Decline in ischaemic heart disease in Iceland and change in risk factor levels.

OBJECTIVE--To monitor trends in mortality and morbidity due to ischaemic heart disease and compare these with observed levels of risk factors from population surveys. DESIGN--Analysis of trends in death rates from ischaemic heart disease in Iceland compared with expected rates computed from population surveys. Risk factor levels together with beta factors obtained from Cox''s regression analysis were used to compute expected death rates. Trends in morbidity due to acute myocardial infarction were assessed and secular trends in dietary consumption compared with trends in cholesterol concentrations. SETTING--Reykjavik, Iceland (total population 250,000; over half the population live in Reykjavik). SUBJECTS--12,814 randomly selected residents in the Reykjavik area aged 45-64 (6623 men, 6191 women; 72% and 80% of those invited). MAIN OUTCOME MEASURES--Age adjusted rates of myocardial infarction and deaths from ischaemic heart disease. Expected risk from risk factor levels (smoking, total serum cholesterol concentration, systolic blood pressure) at each unique survey visit. RESULTS--Mortality from ischaemic heart disease has decreased by 17-18% since 1970. During 1981-6 the myocardial infarction attack rate in men under 75 decreased by 23%. A decrease occurred in the level of all three major risk factors after 1968. The fall in the serum cholesterol concentration coincided with a reduction in consumption of dairy fat and margarine. The calculated reduction in risk for the age group 45-64 was about 35%, which was closely similar to the observed decrease in mortality due to ischaemic heart disease in that age group. CONCLUSION--The reduction in mortality from ischaemic heart disease was substantially due to a decreased incidence of myocardial infarction and could be attributed largely to the reduction in risk factors.     

Improved prognosis since 1969 of myocardial infarction treated in a coronary care unit: lack of relation with changes in severity.

OBJECTIVE--To study changes from 1969 to 1983 in the prognosis of patients with acute myocardial infarction treated in a coronary care unit. DESIGN--Mortality follow up of all patients with definite acute myocardial infarction. SETTING--The coronary care unit of the Royal Melbourne Hospital, a tertiary referral centre. SUBJECTS--4253 Patients (3366 men, 887 women) admitted from 1969 to 1983. MAIN OUTCOME MEASURE--Mortality recorded at discharge from hospital and 12 months after admission. RESULTS--Details of clinical findings, history, electrocardiograms, arrhythmias, and radiological findings were recorded on admission. Mean ages were 63 for women and 57 for men, and women had haemodynamically more severe infarcts than men. In the later years patients were older and had less severe infarcts. Overall, hospital mortality in men was 16.7% in 1969-73 and 8.5% in 1979-83 and declined in all grades of the Norris and Killip infarct severity indices compared with a constant 19.2% in women. Even after adjustment for age and severity by logistic regression, hospital mortality fell in men by an average of 8% (95% confidence interval 4% to 11%) a year but remained constant in women. By 1983 male mortality was 60% that of women of similar age and comparable severity of infarction. Mortality of hospital survivors at 12 months declined by 7% (4% to 9%) a year in both sexes, even after adjustment for age and severity, with a male to female mortality ratio of about 0.8. New indices were derived to predict mortality in hospital and at 12 months. CONCLUSION--The observed declines in mortality cannot be explained by changes in severity of infarction or in prognostic characteristics of patients.     

Incubation period of coronary heart disease.

Serum cholesterol concentrations and blood pressure were measured during 1958-64 among men aged 40-59 who took part in the Seven Countries Study. In the present study these measurements were related to the national mortality from coronary heart disease in the periods 1959-61, 1964-6, 1969-71, and 1974-6. The correlations increased with time (r = +0.86, 0.90, 0.93, and 0.96 respectively for serum cholesterol concentration and r = +0.48, 0.56, 0.57, and 0.64 for systolic blood pressure), suggesting that the "incubation period" between exposure to major coronary risk factors and the maximum effects on mortality may be 10 years or more.     

Hospital admission for acute pancreatitis in an English population, 1963-98: database study of incidence and mortality

Objectives To investigate trends in the incidence of acute pancreatitis resulting in admission to hospital, and mortality after admission, from 1963 to 1998.Design Analysis of hospital inpatient statistics for acute pancreatitis, linked to data from death certificates.Setting Southern England.Subjects 5312 people admitted to hospital with acute pancreatitis.Main outcome measures Incidence rates for admission to hospital, case fatality rates at 0-29 and 30-364 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission.Results The incidence of acute pancreatitis with admission to hospital increased from 1963-98: age standardised incidence rates were 4.9 per 100 000 population in 1963-74, 7.7 in 1975-86, and 9.8 in 1987-98. Age standardised case fatality rates within 30 days of admission were 14.2% in 1963-74, 7.6% in 1975-86, and 6.7% in 1987-98. From 1975-98, standardised mortality ratios at 30 days were 30 in men and 31 in women (compared with the general population of equivalent age in the same period = 1), and they remained significantly increased until month 5 for men and month 6 for women.Conclusions Incidence rates for acute pancreatitis with admission to hospital rose in both men and women from 1963 to 1998, particularly among younger age groups. This probably reflects, at least in part, an increase in alcoholic pancreatitis. Mortality after admission has not declined since the 1970s. This presumably reflects the fact that no major innovations in the treatment of acute pancreatitis have been introduced. Pancreatitis remains a disease with a poor prognosis during the acute phase.     

Epidemiology of the Hong Kong/68 Variant of Influenza A2 in Britain

Two influenza epidemics in Britain in 1968-9 and 1969-70, were due to the Hong Kong/68 variant of influenza A2 virus. The first epidemic was prolonged with low morbidity and mortality rates; the second was sharp with high rates. The difference between total morbidity and mortality in the two epidemics, however, was less than it appeared to be—the estimated excess morbidity and mortality due to all causes in 1969-70 was only about 50% greater than in 1968-9.Antibody studies showed that about one-quarter of two groups of adults investigated were infected in the first epidemic and about one-third in the second. After the two epidemics about one-third still had no antibody to the A2/Hong Kong/68 virus.     

Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients

ObjectiveTo determine the effects of antiplatelet therapy among patients at high risk of occlusive vascular events.DesignCollaborative meta-analyses (systematic overviews).ResultsOverall, among these high risk patients, allocation to antiplatelet therapy reduced the combined outcome of any serious vascular event by about one quarter; non-fatal myocardial infarction was reduced by one third, non-fatal stroke by one quarter, and vascular mortality by one sixth (with no apparent adverse effect on other deaths). Absolute reductions in the risk of having a serious vascular event were 36 (SE 5) per 1000 treated for two years among patients with previous myocardial infarction; 38 (5) per 1000 patients treated for one month among patients with acute myocardial infarction; 36 (6) per 1000 treated for two years among those with previous stroke or transient ischaemic attack; 9 (3) per 1000 treated for three weeks among those with acute stroke; and 22 (3) per 1000 treated for two years among other high risk patients (with separately significant results for those with stable angina (P=0.0005), peripheral arterial disease (P=0.004), and atrial fibrillation (P=0.01)). In each of these high risk categories, the absolute benefits substantially outweighed the absolute risks of major extracranial bleeding. Aspirin was the most widely studied antiplatelet drug, with doses of 75-150 mg daily at least as effective as higher daily doses. The effects of doses lower than 75 mg daily were less certain. Clopidogrel reduced serious vascular events by 10% (4%) compared with aspirin, which was similar to the 12% (7%) reduction observed with its analogue ticlopidine. Addition of dipyridamole to aspirin produced no significant further reduction in vascular events compared with aspirin alone. Among patients at high risk of immediate coronary occlusion, short term addition of an intravenous glycoprotein IIb/IIIa antagonist to aspirin prevented a further 20 (4) vascular events per 1000 (P<0.0001) but caused 23 major (but rarely fatal) extracranial bleeds per 1000.ConclusionsAspirin (or another oral antiplatelet drug) is protective in most types of patient at increased risk of occlusive vascular events, including those with an acute myocardial infarction or ischaemic stroke, unstable or stable angina, previous myocardial infarction, stroke or cerebral ischaemia, peripheral arterial disease, or atrial fibrillation. Low dose aspirin (75-150 mg daily) is an effective antiplatelet regimen for long term use, but in acute settings an initial loading dose of at least 150 mg aspirin may be required. Adding a second antiplatelet drug to aspirin may produce additional benefits in some clinical circumstances, but more research into this strategy is needed.

What is already known on this topic

Antiplatelet therapy is effective for short term treatment of patients with suspected acute myocardial infarction and unstable anginaLong term treatment is beneficial for patients who have had a myocardial infarction, stroke, or transient ischaemic attackDaily aspirin doses of 75-325 mg are effective

What this study adds

Antiplatelet therapy protects against vascular events among patients with stable angina, intermittent claudication, and (if oral anticoagulants are unsuitable) atrial fibrillationAntiplatelet therapy can be started promptly during acute presumed ischaemic stroke and continued long termDaily aspirin doses of 75-150 mg seem to be as effective as higher doses for long term treatments (and clopidrogel is an appropriate alternative for patients with a contraindication to aspirin)Short term addition of a glycoprotein IIb/IIIa antagonist to aspirin prevents vascular events in patients having percutaneous coronary intervention and those with unstable angina but causes increased bleeding     

One year's treatment with propranolol after myocardial infarction: preliminary report of Norwegian multicentre trial.

A prospective, randomised, double-blind study was performed to compare the effects of propranolol and placebo on sudden cardiac death in a high-risk group of patients who survived acute myocardial infarction. Altogether 4929 patients with definite acute myocardial infarction were screened for inclusion: 574 (11.6%) died before randomisation, and 3795 (77%) were excluded. Five hundred and sixty patients aged 35 to 70 years were stratified into two risk groups and randomly assigned treatment with propranolol 40 mg four times a day or placebo. Treatment started four to six days after the infarction. By one year there had been 11 sudden deaths in the propranolol group and 23 in the placebo group (p less than 0.038, two-tailed test analysed according to the "intention-to-treat" principle). Altogether there were 25 deaths in the propranolol group and 37 in the placebo group (P less than 0.12), with 16 and 21 non-fatal reinfarctions respectively. A quarter of the patients were withdrawn from each group. Withdrawal because of heart failure during the first two weeks of treatment was significantly more common among propranolol-treated patients than among the controls, but thereafter the withdrawal rate was the same. The significant reduction in sudden death was comparable with that after alprenolol, practolol, and timolol, which suggests that the mechanism of prevention is beta-blockade rather than any other pharmacological property of the individual drugs.     

Reduced risk of death at 28 days in patients taking a beta blocker before admission to hospital with myocardial infarction.

OBJECTIVE--To see whether patients taking an oral beta blocker at the time of admission to hospital with myocardial infarction have a reduced risk of death at 28 days. DESIGN--Retrospective analysis of data collected on patients admitted over four years. SETTING--Community based study. PATIENTS--2430 Consecutive patients living in the Perth statistical division admitted to hospital with myocardial infarction during 1984-7. MAIN OUTCOME MEASURE--Survival at 28 days among patients taking a beta blocker at onset of myocardial infarction. RESULTS--Patients were grouped into those who were and were not taking a beta blocker at the time of admission. Though patients taking a beta blocker were older and more likely to have a history of myocardial infarction, angina, or hypertension, the overall mortality at 28 days was similar in the two groups. A logistic regression model used to adjust for factors predictive of cardiac death at 28 days confirmed that patients taking a beta blocker at the time of admission had a significantly reduced risk of death (relative risk 0.50; 95% confidence interval 0.34 to 0.76). Though the incidence of fatal ventricular fibrillation was similar in the two groups, mean peak creatine kinase activity was significantly lower in the beta blocker group. CONCLUSIONS--These data support the value of long term use of beta blockers in patients at risk of myocardial infarction. They suggest that patients taking these agents before admission to hospital with myocardial infarction have a significant survival advantage at 28 days, which may be due to a reduction in infarct size.     

Basic patterns in the epidemic process of measles under conditions of massive immunization]

Observations over the measles epidemic process in Leningrad showed that the sporadic morbidity level reached in 1974--4.1 per 100 000 residents; however periodic elevation and decline of morbidity and tis seasonal variations persisted. A rise of morbidity in 1972--1973, and by preliminary data--in 1975, occurred on account of the older age groups. There was revealed no dependence of the disease incidence among the persons vaccinated on the time lapse after their vaccination. Individual batches of live measles vaccine issued in 1963--1969 were not up to the standard, this serving as one of the cases of the occurence of group incidence of the infection in some foci.     

Demography of Amboseli baboons, 1963–1983

Repeated censuses of a population of yellow baboons (Papio cynocephalus) in Amboseli National Park, Kenya, revealed a decrease from over 2,500 animals in 1963–1964 to 123 individuals in 1979, or from a density of about 73 to 1.8 baboons per km² over a 15-year period. Median group size decreased from 43 in 1964 to 27 in 1979. The largest and smallest groups declined the most; groups near the median have maintained fairly stable size and age distributions. The population seemed to have stabilized by 1983 at approximately 150 animals in six groups (median group size 28; density 2.2/km²). Although baboon population and group size appeared to be stable during 1963–1964, the age distribution and demographic parameters (age-specific mortality and natality for one social group) during that year indicate that the population decline had already started. The rate of population decline was greatest in the 1964–1969 period and remained appreciable during the next 5 years. The decline of the baboon population was paralleled by that of other Amboseli savannah woodland mammalian species and took place during a period of very high mortality of fever trees (Acacia xanthophloea) and extensive invasion of the area by halophytes, a transition brought on by rising ground water and consequent elevation of the soil salinity zone. In this and several other primate populations, mortality of infants and juveniles appears to be the demographic variable most sensitive to environmental change.     

Oral contraceptive use in older women and fatal myocardial infarction.

A previous study of women who had died from myocardial infarction and of a control group of women matched with them for age suggested a fivefold increase in the risk of death from myocardial infarction among users of oral contraceptive aged 40-44 years compared with women not using such preparations. Only a small proportion of women in the infarction and control groups had used oral contraceptives, however, so the margin of error was wide. We therefore investigated a further 54 women in this age group who died from myocardial infarction and compared their oral contraceptive histories with those of age-matched, living controls. Combination of the findings from the present investigation with the previous results have enabled a revised estimate of a threefold increase in risk to be made. Although this risk estimate is similar to that previously shown for a younger age group, the total mortality attributable to complications associated with the use of oral contraceptives remained considerably greater among women over the age of 40.     

Increasing incidence and mortality from myocardial infarction in Stockholm county.

A study was undertaken to examine trends in the incidence and mortality of myocardial infarction in Sweden. All cases (n = 19908) of myocardial infarction diagnosed in the population of Stockholm county during 1974-80 were identified by means of the cause of death register and the inpatient care register. Information on patients at risk was obtained from the civil registration system. The relative risk of developing, or dying of, myocardial infarction in one specific year, compared with the average for the whole period, was taken as the basis for describing the trends. For men in Stockholm the incidence as well as the mortality was appreciably increased; the annual increase in incidence was 3% and in mortality 4%. There were no signs of decreasing lethality. For women there was an appreciable increase in incidence; for mortality the result was less specific but was compatible with an increase. The observed increases in incidence and mortality appeared to be real and were probably not due to an increasing tendency for patients to seek hospital treatment or for doctors to make the diagnosis. The reason for the increase is unknown.     

Effects of intravenous magnesium in suspected acute myocardial infarction: overview of randomised trials.

OBJECTIVE--To investigate the effect of intravenous magnesium on mortality in suspected acute myocardial infarction. DESIGN--Systematic overview of all available randomised trials in which patients were allocated to receive either intravenous magnesium or otherwise similar treatment without magnesium. SETTING--Coronary care units of several hospitals. PATIENTS--1301 patients in seven randomised trials. MAIN OUTCOME MEASURE--Short term mortality. RESULTS--Considering the seven trials collectively there were 25 (3.8%) deaths among 657 patients allocated to receive magnesium and 53 (8.2%) deaths among 644 patients allocated control, generally during hospital follow up. This represents a 55% reduction in the odds of death (p less than 0.001) with 95% confidence intervals ranging from about one third to about two thirds. 70 of 648 patients allocated magnesium compared with 109 of 641 controls had serious ventricular arrhythmias, suggesting that magnesium reduces the incidence, though the definition varied among trials. Other adverse effects were rare in the limited number of patients for whom this data were available. CONCLUSION--Despite the limited number of patients randomised this overview suggests that intravenous magnesium therapy may reduce mortality in patients with acute myocardial infarction. Further large scale trials to confirm (or refute) these findings are desirable.     

Epidemiologic analysis morbidity with meningococcal infections in the USSR]

The authors present the analysis of the incidence of epidemic cerebrospinal meningitis in the USSR from 1937 to 1974, and of meningococcus infection from 1965 to 1974. A rise of the meningococcus infection incidence from 1969 to 1974 was recorded 28 years after the elevation of 1940-1942 and was 1.5 times below this latter rise. The rise in 1969-1974 was characterized by marked signs peculiar to the infection with the droplet transmission mechanism; among those who contracted the disease prevalence was seen among children aged under 14 years (63-72%). A marked affection of juveniles was noted. Three types of the dynamic of the meningococcus infection incidence in the republics located in different climatic-geographical zones of the USSR were noted: slow, gradual increase of the level, interrupted and explosive. Such character was determined in the dynamics of the seasonal elevations of morbidity. Antiepidemic measures including a complex of nonspecific measures could not be assessed as sufficiently effective. This finds reflection in the natural course of the epidemic process of the meningococcus infection which remains uncontrolled. From the patients with generalized form of the disease meningococci of group A were isolated in 80-100% of cases, from the number of those typed. The group-specific reference of the nasopharyngeal strains depended on the epidemic situation: strains of serological group A prevailed at the period of the morbidity elevation, and other serological groups (particularly of C and B) increased at its decline.     

Effect of intravenous infusion of insulin in diabetics with acute myocardial infarction.

Diabetes mellitus is associated with a high mortality after myocardial infarction. To see whether this may be decreased by improved diabetic control the effect of an insulin infusion regimen was studied in patients with acute myocardial infarction. From April 1982 to April 1983, 33 diabetics were admitted with acute myocardial infarction. Those being treated with diet alone or oral hypoglycaemic drugs continued with this unless control was poor, when they were changed to a "sliding scale" regimen of subcutaneous insulin injections thrice daily. Those already receiving insulin were maintained on thrice daily subcutaneous injections. From April 1983 to April 1984, 29 diabetics had acute myocardial infarction. Those receiving treatment with oral hypoglycaemic drugs or insulin were changed to continuous intravenous infusion of insulin, the aim being to maintain the blood glucose concentration at 4-7 mmol/I (72-126 mg/100 ml). Those being treated with diet alone continued with this if blood glucose concentrations were acceptable. Total mortality fell from 42% in the first year to 17% in the second (p less than 0.05). Over the same period mortality among non-diabetic patients with myocardial infarction did not change significantly. There was a significant fall in cardiac arrhythmias (expressed as the percentage of patients in whom arrhythmias were recorded) from 42% to 17% (p less than 0.05). The most significant fall in the incidence of complications occurred in those who had been receiving oral hypoglycaemic drugs on entry to the study (87% to 50%, p less than 0.05).     

Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus,Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group.

OBJECTIVES: To test the hypothesis that intensive metabolic treatment with insulin-glucose infusion followed by multidose insulin treatment in patients with diabetes mellitus and acute myocardial infarction improves the prognosis. DESIGN: Patients with diabetes mellitus and acute myocardial infarction were randomly allocated standard treatment plus insulin-glucose infusion for at least 24 hours followed by multidose insulin treatment or standard treatment (controls). SUBJECTS: 620 patients were recruited, of whom 306 received intensive insulin treatment and 314 served as controls. MAIN OUTCOME MEASURE: Long term all cause mortality. RESULTS: The mean (range) follow up was 3.4 (1.6-5.6) years. There were 102 (33%) deaths in the treatment group compared with 138 (44%) deaths in the control group (relative risk (95% confidence interval) 0.72 (0.55 to 0.92); P = 0.011). The effect was most pronounced among the predefined group that included 272 patients without previous insulin treatment and at a low cardiovascular risk (0.49 (0.30 to 0.80); P = 0.004). CONCLUSION: Insulin-glucose infusion followed by intensive subcutaneous insulin in diabetic patients with acute myocardial infarction improves long term survival, and the effect seen at one year continues for at least 3.5 years, with an absolute reduction in mortality of 11%. This means that one life was saved for nine treated patients. The effect was most apparent in patients who had not previously received insulin treatment and who were at a low cardiovascular risk.     

Influence on clinical practice of routine intra-partum fetal monitoring.

An attempt has been made to monitor by continuous fetal heart rate according all women admitted in labour. Altogether 85% of the 1070 patients delivered at one hospital were monitored in 1973 and 92% in 1974. Perinatal mortality fell significantly from levels in preceding years to 15-8 and 11-7 per 1000 births, respectively, in 1973 and 1974. The fall was primarily due to the elimination of intra-partum stillbirths and a significant reduction in neonatal mortality. The incidence of caesarean sections also fell from 9-7% in 1973 to 5-8% in 1974. All patients should be monitored because it is impossible to predict reliably intra-partum fetal distress from maternal "high-risk" factors present before the onset of labour.     

Cardiac predictors of death after non-cardiac surgery evaluated by intention to treat.

Cardiac risk factors were studied among patients who were admitted to hospital with appendicitis or a fracture of the proximal femur less than one year after being admitted with myocardial infarction. Of 99 patients with myocardial infarction and appendicitis, 87 underwent appendicectomy; and of 221 with myocardial infarction and hip fracture, 179 were operated on. The patients were studied on an intention to treat basis. The mortality within one month was 9% and 16% respectively. A history of congestive heart failure was the dominating risk factor, while ischaemic heart disease (recent myocardial infarction or angina pectoris) had no independent association with mortality. If the ventricular function is known additional preoperative information about the heart is of negligible value when estimating the mortality of non-cardiac surgery.     

Comparison of case fatality in south Asian and white patients after acute myocardial infarction: observational study.

OBJECTIVE--To compare mortality in south Asian (Indian, Pakistani, and Bangladeshi) and white patients in the six months after hospital admission for acute myocardial infarction. DESIGN--Observational study. SETTING--District general hospital in east London. PATIENTS--149 south Asian and 313 white patients aged < 65 years admitted to the coronary care unit with acute myocardial infarction from 1 December 1988 to 31 December 1992. MAIN OUTCOME MEASURE--All cause mortality in the first six months after myocardial infarction. RESULTS--The admission rate in the south Asians was estimated to be 2.04 times that in the white patients. Most aspects of treatment were similar in the two groups, except that a higher proportion of the south Asians received thrombolytic drugs (81.2% v 73.8%). After adjustment for age, sex, previous myocardial infarction, and treatment with thrombolysis or aspirin, or both, the south Asians had a poorer survival over the six months from myocardial infarction (hazard ratio 2.02 (95% confidence interval 1.14 to 3.56), P = 0.018), but a substantially higher proportion were diabetic (38% v 11%, P < 0.001), and additional adjustment for diabetes removed much of their excess risk (adjusted hazard ratio 1.26 (0.68 to 2.33), P = 0.47). CONCLUSION--South Asian patients had a higher risk of admission with myocardial infarction and a higher risk of death over the ensuing six months than the white patients. The higher case fatality among the south Asians, largely attributable to diabetes, may contribute to the increased risk of death from coronary heart disease in south Asians living in Britain.     

Risks of discontinuing anticoagulant therapy in a selected group of patients with atherosclerotic heart disease: a prospective study

In 134 patients with coronary artery disease, long-term oral anticoagulant therapy (mean duration, 56 months) for acute myocardial infarction (98 patients), acute coronary insufficiency (25 patients) or severe chronic angina (11 patients) was terminated abruptly in 50 patients (group 1) and gradually in 84 (group 2). The 134 patients represented a homogeneous population of patients with coronary artery disease since most patients older than 75 years and those with conditions known to increase the risks of thromboembolic complications were excluded. The two groups were comparable in terms of sex, age, presence of risk factors, duration of anticoagulant therapy, and presence of angina and abnormal resting electrocardiograms during therapy. Patients were evaluated 6 months after cessation of anticoagulant therapy and, since abrupt withdrawal of therapy did not carry a higher risk than gradual discontinuation, data for groups 1 and 2 were tabulated together.Of the 84 patients with angina at the end of therapy 15 experienced an increase in its severity and this symptom appeared in another patient (relapse rate, 18%). Angina progressed to fatal acute myocardial infarction in four (mortality, 3%) and nonfatal infarction in two; however, all six had extensive coronary artery disease and poor left ventricular function. The results of this study suggest that neither abrupt nor gradual cessation of anticoagulant therapy is associated with an inordinate exacerbation of heart disease.