Course of angina pectoris after an acute coronary event.

The course of postcoronary angina pectoris was examined in 555 men who had survived a first attack of myocardial infarction or unstable angina. Patients were aged less than 60 and were followed up yearly for up to 17 years. Only 25 (4.5%) had coronary artery bypass surgery. Most patients with angina were treated by nitrates alone. One year after infarction 24.1% of survivors (124/515) reported the presence of angina pectoris, and the proportions at five, 10, and 15 years were 29.9%, 30.4%, and 43.5% respectively. Seventeen years after the initial event 35.3% of the survivors had never reported postcoronary anginal symptoms. The patients who experienced anginal symptoms in the year after their coronary attack had a poorer long term survival than the group who were symptom free over the first year. These patients also had longer subsequent periods with angina, though in 41.7% angina resolved before death after a median of 2.9 years. Throughout follow up mortality during periods in which patients experienced angina was higher than in the symptom free periods. This long term follow up study of patients after a coronary event confirms that the presence or absence of angina may vary considerably over time in patients treated medically and that the presence of angina is associated with a poorer prognosis. These findings have important implications when assessing the effects of various treatment modalities on postcoronary angina, including coronary artery bypass surgery.     

Does stopping smoking delay onset of angina after infarction?

This study was designed to determine the relation between stopping smoking and angina after infarction in survivors of an acute coronary attack. The study population comprised 408 men aged under 60 who survived a first attack of unstable angina or myocardial infarction by 28 days and were smoking cigarettes at the time of their attack. These patients were followed up for an average of nine years. Three hundred and eighty four were alive at the one year follow up examination, when the presence or absence of angina together with habits of smoking were recorded. The prevalence of angina at one year was 19.5% in the 241 who had stopped smoking cigarettes compared with 32.2% in those who had continued (p less than 0.01). Six years later, however, the prevalence of angina after infarction was the same in the two groups. It is concluded that the onset of angina after infarction can be delayed by stopping smoking cigarettes but that this effect is not maintained in the long term.     

High-dosage isosorbide dinitrate therapy for angina.

We investigated the possibility that high dosages (480 mg/d) of isosorbide dinitrate might reduce the frequency of angina attacks in selected patients who had not responded to low dosages of the drug (40 mg/d), and that the patients could tolerate the high levels of medication and maintain their responsiveness over the long term. In the single-blind phases of this trial 24 patients with grade 3 stable angina pectoris were given a placebo for 4 weeks and then increasing doses of isosorbide dinitrate for a further 6 weeks. The 19 patients who both responded to and tolerated high doses of the drug kept taking 480 mg/d for an average of 1 year. The average weekly rate of angina attacks fell by 74%, from 6.05 in the placebo phase to 1.6 during long-term active treatment (p less than 0.01). Nitroglycerin consumption decreased accordingly. The patients'' assessments of their levels of activity and well-being and their angina thresholds showed improvement among most of them. The trend of angina frequency was stable in 12 cases, downward in 6 and upward in only 1 case. Exercise performance as evaluated by a graded treadmill test showed a small but nonsignificant improvement of 18%. It was concluded that some patients who do not respond to the antianginal action of low-dosage isosorbide dinitrate and cannot be given beta-blockers may respond to high dosages and tolerate them for over a year. Isosorbide dinitrate may be clinically useful in patients with coronary heart disease even though their exercise performance is not significantly improved.     

Prognosis of new and worsening angina pectoris.

The natural history of new and worsening angina pectoris was studied in 251 men aged under 70 years. Most were ambulant and all were referred by selected general practitioners to a special hospital clinic over two and a half years. Heart attacks developed in 39 patients, nine of whom died. Seventy-two per cent of the attacks occurred within six weeks of the onset or worsening of angina. Of the 212 patients who did not suffer myocardial infarction and who were clinically reviewed six months after their first attendance 66 had been pain free for the previous three months and 14 had experienced only infrequent attacks of angina. Of the 128 men aged under 65 years who were previously in employment 81% had returned to full-time work six months after their first attendance. A discriminant function analysis using many variables was made to develop a predictive index that would allow patients with new or worsening angina who were likely to develop serious cardiac complications to be identified. This did not prove possible, and the only predictive factor of significance was an increased cardiothoracic ratio. The syndrome of new and worsening angina has a low risk of early death, and many patients are symptom free six months later. In general, emergency coronary arteriography and surgery is not indicated.     

Respiratory poliomyelitis: a follow-up study.

Data from the medical records of 113 patients living in Manitoba who had contracted respiratory poliomyelitis between 1952 and 1959 were compared with information obtained from interviews with these patients in 1980. The study was designed to determine whether the patients'' respiratory function, mobility, ability to perform daily tasks, and employment, residential and marital status had changed between 1 year after the onset of polio and 1980. The patients'' dependence on mechanical aids and other people was also studied. More than half (56%) of the patients perceived their respiratory impairment to be the same as it was 1 year after the onset of polio, 27% perceived the impairment to be increased, and 17% perceived it to be decreased. There was an association between level of respiratory function, mobility and ability to perform daily tasks. The 69 patients who lived at home had better respiratory function, mobility and ability to perform daily tasks than the 24 patients who were assisted by a home care program and the 20 who lived in hospital. The latter group had the lowest levels of respiratory and functional ability.     

不同剂量氯吡格雷治疗急性ST段抬高心肌梗死的临床研究

目的:观察标准治疗基础上联合不同剂量氯吡格雷治疗急性ST段抬高心肌梗死的疗效及安全性。方法:2004年9月至2008年3月就诊我院的124例12小时以内发病的ST段抬高型心肌梗死患者,随机分为3组,3组均在入院后前3天给予阿司匹林300mg/d,此后给予阿司匹林100mg/d,A组常规不给予氯吡格雷治疗,B组给予氯吡格雷75mg/d,C组入院即刻给予氯吡格雷300mg,继之75 mg/d治疗,随访30天。观察溶栓血管再通率、梗死后心绞痛发作、心力衰竭事件及死亡、再发心肌梗死、或脑卒中的联合终点。结果:与A组相比,B组、C组患者溶栓成功率提高、梗死后心绞痛发作减少。P<0.05:进一步分析发现C组与B组差异无统计学意义,P>0.05。三组均无主要和次要出血事件发生,轻微出血发生率无统计学差异,P<0.05。结论:ST段抬高的急性心肌梗死患者在标准治疗的基础上早期加用氯吡格雷75 mg/d或先予300 mg负荷量,继之75 mg/d口服,均可提高溶栓成功率,降低梗死后心绞痛发生,而氯吡格雷负荷剂量组并不优于普通剂量组,且两组安全耐受性好。     

Clinical trends in stent treatment of simple and complex coronary disease

This is a retrospective analysis of a consecutive group of patients from a single medical center who underwent stent implantation. It describes 316 patients who constituted 53% of the angioplasty procedures carried out in a single year. The authors describe the complications and their 1-year follow-up. We aimed to study the short and long-term results of stenting in our centre in relation to multiple clinical and angiographic variables. During 1996, 316 consecutive patients were treated with stent implantation for a total of 381 coronary lesions. The pharmacological protocol methods of stent implantation and patient characteristics were used. Clinical variables were: age 59.1 3 10.7 years, diabetes mellitus 25.3%, hypertension 33.0% and angina pectoris 88.7% (unstable in 44.1%). Previous coronary surgery had been undergone by 9.2%. Multivessel disease was present in 56% of the patients. The indications for stenting were: primary 58.5%, suboptimal results 33.0% and threatened or acute occlusion 8.5%. Angiographic success was 98.9% and clinical success 96.8%. The major in-hospital complications were acute myocardial infarction (2.2%), acute revascularization (0.3%) and major bleeding (0.6%). All occurred within 24 h of revascularization. Repeated angiography was performed in 115 cases (30.2%) at 160.3 3 109.4 days after stent procedure for unstable angina (38.7%), stable angina (26.1%) and other causes (35.2%). The restenosis rate in those catheterized was 38.1%, with an overall clinical restenosis rate of 11.3% during the follow-up period. Restenosis was more prevalent among diabetic patients (17.9 vs 9.15%, P 3 0.02) and patients with prior balloon angioplasty (18.6 vs 9.75%, P 3 0.046). Clinical follow-up was available in 90.8% of the patients for 291 3 112 days. The actuarial survival at the end of the follow-up period was 93.8%. Death/myocardial infarction was associated with unstable angina pectoris (P 3 0.006), hypertension (P 3 0.001), smoking (P 3 0.046) and threatened or acute occlusion (P < 0.001). In the first year of extensive stent use, stenting is associated with high technical and clinical success rates. Long-term results after stent implantation are associated with the occurrence of acute or threatened occlusion, and the in-hospital complications diabetes mellitus and hypertension.     

Trasicor in Angina Pectoris: a Double-blind Trial

Eighteen patients entered a double-blind trial of the beta-adrenergic blocking drug Trasicor in the treatment of angina pectoris. Six patients had to be withdrawn from the trial when substitution of placebo for Trasicor caused severe exacerbation of angina attacks. In these cases the frequency and severity of angina attacks fell to a minimum when Trasicor was re-established. A further 10 patients were significantly improved by Trasicor. Two patients showed no significant improvement. No side-effects were observed in doses ranging up to 400 mg. daily.     

Controlled Comparison of Oral Twice-weekly and Oral Daily Isoniazid plus PAS in Newly Diagnosed Pulmonary Tuberculosis

A controlled clinical trial was undertaken in 247 patients with newly diagnosed pulmonary tuberculosis to assess the relative efficacies of a fully supervised twice-weekly oral regimen of isoniazid plus PAS (para-aminosalicylic acid) and a standard self-administered daily regimen of the same drugs following an initial intensive phase of two weeks of daily streptomycin, PAS, and isoniazid. Among patients who had isoniazid-sensitive cultures initially and who attended the clinic regularly the numbers with a favourable bacteriological response at the end of the year of chemotherapy were 79 (88%) out of 90 for the twice-weekly regimen and 72 (87%) out of 83 for the daily regimen; the numbers of patients with considerable radiographic improvement were 54 (60%) and 53 (64%) respectively. Complaints of vomiting or diarrhoea that did not require a reduction of the PAS dosage were made on one or two occasions by 23(21%) out of 109 twice-weekly and 25 (23%) out of 108 daily patients, and on at least three occasions by 4 (4%) and 12 (11%) respectively. Finally, all five patients who had chemotherapy changed on account of hypersensitivity to PAS had been receiving the daily regimen, as also had one patient who died of agranulocytosis.     

Double-blind Evaluation of Verapamil,Propranolol, and Isosorbide Dinitrate against a Placebo in the Treatment of Angina Pectoris

In the treatment of angina pectoris a double-blind evaluation of verapamil (Cordilox) at two dose levels—namely, 80 mg thrice daily and 120 mg thrice daily—propranolol (Inderal) 100 mg thrice daily, and isosorbide dinitrate (Vascardin) 20 mg thrice daily has been made against a placebo. The assessment was based on relief from daily attacks of angina on effort and the response to a whole-body exercise test. We can find no statistically significant difference between the effects of verapamil (120 mg three times a day) and propranolol (100 mg three times a day) in the treatment of angina of effort. Both of these preparations are more effective than a placebo both in the reduction of daily attacks (P < 0·01) and in the prolongation of exercise test (P < 0·05). Isosorbide dinitrate (20 mg three times a day) appears to be no more effective than a placebo in the treatment of angina on effort, but 14 out of 32 patients experienced headache of such severity that even when the dose was reduced to 10 mg thrice daily this drug therapy had to be withdrawn. Both propranolol (100 mg three times a day) and verapamil (120 mg three times a day) had a significant lowering effect on the diastolic blood pressure as measured with the patient standing (P < 0·01).     

Predictors of Operative Mortality for Coronary Bypass Grafting in Patients with Ischemic Heart Disease

Predictors for operative mortality (OM) were studied in 172 consecutive patients (pts) undergoing coronary artery grafts (CAG) for angina pectoris.Seventy eight pts had Class IV angina; of the 147 patients given propranolol, 41 were gradually withdrawn from propranolol and finally discontinued 24 hours before surgery, and 106 were abruptly withdrawn from propranolol 24 hours before CAG; 20 pts had left main coronary disease; 156 pts had cardiopulmonary bypass (CPB) time shorter than 20 minutes, and 16 pts had a CPB longer than 120 minutes.The operative mortality was 5.2% (9/172) for the entire group. Class IV angina (OM 7%), abrupt propranolol withdrawal (OM 6.6%), left main coronary artery disease (OM 25%), and CPB longer than 120 minutes (OM 50%), all significantly increased OM. These variables were interdependent, however, as many pts belonged to several predictor categories, combinations of predictors were examined, in order to more accurately predict the risk of individual pts. The combination of left main coronary artery disease and CPB longer than 120 minutes; and Class IV angina and CPB longer than 120 minutes were significantly associated with higher operative mortality.We conclude that Class IV angina, abrupt propranolol withdrawal, left main coronary artery disease and prolonged CPB are potent, interdependent predictors of OM in pts undergoing CAG. Consideration of these predictors, alone and in combination, allows effective prediction of OM for CAG in patients with stable angina pectoris.     

Revascularization of the Entire Heart by Internal Mammary Artery Implantation,Epicardiectomy and Free Omental Graft

The indications for and the contraindications to total cardiac revascularization are described on the basis of the author''s experience. The combined operation of internal mammary artery implant, epicardiectomy and free omental graft was performed on 62 patients. Of 45 who did not have angina at rest without exciting cause (Grade I) 39 showed improvement; 32 returned to full-time work, 18 of whom had been unable to work before operation. There were two operative deaths. Among the 17 patients who were “bed-chair cripples” (angina at rest without cause-Grade II), there was a 24% operative mortality (four deaths), but 76% of the survivors had marked improvement. Only one of this group had been working full-time preoperatively; now nine are working full-time.     

Exertional gastro-oesophageal reflux: a mechanism for symptoms in patients with angina pectoris and normal coronary angiograms.

During 24 hour oesophageal pH monitoring 52 patients who had angina pectoris and normal coronary angiograms underwent exercise testing, as far as their symptoms allowed, on a treadmill to determine whether gastro-oesophageal reflux occurred during exertion. In 11 patients the 24 hour oesophageal pH score was abnormally high; 10 of these showed exertional gastro-oesophageal reflux, and in nine this was associated with their usual chest pain. A further 13 patients had a normal 24 hour pH score but had exertional reflux coincident with chest pain during exercise testing. The mean lower oesophageal sphincter pressure in both of these groups of patients was appreciably lower than that in 28 patients who had a normal 24 hour pH score and no exertional reflux. These findings suggest that exertional gastro-oesophageal reflux accounts for the symptoms of a large proportion of patients who have angina pectoris and normal coronary angiograms and that oesophageal pH monitoring during exercise testing on a treadmill enables this group of patients to be identified.     

Myocardial ischaemia in patients with frequent angina pectoris.

One hundred patients with angina pectoris underwent 16-point electrocardiographic (ECG) mapping of the left hemithorax during a standardised exercise test. Forty-five patients had maximum ST-segment depression at position V5, while 35 had no ECG signs of ischaemia at this position. In 20 V5 was on the edge of the precordial area, which showed less severe ST-depression than the central positions. An Oxford ECG recorder and highspeed analyser were modified and used in 50 of the patients with daily angina for recording ST-segment changes over 24 hours. Serial 24-hour ambulatory recordings from the edge of the precordial area of ischaemia identified during exercise detected a mean of only 14 +/- SD 3% of the episodes of ST-segment changes recorded from the centre of the same area. Only 16 +/- 2% of the episodes detected by ECG were accompanied by chest pain. More episodes occurred between 4 am and 6 am than at any other time during the night. This study shows the importance of recording ECG evidence of ischaemia from the precordial position showing maximum changes during exercise. ECG evidence of ischaemia occurs more frequently than anginal pain. These objective measurements add important information to the frequency of chest pain reported by patients with ischaemic heart disease.     

负荷剂量氯吡格雷治疗急性ST段抬高心肌梗死

目的:观察标准治疗基础上联合负荷剂量氯吡格雷治疗急性ST段抬高型心肌梗死(STEMI)的疗效及安全性。方法:106例12小时以内发病的ST段抬高型心肌梗死患者随机分为2组,2组均在入院后前3天给予阿司匹林300 mg.d~(-1),此后给予阿司匹林100 mg.d~(-1),A组不给予氯吡格雷治疗,B组入院即刻给予氯吡格雷300 mg,继之75 mg.d~(-1)治疗,平均随访30天。观察溶栓血管再通率、梗死后心绞痛发作、心力衰竭事件及死亡、再发心肌梗死或脑卒中的联合终点。结果:与A组相比,B组患者溶栓血管再通率显著提高、梗死后心绞痛发作明显减少;而在心力衰竭事件及死亡、再发心肌梗死、或脑卒中的联合终点的比较上差异无显著性意义。2组均无主要和次要出血事件发生,轻微出血发生率无统计学差异。结论:急性ST段抬高的急性心肌梗死患者,不论是否接受择期的冠脉介入治疗(PCI),在标准治疗的基础上早期加用氯吡格雷300mg负荷量,继之75 mg.d~(-1)口服,可显著提高溶栓成功率、降低梗死后心绞痛发作,且安全耐受性好。     

Vitamin E in angina pectoris

The claim that the symptoms of angina pectoris can usually be relieved by large doses of vitamin E has been reinvestigated by means of a randomized double-blind trial. The trial lasted nine weeks and consisted of two parts. One part was conducted as a regular double-blind trial involving 40 patients, half of whom received 3200 IU of vitamin E daily, while an equal number received an indistinguishable placebo. The second part of the trial involved 15 patients who were already taking a regular daily dose of between 400 and 2400 IU of vitamin E. Eight patients were assigned the same (or a larger) dose of vitamin E, while seven received placebo. Neither part of the trial yielded statistically convincing evidence that vitamin E is of value in the treatment of angina, but a small beneficial effect could not be ruled out. Taken in conjunction with the positive (but statistically non-significant) results obtained in the only other double-blind trial of vitamin E ever carried out on angina, and the encouraging results reported by other investigators in the treatment of intermittent claudication, it is suggested that further double-blind trials are justified.     

Tamoxifen versus aminoglutethimide in advanced breast carcinoma: a randomized cross-over trial.

Altogether 117 patients with advanced breast cancer were treated with either tamoxifen 10 mg by mouth twice daily or aminoglutethimide 250 mg by mouth four times daily with hydrocortisone 20 mg twice daily in a randomised cross-over trial in which patients who failed to respond to the first treatment or relapsed while receiving it were switched to the other. Eighteen (30%) out of 60 patients initially treated with tamoxifen achieved an objective response and 11 (18%) showed stable disease. Seventeen (30%) out of 57 patients treated initially with aminoglutethimide achieved an objective response and 13 (23%) achieved stable disease. Objective responses in bone metastases were achieved more commonly with aminoglutethimide (11 patients (35%)) than with tamoxifen (five (17%)). The predicted median duration of response for tamoxifen was 15 months and for aminoglutethimide over 15 months (no significant difference). Five (15%) out of 34 patients who failed to respond to tamoxifen and four out of six patients who relapsed after responding to tamoxifen subsequently responded to aminoglutethimide. In contrast, only two (6%) out of 31 patients who failed to respond to aminoglutethimide and none out of four patients who relapsed while receiving aminoglutethimide subsequently responded to tamoxifen. The main side effects occurring in the 97 patients who received aminoglutethimide as first- or second-line treatment were lethargy and drowsiness (36 patients) and rash (29); seven patients had to stop treatment because of side effects. In contrast, side effects were rare and mild with tamoxifen and no patient had to stop treatment because of them. Both tamoxifen and aminoglutethimide appeared from this study to be equally effective in the medical endocrine treatment of advanced breast cancer.     

Prognosis of angina with and without a diagnosis: 11 year follow up in the Whitehall II prospective cohort study

Objective To investigate the prognosis of angina among people with and without diagnosis by a doctor and an abnormal cardiovascular test result.Design Prospective cohort study with a median follow up of 11 years.Setting 20 civil service departments originally located in London.Participants 10 308 civil servants aged 35-55 years at baseline.Main outcome measures Recurrent reports of angina; quality of life (SF-36 physical functioning); non-fatal myocardial infarction; death from any cause (n = 344).Results 1158 (11.4%) participants developed angina, and 813 (70%) had no evidence of diagnosis by a doctor at the time of the initial report. Participants without a diagnosis had an increased risk of impaired physical functioning (age and sex adjusted odds ratio of 2.36 (95% confidence interval 1.91 to 2.90)) compared with those who had neither angina nor myocardial infarction throughout follow up. Among reported cases of angina without a diagnosis, the 15.5% with an abnormality on a study electrocardiogram had an increased risk of death (hazard ratio 2.37 (1.16 to 4.87)). These effects were similar in magnitude to those in participants with a diagnosis of angina.Conclusion Undiagnosed angina was common and had an adverse impact on prognosis comparable to that of diagnosed angina, particularly among people with electrocardiographic abnormalities. Efforts to improve prognosis among people with angina should take account of this submerged clinical iceberg.     

Ischaemic Heart Disease: A Secondary Prevention Trial Using Clofibrate

A trial is reported of the effects of giving clofibrate to prevent progression of pre-existing ischaemic heart disease. There were two groups randomly distributed between clofibrate (350 patients) and placebo (367 patients) regimens. The trial lasted about six years and was conducted in 19 hospitals in Scotland. The criteria of acceptance into the trial were precise and were monitored by one observer. The standards of diagnosis of events were defined and all protocols and electrocardiograms were read blind by one observer.Three categories of patients were admissible to the trial: (1) patients with one myocardial infarction (W.H.O. E.C.G. criteria) between 8 and 16 weeks before the start of the trial; (2) patients with angina of a duration of 3 to 24 months, provided their E.C.G. showed signs of myocardial ischaemia at rest or after exercise; and (3) patients with one recent myocardial infarction and pre-existing angina as defined above.There were fewer deaths in patients with angina (categories 2 and 3 above) treated with clofibrate than in those on placebo. The mortality in the former group was reduced by 62%, and this is a statistically significant difference. Clofibrate did not have any statistically significant effect in reducing the rate of non-fatal infarction in patients with angina or in those with myocardial infarction and pre-existing angina, though a beneficial trend was evident when both subgroups were combined (a 44% reduction compared with the placebo group). There was a significant reduction in all events (fatal and non-fatal) in patients with angina (“all anginas”) in the clofibrate-treated group; the rate was reduced by 53%.Clofibrate did not alter the overall mortality or morbidity rates in patients admitted to the trial with recent myocardial infarction without preceding angina of more than three months'' duration. In one subgroup there was a statistically significant adverse effect in the clofibrate-treated group. The lack of any overall effect in patients with myocardial infarction might be related to the unexpectedly low mortality rate (2·97%) in the placebo group; it is usually in the region of 4-9% per annum after first myocardial infarction.In patients categorized as “all anginas” there was significant reduction in events whether the initial serum cholesterol level was high (greater than 260 mg/100 ml) or normal. Clofibrate seemed to have a small but not significant beneficial effect in patients with myocardial infarction with initially high serum cholesterol levels, but was of no value in those with initially normal serum cholesterol levels. There was no significant relationship between the response or lack of response of serum cholesterol to clofibrate and the incidence of events either in patients with angina or in those with infarction.The main conclusion of this trial is that clofibrate had a beneficial effect in reducing mortality and, to a lesser extent, morbidity in patients who presented with angina (“all anginas”). This effect was independent of initial serum cholesterol levels or the extent to which serum cholesterol was lowered. The drug had no significant overall effect on prognosis in patients with myocardial infarction alone.     

Urinary incontinence in the community--analysis of a MORI poll.

OBJECTIVES--To investigate the prevalence of urinary incontinence among people living at home, their responses to it, and its emotional and social effects. DESIGN--Random sample of 4007 adults interviewed in their own homes. SETTING--Random sample of 178 constituency sampling points throughout Great Britain. SUBJECTS--1883 men, 2124 women aged 30 and over. MAIN OUTCOME MEASURES--Responses to questionnaire. RESULTS--6.6% (125) men and 14.0% (297) women had been incontinent of urine at some time--2.8% (52) men and 7.5% (159) women in the previous two months and 61% (124) of these for more than four years. 52% (108) had consulted their general practitioner at the onset of incontinence and a further 31% (65) later. Doctors commonly took a urine sample (163, 54%), referred the patient to a specialist (127, 42%), and prescribed tablets (109, 36%); only 22% (66) carried out an abdominal, rectal, or vaginal examination. Patients were not embarrassed in seeing their doctor and most thought they were treated sympathetically. 60% (265) of all those affected were concerned or worried about their incontinence, and in almost half incontinence limited their daily social activities. CONCLUSION--More people with incontinence seem to be consulting their doctors about it than has been found in previous studies, but the procedures carried out by general practitioners still seem to be suboptimal. Urinary incontinence has a profound effect on the day to day lives of most of those who suffer from it.