk factors for coronary artery disease have been identified primarily from investigations of white populations. In this investigation, we estimated mortality rates for coronary disease and for any cause and identified risk factors for death from coronary disease among whites and blacks. METHODS Data collected over a 30-year period in the Charleston Heart Study were used to estimate mortality rates and quantify associations with risk factors assessed at the base-line examination in 1960 and 1961 of 653 white men, 333 black men, 741 white women, and 454 black women. RESULTS There were no significant racial differences in the rate ratios for death from coronary disease; however, women had significantly lower death rates than men. Over the 30-year period, the mortality rates for coronary disease per 1000 person-years were 5.2 for white men (95 percent confidence interval, 4.1 to 6.3), 4.6 for black men (3.0 to 6.2), 2.1 for white women (1.6 to 2.6), and 3.2 for black women (2.3 to 4.0). Significant, or nearly significant, predictors of mortality due to coronary disease were systolic blood pressure in all four groups; serum cholesterol level among white men, white women, and black women; and smoking among white men, white women, and black men. Although the difference was not statistically significant, the risk of death from coronary disease was consistently increased among diabetics in all four groups. A higher level of education was predictive of lower rates of death due to coronary disease among white men and black women. For all causes of death taken together, the rates for blacks were higher than the rates for whites. The presence of hypertension, a history of smoking, and a history of diabetes were significant or nearly significant predictors of mortality from any cause in all four groups. CONCLUSIONS Although the rates of death from coronary disease were somewhat lower among black men than white men and higher among black women than white women, the black:white mortality rate ratios were not statistically significant, and the major risk factors for mortality from coronary disease were similar in blacks and whites in the 30-year follow-up of the Charleston Heart Study.

Plasma Catechol Amine Concentrations in Myocardial Infarction and Angina Pectoris

Urinary catechol amines have been shown to be increased in a few cases of acute myocardial infarction. The present study shows that patients with acute myocardial infarction and with angina pectoris (after exercise) have an increase in plasma catechol amines as compared to normal subjects before and after exercise and as compared to patients with noncardiac types of pain. The significance of these findings is discussed.

Predictors of physical disability in elderly blacks and whites of the Charleston heart study

During the 1984/85 recall of the Charleston Heart Study Cohort, physical function data were obtained for 247 white males, 376 white females, 123 black males, 247 black females and 71 high socioeconomic status (SES) black males over 60 years of age. Black females had the highest prevalence of physical disability (55.8%), followed by white females (43.2%), black males (39.0%) and white males (25.8%) and high SES black males (22.3%). Physical disability was 1.5-2.5 times as prevalent among individuals with a history of cardiovascular disease (CVD) than those without such a history. Among individuals without a current history of CVD univariate analyses showed the following as significant (lower 95% CI greater than 1.0) predictors of physical disability: elevated systolic blood pressure in white females, black males, and black females; elevated cholesterol in black females; obesity in black females; and low educational level in white females. Regression analyses indicated that obesity in 1960 accounted for 10.9 and 2.9% respectively of the variability in physical disability scores in 1985 for black females and white females.

Electrocardiographic abnormalities and 30-year mortality among white and black men of the Charleston Heart Study.

BackgroundThe long-term predictive significance of a single ECG tracing for mortality was explored among the white and black men of the Charleston Heart Study. Methods and ResultsThe 1960 baseline tracings of men ages 35 to 74 in the Charleston Heart Study cohort were coded according to the Minnesota classification. Tracings were categorized as being normal or having minor or major abnormalities. The 30-year vital status was ascertained for the cohort, and the association between ECG findings and coronary and all-cause mortality was evaluated. The proportion of black men with major abnormalities at the 1960 baseline examination was almost twice that ofwhite men. Rates of all-cause mortality increased with severity of abnormalities for white and black men. The absolute excess risk for black men with major abnormalities was 23.3 per 1000 person-years and 12.8 for white men. The excess risk for coronary mortality was 73 for white men and 6.5 for black men. ConclusionsMany of the findings in this study confirm earlier associations derived from studies ofwhite populations and extend the observations to black men. However, the magnitude of the relative risk for mortality was different for white and black men. After controlling for traditional coronary disease risk factors and minor abnormalities, white men with major abnormalities were 2.72 (95% confidence interval, 1.47, 5.04) times more likely to die of coronary disease compared with black men, who were 1.95 (95% confidence interval, 0.93, 4.11) times more likely to die of coronary disease.

Acute Hemorrhage and Necrosis of the Intestines Associated with Digitalization

Eleven cases with acute hemorrhage and necrosis of the bowel are described. In all cases there was high dosage of digitalis and definite toxicity in seven. Digitalis was considered as the main associated factor, especially since there was no mesenteric arterial involvement and, in four cases, there was no congestive failure at autopsy. Hepatic vein or sinusoidal sphincter constriction with resulting portal splanchnic venous congestion was considered as possible mechanisms by which digitalization produced this syndrome.

Congenital Familial Cardiac Conduction Defects

A family in which several members of three separate generations have evidence of congenital familial conduction disturbance has been described. The occurrence of Adams-Stokes seizures with congenital AV block was also noted. From the available information it is clear that the conduction disturbance was congenital in two generations, and the family history suggests that three or four generations were probably involved. The data suggest that in this family the congenital cardiac conduction defects were transmitted as an autosomal dominant trait with incomplete penetrance.

Heart Force Effects of Sympathomimetic Amines as a Basis for Their Use in Shock Accompanying Myocardial Infarction

The treatment of 14 patients in severe shock accompanying myocardial infarction with l-norepinephrine (Levophed) in some cases and phenylephrine (Neo-Synephrine) in others demonstrated a significantly higher recovery rate with l-norepinephrine. Twelve of the patients were in congestive heart failure. Using strain-gage technics in fully conscious, trained dogs, l-norepinephrine was shown to produce substantial increments in heart contractile force in addition to its recognized pressor effects. Approximately equipressor doses of Neo-Synephrine under the same conditions had little effect on contractile force. These pronounced differences in heart force effects are presented as a basis for the difference in clinical results.

Electrocardiographic Findings After Alcohol Septal Ablation Therapy for Obstructive Hypertrophic Cardiomyopathy

Ablation of the septal myocardium with alcohol in patients with obstructive hypertrophic cardiomyopathy has been shown to improve symptoms, reduce ventricular outflow gradients, and improve cardiac function. 1,2 Acute electrocardiographic changes in a small group of patients have been reported. 3,4 Later changes have not been evaluated. This study presents 165 patients who underwent ablation therapy and preand post-procedure electrocardiography. ••• One hundred sixty-five consecutive patients treated for symptomatic obstructive hypertrophic cardiomyopathy with alcohol septal reduction therapy underwent pre- and post-procedure electrocardiography. All patients had symptoms refractory to medical therapy and resting gradients of 40 mm Hg or a dobutamineprovoked gradient 60 mm Hg using 5 to 20 g/kg/ min of dobutamine. Almost all patients were classified as having New York Heart Association class III or IV symptoms before the procedure. More details of the procedure have been reported in an earlier publication. 5 Resting 12-lead electrocardiograms were obtained before the procedure and then 2 to 286 days after ablation therapy. All electrocardiograms were reviewed independent of outcomes by 2 observers. Electrocardiograms were reviewed for Q waves, repolarization abnormalities, conduction abnormalities, QRS morphology, arrhythmias, left atrial enlargement, and left ventricular hypertrophy. Romhilt-Estes point system criteria were used to diagnose left ventricular hypertrophy. 6 The median follow-up period was 3 months (mean 60 days). Of the initial 190 patients, 25 (13%) had paced rhythms from prior placed pacemakers as a method of treatment for hypertrophic cardiomyopathy (which was unsuccessful) and were excluded from the study. The most common finding at baseline in the remaining 165 patients (Figure 1) was left ventricular hypertrophy (82 patients, 50%). Left atrial enlargement was also seen in 67 patients (41%) at baseline. Forty-nine patients (30%) were found to have significant Q waves at baseline. Most Q waves (30 of 49, 61%) were found in the septal precordial leads. Atrial fibrillation or atrial flutter was found in 8 patients (5%) before alcohol ablation. The most common conduction abnormality was left anterior fasicular block (17 patients, 10%). Six patients (4%) had right bundle branch block and 6 (4%) had left bundle branch block. First-degree atrioventricular block was noted in 9 patients (6%).

Outcomes of Black and White Hypertensive Individuals After 30 Years of Follow-Up

Outcomes of a 30-year follow-up for the participants of the Charleston Heart Study were studied with elevated blood pressure assessed using various classifications. The traditional categories of > or = 140/90 mmHg, > or = 160/95 mmHg and isolated systolic hypertension, as well as high normal and the four stages of high blood pressure were utilized in analyses. Prevalence rates of hypertension were, in general, higher among blacks compared to whites. Blacks had higher prevalence rates of hypertension and greater prevalence of high blood pressure at younger ages. Risk ratios were higher for black and white hypertensives than their normotensive counterparts. Blacks were found to have substantially higher population attributable risk proportions, particularly at the higher blood pressure categories. The results suggest that the standard clinical classifications of hypertension as related to mortality are appropriate for blacks and white.