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.     

Immunoscintigraphy for detecting acute myocardial infarction without electrocardiographic changes.

OBJECTIVE--To establish whether immunoscintigraphy with antibody to myosin may detect acute myocardial infarction without electrocardiographic changes. DESIGN--Prospective study of patients with suspected acute myocardial infarction or unstable angina with cardiac imaging with 111indium myosin antibody, estimation of cardiac enzyme concentrations, electrocardiography, 201thallium imaging, and radionuclide ventriculography. SETTING--Coronary care unit in a district general hospital. PATIENTS--119 Consecutive patients with suspected acute myocardial infarction or unstable angina. Patients with cardiomyopathy, myocarditis, valvular heart disease, myocardial infarction or cardiac surgery in the previous two weeks or with left bundle branch block and women of childbearing age were excluded. RESULTS--Of 75 patients with suspected acute myocardial infarction, seven had no diagnostic electrocardiographic changes despite normal conduction patterns. Immunoscintigraphy with myosin antibody disclosed necrosis in all seven patients, which was localised in regions supplied by diseased coronary arteries in all but one. Six patients had abnormal images on 201thallium imaging, and all seven had abnormal wall motion at the site of antibody uptake. One patient with minimal left main stem and right coronary artery atheroma had uptake of antibody at two discrete sites. CONCLUSIONS--Immunoscintigraphy with antibody to myosin confirms myocardial infarction in the absence of electrocardiographic changes and discloses the site of infarction.     

Disturbances of insulin in British Asian and white men surviving myocardial infarction.

OBJECTIVE--To examine the role of insulin as a cardiovascular risk factor in British Asian and white men. DESIGN--Case-controlled study of survivors of first myocardial infarction. SETTING--District general hospital. PATIENTS--Consecutive series of 76 white and 74 Asian men who survived first myocardial infarction compared with 58 white and 61 Asian male controls without coronary artery disease who were randomly sampled from the community. RESULTS--More Asians than white subjects had impaired glucose tolerance or overt diabetes as measured by the two hour glucose tolerance test (23/74 (32%) v 11/76 (15%) (p less than 0.001) among patients; 17/61 (28%) v 3/58 (6%) (p less than 0.001) among controls). Insulin and C peptide concentrations were higher in both patient groups than in respective controls (p less than 0.001) and higher in Asian than in white subjects, irrespective of their glucose tolerance. Triglyceride concentrations were higher in patients than in controls (1.92 (SD 1.05) v 1.43 (0.82) mmol/l among Asian men; 1.65 (0.83) v 1.3 (0.61) mmol/l among white subjects; p less than 0.001). Total cholesterol concentrations were lower in both groups of Asians than in respective white subjects (5.78 (0.99) v 6.22 (1.04) mmol/l (p less than 0.01) among patients; 5.54 (1.01) v 5.65 (1.11) mmol/l (p less than 0.6) among controls). High density lipoprotein cholesterol concentrations were lower in Asian than in white subjects. The ratio of total cholesterol to high density lipoprotein cholesterol was significantly higher (p less than 0.001) in both patient groups (6.69 (1.81) in Asian patients and 6.31 (1.91) in white patients) than in respective controls (5.24 (1.19) and 4.77 (1.43)). Regression analysis identified C peptide concentration and the ratio of total to high density lipoprotein cholesterol as powerful independent predictors of myocardial infarction in Asian and white men. Total cholesterol concentration predicted infarction in white but not in Asian men. CONCLUSIONS--Secretion and hepatic extraction of insulin are high in survivors of myocardial infarction and especially high in British Asians. Tissue resistance to the action of insulin, giving rise to increased pancreatic secretion, may be an important risk factor for coronary artery disease in both ethnic groups and may be partly responsible for the high incidence of diabetes and coronary artery disease in Asian populations.     

Does access to cardiac investigation and treatment contribute to social and ethnic differences in coronary heart disease? Whitehall II prospective cohort study

Objective To determine whether access to cardiac procedures and drugs contributes to social and ethnic differences in coronary heart disease in a population setting.Design Prospective study with follow up over 15 years. Civil service employment grade was used as a measure of individual socioeconomic position. Need for cardiac care was determined by the presence of angina, myocardial infarction, and coronary risk factors.Setting 20 civil service departments originally located in London.Participants 10 308 civil servants (3414 women; 560 South Asian) aged 35-55 years at baseline in 1985-8.Main outcome measures Use of exercise electrocardiography, coronary angiography, and coronary revascularisation procedures and secondary prevention drugs.Results Inverse social gradients existed in incident coronary morbidity and mortality. South Asian participants also had higher rates than white participants. After adjustment for clinical need, social position showed no association with the use of cardiac procedures or secondary prevention drugs. For example, men in the low versus high employment grade had an age adjusted odds ratio for angiography of 1.87 (95% confidence interval 1.32 to 2.64), which decreased to 1.27 (0.83 to 1.94) on adjustment for clinical need. South Asians tended to be more likely to have cardiac procedures and to be taking more secondary prevention drugs than white participants, even after adjustment for clinical need.Conclusion This population based study, which shows the widely observed social and ethnic patterning of coronary heart disease, found no evidence that low social position or South Asian ethnicity was associated with lower use of cardiac procedures or drugs, independently of clinical need. Differences in medical care are unlikely to contribute to social or ethnic differences in coronary heart disease in this cohort.     

Lipoprotein (a) and coronary heart disease: a prospective case-control study in a general population sample of middle aged men.

OBJECTIVE--To examine the association between the serum lipoprotein (a) concentration and subsequent coronary heart disease. DESIGN--Prospective case-control study based on a six year follow up of a general population sample of men aged 50 at baseline in 1983-4. Serum samples were frozen at the time of the baseline examination and kept at -70 degrees C for six years, after which the lipoprotein (a) concentrations in the samples were measured in cases and controls. SETTING--City of Gothenburg, Sweden. SUBJECTS--26 Men, from a general population sample of 776 men, who had sustained a myocardial infarction or died of coronary heart disease during the six years and 109 randomly selected controls from the same sample who had remained free of myocardial infarction. In neither cases nor controls was there a history of myocardial infarction at baseline. MAIN OUTCOME MEASURES--Proportion of myocardial infarction or deaths from coronary heart disease, or both, in relation to the serum lipoprotein (a) concentration. RESULTS--Men who suffered coronary heart disease had significantly higher serum lipoprotein (a) concentrations than controls (mean difference 105 mg/l; 95% confidence interval 18 to 192 mg/l). Men with the highest fifth of serum lipoprotein (a) concentrations (cut off point 365 mg/l) suffered a coronary heart disease rate which was more than twice that of men with the lowest four fifths of concentrations. Logistic regression analysis showed the serum lipoprotein (a) concentration to be significantly associated with coronary heart disease independently of other risk factors. CONCLUSION--The serum lipoprotein (a) concentration in middle aged men is an independent risk factor for subsequent myocardial infarction or death from coronary heart disease.     

Shortened bleeding time in acute myocardial infarction and its relation to platelet mass.

The bleeding time, using the Simplate method, horizontal incision, and venostasis, was measured in a study of 51 patients admitted to a coronary care unit within 12 hours of the onset of chest pain. The bleeding time was significantly shorter in the 28 patients who were found to have definite myocardial infarction compared with the 23 others with chest pain but no definite infarction (p less than 0.0005). A bleeding time of less than 212 seconds correctly classified 84% of patients (sensitivity for definite myocardial infarction 89%) presenting to the coronary care unit with chest pain. Multiple regression analysis showed the bleeding time in all patients to be determined independently (and with high significance) by the following variables in order of importance: diagnostic group, platelet mass (platelet count X mean volume), and age. Packed cell volume was not a significant determinant. In the group with definite myocardial infarction considered alone the same order of variables was observed in predicting bleeding time, but none of them was significant. A major variable reducing bleeding time in acute myocardial infarction remains to be determined. There was no association between bleeding time and creatine phosphokinase activity or infarct size in the group with definite myocardial infarction.     

Dietary fat and risk of coronary heart disease in men: cohort follow up study in the United States.

OBJECTIVE--To examine the association between fat intake and the incidence of coronary heart disease in men of middle age and older. DESIGN--Cohort questionnaire study of men followed up for six years from 1986. SETTING--The health professionals follow up study in the United States. SUBJECTS--43 757 health professionals aged 40 to 75 years free of diagnosed cardiovascular disease or diabetes in 1986. MAIN OUTCOME MEASURE--Incidence of acute myocardial infarction or coronary death. RESULTS--During follow up 734 coronary events were documented, including 505 non-fatal myocardial infarctions and 229 deaths. After age and several coronary risk factors were controlled for significant positive associations were observed between intake of saturated fat and risk of coronary disease. For men in the top versus the lowest fifth of saturated fat intake (median = 14.8% v 5.7% of energy) the multivariate relative risk for myocardial infarction was 1.22 (95% confidence interval 0.96 to 1.56) and for fatal coronary heart disease was 2.21 (1.38 to 3.54). After adjustment for intake of fibre the risks were 0.96 (0.73 to 1.27) and 1.72 (1.01 to 2.90), respectively. Positive associations between intake of cholesterol and risk of coronary heart disease were similarly attenuated after adjustment for fibre intake. Intake of linolenic acid was inversely associated with risk of myocardial infarction; this association became significant only after adjustment for non-dietary risk factors and was strengthened after adjustment for total fat intake (relative risk 0.41 for a 1% increase in energy, P for trend < 0.01). CONCLUSIONS--These data do not support the strong association between intake of saturated fat and risk of coronary heart disease suggested by international comparisons. They are compatible, however, with the hypotheses that saturated fat and cholesterol intakes affect the risk of coronary heart disease as predicted by their effects on blood cholesterol concentration. They also support a specific preventive effect of linolenic acid intake.     

Changes in severity of myocardial infarction and three year survival rates after myocardial infarction in Auckland, 1966-7 and 1981-2.

Mortality from coronary heart disease has been declining steadily over the past 20 years in Auckland. The possibility that improved survival contributed to this decline was examined in patients who survived four weeks after myocardial infarction, changes in the severity of the disease being controlled for. Patients who had had myocardial infarction in 1966-7 (191 patients) or 1981-2 (203) were compared to determine whether three year survival rates had changed and the severity of the disease altered. With a coronary prognostic index taken as the measure of severity the 1981-2 group had significantly more severe myocardial infarctions than the 1966-7 group, but despite this the three year survival was significantly better (86% in the 1981-2 group v 75% in the 1966-7 group). These findings suggest that improved survival after myocardial infarction contributed to the decline in mortality.     

Vitamin C deficiency and risk of myocardial infarction: prospective population study of men from eastern Finland.

OBJECTIVE: To examine the association between plasma vitamin C concentrations and the risk of acute myocardial infarction. DESIGN: Prospective population study. SETTING: Eastern Finland. SUBJECTS: 1605 randomly selected men aged 42, 48, 54, or 60 who did not have either symptomatic coronary heart disease or ischaemia on exercise testing at entry to the Kuopio ischaemic heart disease risk factor study in between 1984 and 1989. MAIN OUTCOME MEASURES: Number of acute myocardial infarctions; fasting plasma vitamin C concentrations at baseline. RESULTS: 70 of the men had a fatal or non-fatal myocardial infarction between March 1984 and December 1992.91 men had vitamin C deficiency (plasma ascorbate < 11.4 mumol/l, or 2.0 mg/l), of whom 12 (13.2%) had a myocardial infarction; 1514 men were not deficient in vitamin C, of whom 58 (3.8%) had a myocardial infarction. In a Cox proportional hazards model adjusted for age, year of examination, and season of the year examined (August to October v rest of the year) men who had vitamin C deficiency had a relative risk of acute myocardial infarction of 3.5 (95% confidence interval 1.8 to 6.7, P = 0.0002) compared with those who were not deficient. In another model adjusted additionally for the strongest risk factors for myocardial infarction and for dietary intakes of tea fibre, carotene, and saturated fats men with a plasma ascorbate concentration < 11.4 mumol/l had a relative risk of 2.5 (1.3 to 5.2, P = 0.0095) compared with men with higher plasma vitamin C concentrations. CONCLUSIONS: Vitamin C deficiency, as assessed by low plasma ascorbate concentration, is a risk factor for coronary heart disease.     

Sex related differences in short and long-term prognosis after acute myocardial infarction: 10 year follow up of 3073 patients in database of first Danish Verapamil Infarction Trial.

OBJECTIVE--To re-examine the prevailing hypothesis that women fare worse than men after acute myocardial infarction. DESIGN--10 year follow up of all patients with confirmed acute myocardial infarction registered in the database of the Danish verapamil infarction trial in 1979-81. SETTING--16 coronary care units, covering a fifth of the total Danish population. PATIENTS--3073 consecutive patients with acute myocardial infarction, 738 (24%) women and 2335 (76%) men. MAIN OUTCOME MEASURES--Early mortality (before day 15). For patients alive on day 15: mortality, cause of death, admission with recurrent infarction, and mortality after reinfarction. RESULTS--Early mortality increased significantly with age (P < 0.0001) but was not significantly related to sex, with a 15 day mortality of 17% in women and 16% in men. Adjustment for age and sex simultaneously revealed a significant interaction (P = 0.02) between these variables, with a greater increase with age in early mortality for men than for women (early mortality was equal for the two sexes at age 64 years). Ten year mortality in patients alive on day 15 was 58.8%. The overall age adjusted hazard ratio (95% confidence interval) for women versus men was 0.90 (0.80 to 1.01); 0.90 (0.78 to 1.04) for 10 year reinfarction (48.8%); and 0.98 (0.82 to 1.16) for 10 year mortality after reinfarction (82.3%). No difference in cause of death was found between the sexes. With a follow up of up to 10 years for patients alive on day 15 mortality, rate of reinfarction, and mortality after reinfarction increased with increasing age (P < 0.0001). CONCLUSION--Sex by itself is not a risk factor after acute myocardial infarction.     

Role of exercise testing early after myocardial infarction in identifying candidates for coronary surgery.

It has been suggested that ST depression in lead V5 or equivalent on early exercise testing after acute myocardial infarction predicts a high risk of death. To evaluate exercise testing and radionuclide ventriculography in this context 103 consecutive patients with myocardial infarction who were able to undertake a limited exercise test before discharge from hospital were exercised and underwent gated blood pool scanning. No serious complications resulted from exercise testing. Twenty nine patients developed ST depression in lead V5, 19 had exertional hypotension, 31 developed a heart rate of greater than or equal to 130 beats/min, and 15 had complex ventricular arrhythmias. Death during the first year after discharge from hospital was associated with exertional hypotension (p less than 0.001) and a heart rate on exercise testing of greater than or equal to 130 beats/min (p less than 0.05); these two variables identified all nine deaths. Inability to complete the exercise protocol for any reason was also predictive of death (p less than 0.01). Ventricular arrhythmias and ST depression in lead V5 induced by exercise were not significantly associated with an increased risk of death. The mean (SD) radionuclide ejection fraction in the patients who died was 29 (16%) compared with 43 (11)% in the patients who survived (p less than 0.001). ST changes on exercise testing after myocardial infarction appear to be less predictive of later complications than haemodynamic signs, which may indicate left ventricular damage rather than ischaemia.     

Ten year mortality in patients with suspected acute myocardial infarction.

OBJECTIVE--To describe the 10 year mortality in patients with suspected acute myocardial infarction. DESIGN--Follow up of all patients below 76 years of age admitted with acute chest pain to 16 coronary care units participating in the Danish verapamil infarction trial in 1979-81. SUBJECTS--Of the 5993 patients included, 2586 had definite infarction, 402 had probable infarction, and 3005 did not have infarction. MAIN OUTCOME MEASURES--Death and cause of death. Standardised mortality ratio (observed mortality/expected mortality in background population). RESULTS--The estimated 10 year mortalities were 58.8%, 55.5%, and 42.8% in patients with definite, probable, and no infarction, respectively (P < 0.0001). Stratified Cox''s analysis identified a hazard ratio for mortality of 1.25 (95% confidence interval 1.08 to 1.44) for probable infarction compared with no infarction and of 1.15 (1.00 to 1.32) for definite compared with probable infarction. The standardised mortality ratio in the first year was 7.1 (6.5 to 7.8) for definite infarction, 5.0 (3.6 to 6.3) for probable infarction, and 4.7 (4.2 to 5.2) for no infarction. From the second year and onwards the annual standardised mortality ratio in the three groups did not differ significantly. Cardiac causes of deaths were recorded in 89%, 84%, and 71% of the deaths in patients with definite, probable, and no infarction, respectively. CONCLUSIONS--The 10 year mortality of patients with and without infarction is significantly higher than in the background population. Most deaths are caused by coronary heart disease, and these patients should consequently be further evaluated at the time of discharge and followed up closely.     

How long should patients with suspected myocardial infarction be under observation in hospital?

Out of 368 patients admitted to hospital for chest pain and suspected acute myocardial infarction, 267 were discharged within 24 hours on the basis of the clinical picture, electrocardiogram, and serum activities of aspartate transaminase, alpha-hydroxybutyrate dehydrogenase, and creatine phosphokinase. The patients were followed up for 28 days, during which 17 were readmitted, two of them twice and one three times. Two of the patients were readmitted with non-fatal acute myocardial infarction, and two died. The patients had been primarily divided into two groups: those admitted with presumably non-coronary chest pain (77 patients) formed group 1 and those with obvious coronary chest pain (190 patients) group 2. Both deaths occurred in patients in group 2 but the incidences of events during the follow-up period were otherwise similar in the two groups, and some patients in both groups may have had small acute myocardial infarctions when first admitted. The decision to keep in hospital or discharge a patient with chest pain of recent onset can be made within 24 hours of admission. To discharge the patient acute myocardial infarction need not necessarily be excluded and conventional tests are enough to enable a decision to be made.     

Myocardial infarction,hyperthyroidism and normal coronary arteries: report of two cases.

Myocardial infarction is uncommon in persons with hyperthyroidism and also uncommon in the absence of demonstrable coronary artery disease. Cardiac catheterization and selective coronary angiography were performed in two men following apparent myocardial infarctions. Both patients were 33 years of age, thyrotoxic and angiographically free of coronary artery abnormalities.     

Statin use in the secondary prevention of coronary heart disease in primary care: cohort study and comparison of inclusion and outcome with patients in randomised trials

Objective To compare the social and demographic profiles of patients who receive statin treatment after myocardial infarction and patients included in randomised trials. To estimate the effect of statin use in community based patients on subsequent all cause mortality and cardiovascular recurrence, contrasting effects with trial patients.Design Observational cohort study using a record linkage database.Setting Tayside, Scotland (population size and characteristics: about 400 000, mixed urban and rural).Subjects 4892 patients were discharged from hospital after their first myocardial infarction between January 1993 and December 2001. 2463 (50.3%) were taking statins during an average follow-up of 3.7 years (3.1% in 1993 and 62.9% in 2001).Main outcome measures All cause mortality and recurrence of cardiovascular events.Results 319 deaths occurred in the statin treated group (age adjusted rate 4.1 per 100 person years, 95% confidence interval 3.2 to 4.9), and 1200 in the statin untreated group (12.7 per 100 person years, 11.1 to 14.3). More older people and women were represented in the population of patients treated with statins than among those recruited into clinical trials (mean age 67.8 v 59.8; women 39.6% v 16.9%, respectively). The effects of statins in routine clinical practice were consistent with, and similar to, those reported in clinical trials (adjusted hazard ratio for all cause mortality 0.69, 95% confidence interval 0.59 to 0.80; adjusted hazard ratio for cardiovascular recurrence 0.82, 0.71 to 0.95).Conclusions The community effectiveness of statins in those groups that were not well represented in clinical trials was similar to the efficacy of statins in these trials.     

Likelihood of Treatment in a Coronary Care Unit for a First-Time Myocardial Infarction in Relation to Sex,Country of Birth and Socioeconomic Position in Sweden

Objective

To examine the relationship between sex, country of birth, level of education as an indicator of socioeconomic position, and the likelihood of treatment in a coronary care unit (CCU) for a first-time myocardial infarction.

Design

Nationwide register based study.

Setting

Sweden.

Patients

199 906 patients (114 387 men and 85,519 women) of all ages who were admitted to hospital for first-time myocardial infarction between 2001 and 2009.

Main outcome measures

Admission to a coronary care unit due to myocardial infarction.

Results

Despite the observed increasing access to coronary care units over time, the proportion of women treated in a coronary care unit was 13% less than for men. As compared with men, the multivariable adjusted odds ratio among women was 0.80 (95% confidence interval 0.77 to 0.82). This lower proportion of women treated in a CCU varied by age and year of diagnosis and country of birth. Overall, there was no evidence of a difference in likelihood of treatment in a coronary care unit between Sweden-born and foreign-born patients. As compared with patients with high education, the adjusted odds ratio among patients with a low level of education was 0.93 (95% confidence interval 0.89 to 0.96).

Conclusions

Foreign-born and Sweden-born first-time myocardial infarction patients had equal opportunity of being treated in a coronary care unit in Sweden; this is in contrast to the situation in many other countries with large immigrant populations. However, the apparent lower rate of coronary care unit admission after first-time myocardial infarction among women and patients with low socioeconomic position warrants further investigation.     

Comparison of cardiovascular risk between patients with type 2 diabetes and those who had had a myocardial infarction: cross sectional and cohort studies

ObjectiveTo compare risks of cardiovascular outcomes between patients with type 2 diabetes and patients with established coronary heart disease.DesignCross sectional study and cohort study using routinely collected datasets.SettingTayside, Scotland (population 400 000) during 1988-95.SubjectsIn the cross sectional study, among patients aged 45-64, 1155 with type 2 diabetes were compared with 1347 who had had a myocardial infarction in the preceding 8 years. In the cohort study 3477 patients of all ages with newly diagnosed type 2 diabetes were compared with 7414 patients who had just had a myocardial infarction.ResultsIn the cross sectional study the adjusted risk ratio for death from all causes was 2.27 (95% confidence interval 1.82 to 2.83) for patients who had had myocardial infarction compared with those with diabetes, and the risk ratio for hospital admission for myocardial infarction was 1.33 (1.14 to 1.55). In the cohort study, patients who had just had a myocardial infarction had a higher risk of death from all causes (adjusted risk ratio 1.35 (1.25 to 1.44)), cardiovascular death (2.93 (2.54 to 3.41)), and hospital admission for myocardial infarction (3.10 (2.57 to 3.73)).ConclusionsPatients with type 2 diabetes were at lower risk of cardiovascular outcomes than patients with established coronary heart disease.

What is already known on this topic

A recent influential study suggested that patients with type 2 diabetes without established cardiovascular disease have as high a risk of cardiovascular events and death as non-diabetic patients who have had a myocardial infarctionSome clinicians therefore advocate aggressive treatment of cardiovascular risk factors in the presence of diabetes

What this study adds

Patients with type 2 diabetes are at lower risk of death from all causes or cardiovascular causes and of hospital admission for myocardial infarction than patients with established coronary heart disease     

Randomised trial of treatment of hypertension in elderly patients in primary care.

A randomised trial of the treatment of hypertension in 884 patients aged 60 to 79 years at the onset showed a reduction of 18/11 mm Hg in blood pressure over a mean follow up period of 4.4 years. The principal antihypertensive agents were atenolol and bendrofluazide. There was a reduction in the rate of fatal stroke in the treatment group to 30% of that in the control group (95% confidence interval 11-84%, p less than 0.025). The rate of all strokes (fatal and non-fatal) in the treatment group was 58% of that in the control group (95% confidence interval 35-96%, p less than 0.03). The incidence of myocardial infarction and total mortality was unaffected by treatment. Questionnaires completed by the patients and their relatives failed to identify any differences in symptoms that were likely to be due to treatment.     

Cigar and pipe smoking and myocardial infarction in young men.

The effect of cigar and pipe smoking on the risk of myocardial infarction was evaluated in an interview study of 572 men with non-fatal first myocardial infarctions and 934 hospital controls. The study was conducted in the north eastern United States from 1980 to 1983. All subjects were 40-54 years of age, and none had smoked cigarettes for at least two years. Among men who had never smoked cigarettes the relative risk of myocardial infarction for those who smoked at least five cigars a day, compared with not smoking cigars and pipes and allowing for other risk factors, was estimated to be 1.7 (95% confidence interval 0.6 to 4.8). Among ex-smokers of cigarettes the corresponding estimate for those who smoked at least five cigars a day was 4.5 (2.2 to 9.2). The estimates for men who smoked fewer cigars, or pipes, were closer to 1.0 and not significant. Men who stop smoking cigarettes and switch to at least five cigars a day apparently continue to have an increased risk of myocardial infarction, possibly because they continue to inhale the smoke.     

Prognosis for South Asian and white patients newly admitted to hospital with heart failure in the United Kingdom: historical cohort study

Objectives To compare patterns of admission to hospital and prognosis in white and South Asian patients newly admitted with heart failure, and to evaluate the effect of personal characteristics and comorbidity on outcome.Design Historical cohort study.Setting UK district health authority (population 960 000).Participants 5789 consecutive patients newly admitted with heart failure.Main outcome measures Population admission rates, incidence rates for first admission with heart failure, survival, and readmission rates.Results When compared with the white population, South Asian patients had significantly higher age adjusted admission rates (rate ratio 3.8 for men and 5.2 for women) and hospital incidence rates (2.2 and 2.9). Among 5789 incident cases of heart failure, South Asian patients were younger and more often male than white patients (70 (SD 0.6) v 78 (SD 0.1) years and 56.5% (190/336) v 49.3% (2494/5057)). South Asian patients were also more likely to have previous myocardial infarction (10.1% (n = 34) v 5.5% (n = 278)) or concomitant myocardial infarction (18.8% (n = 63) v 10.7% (n = 539)) or diabetes (45.8% (n = 154) v 16.2% (n = 817), all P < 0.001). A trend was shown to longer unadjusted survival for both sexes among South Asian patients. After adjustment for covariables, South Asian patients had a significantly lower risk of death (hazard ratio 0.82, 95% confidence interval 0.68 to 0.99) and a similar probability of death or readmission (0.96, 0.81 to 1.09) compared with white patients.Conclusions Population admission rates for heart failure are higher among South Asian patients than white patients in Leicestershire. At first admission South Asian patients were younger and more often had concomitant diabetes or acute ischaemic heart disease than white patients. Despite major differences in personal characteristics and risk factors between white and South Asian patients, outcome was similar, if not better, in South Asian patients.