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A questionnaire survey was carried out to estimate activity levels in a sample of 784 men and women aged 35 to 64 years in County Kilkenny, Ireland. Men were more likely to have sedentary, heavy or very heavy work activity while the majority of women had moderate activity during an average day. Only a small minority of respondents walked or cycled to work. 44% of those surveyed had leisure pursuits which were sedentary. At leisure, a higher proportion of men were involved in active sports or other vigorous activities for at least three hours per week. Men also spent longer each day walking, cycling or jogging. 16.5% of those surveyed engaged in vigorous activities for at least 20 minutes on one to three occasions weekly while 5.1% did so on four or more occasions. Younger people were more likely to take such exercise while older people were more likely to take less vigorous exercise. Path analysis using multiple regression techniques found that an increase in activity levels in this population could lead to substantial reductions in blood pressure, some of which would be mediated through changes in body weight.

Trends in mortality from cardiovascular diseases in Ireland from 1950 to 1986 are examined and compared with trends in some other developed countries. There was a decline in mortality from all causes which was greater in women than in men. Mortality from coronary heart disease (CHD) increased in males from 1953 to 1974 and has been declining slowly since. Mortality rates in men in Canada and the United States are now lower than those in Ireland and rates in Finnish men are approaching those in Ireland. CHD mortality in Irish males was sixth highest of developed countries in 1985. In women, CHD mortality declined in the 1950s, was stable in the 1960s and early 1970s and has been decreasing slowly since 1974. CHD mortality in Irish women was fifth highest of developed countries in 1985. Mortality rates from cerebrovascular disease have been falling in Irish women since 1958 and in men since 1969. The continuing high mortality from CHD in Ireland warrants the establishment of effective community prevention programmes.

The early trials of coronary artery surgery compared to conservative management in patients with non-acute coronary heart disease are no longer relevant because of recent advances in surgery and medical treatment. There have been no recent major trials, including trials of female patients. Only one recent limited trial has been reported about patients over 70 years. The widespread adoption of angioplasty has taken place without adequate trial evidence to suggest that angioplasty is superior to medical treatment in many patients subjected to this invasive procedure. The limited evidence would suggest that medical treatment is less effective in the relief of chronic angina but more effective in terms of further events. Current uncertainties and important advances in angioplasty and medical treatment are compelling reasons for proper trials. Medical treatment has rarely been defined in the earlier surgical and angioplasty trials. Anti-platelet agents and statins were not available and risk factor identification and modification were never referred to. Medical treatment to-day includes risk factor identification and modification, graduated aerobic exercises, the use of anti-platelet agents and statins, B-blockers and ACE inhibitors where indicated, and symptomatic treatment, including the nitrates for chronic angina. The paucity of recent trials comparing invasive procedures with medical treatment leaves uncertainties about the management of many patients with coronary heart disease and these uncertainties are increased by poor adherence to the limited trial evidence available. It raises doubts about our adherence to evidence based cardiology and concerns about the wide variations in the management of patients in different centres. It has important implications relating to the cost of overstretched health delivery systems and therefore has political implications. Current uncertainties can only be resolved by new trials to assess the indications for the different treatment modalities and by more effective audit to ensure that accepted indications are adhered to.

Objective To investigate the incidence and prognostic significance of fasting hyperglycemia in a large group of patients with a first myocardial infarction. Research Design and Methods Blood glucose was measured after an 8-h overnight fast in 752 patients with a first myocardial infarction. Three groups of patients were identified: patients with normal fasting blood glucose (92.5%), patients with fasting hyperglycemia but no prior history of glucose intolerance (3%), and patients previously known to have diabetes mellitus (4.5%). Results The fasting hyperglycemic patients were significantly older and had significantly more in-hospital complications than the normal blood glucose group. Previously known diabetic subjects tended to be older and had more mechanical complications postinfarction than the group with normal blood glucose but the difference did not reach statistical significance. There was no significant difference between the diabetic subjects and patients with fasting hyperglycemia in mean age and in-hospital prognosis. Conclusions Fasting hyperglycemia detected after a first myocardial infarction is associated with a poor in-hospital prognosis that was not due to larger infarct size, as reflected in peak levels of cardiac enzymes. The measurement of a fasting blood glucose level provides additional information in identifying high-risk groups of patients postinfarction.

We report on the 15-year prognosis of 720 male and 246 female 28-day survivors of a first myocardial infarction or episode of unstable angina who were aged under 60 years at the time of admission to the study. Women were on average 1.9 years older than men, had higher cholesterol levels, a higher prevalence of hypertension and angina prior to admission and a higher proportion were lifetime non-smokers. Women were more likely to be admitted with unstable angina rather than infarction. When adjusted for age, smoking status, angina, hypertension and the difference in prevalence of infarction, women had a relative risk of death of 1.054 in a 15-year life table mortality analysis. Prognostic differences between the sexes reported may be the result of failure to allow for differences in other prognostic factors.

Three hundred and forty-six patients of all ages and both sexes were admitted to coronary care with documented unstable angina. Management was conservative, without the routine use of beta-blockers or calcium antagonists. Mortality was 3.2%, and the nonfatal myocardial infarction rate was 10.1% during the first 28 days. After one year, coronary mortality was 10.5% with a nonfatal infarction rate of 13.1%. Twenty-six patients were subjected to coronary artery bypass surgery, eleven during the first 28 days and fifteen subsequently. No patient underwent coronary angioplasty. The factors influencing immediate and long-term prognosis in these patients were studied. Persistence of pain in hospital, previous chronic angina, and age had an adverse effect on outcome. A total of 143 patients complained of persistent pain lasting for 24 hours or more. The use of beta blockers or calcium antagonists in patients with persistent pain exceeding five days did not appear to influence outcome. The current widespread adherence to "intensive medical treatment," including the routine use of beta blockers and calcium antagonists, is questioned.

We investigated the relationship between atrioventricular block and in-hospital mortality in 705 successive patients admitted with a first Q-wave myocardial infarction of the anterior or inferior wall. Second- or third-degree atrioventricular block developed in 61 (8.6 per cent) patients and was more frequent in inferior (12.4 per cent) than anterior infarctions (4.9 per cent). A multiple logistic regression identified three factors which were independently correlated with block: inferior infarction, older age and larger infarct size as determined by cardiac enzymes. Mortality was 27.9 per cent in patients with block and 9.3 per cent in those without; it was significantly higher in both anterior (47.0 per cent vs 11.8 per cent) and inferior (20.4 per cent vs 6.7 per cent) infarction groups. When age, infarct size, infarct site and block were analysed simultaneously as predictors of death, block was a significant independent prognostic factor. The relative risk of death, corrected for age and infarct size, in patients showing block was similar for anterior and inferior infarction. Analysis of deaths revealed a higher incidence of unheralded death in inferior infarcts associated with high-degree block.

In a prospective epidemiologic study of 1001 middle-aged men, we examined the relation between dietary information collected approximately 20 years ago and subsequent mortality from coronary heart disease. The men were initially enrolled in three cohorts: one of men born and living in Ireland, another of those born in Ireland who had emigrated to Boston, and the third of those born in the Boston area of Irish immigrants. There were no differences in mortality from coronary heart disease among the three cohorts. In within-population analyses, those who died of coronary heart disease had higher Keys (P = 0.06) and modified Hegsted (P = 0.02) dietary scores than did those who did not (a high score indicates a high intake of saturated fatty acids and cholesterol and a relatively low intake of polyunsaturated fatty acids). These associations were significant (P = 0.03 for the Keys and P = 0.04 for the modified Hegsted scores) after adjustment for other risk factors for coronary heart disease. Fiber intake (P = 0.04) and a vegetable-foods score, which rose with increased intake of fiber, vegetable protein, and starch (P = 0.02), were lower among those who died from coronary heart disease, though not significantly so after adjustment for other risk factors. A higher Keys score carried an increased risk of coronary heart disease (relative risk, 1.60), and a higher fiber intake carried a decreased risk (relative risk, 0.57). Overall, these results tend to support the hypothesis that diet is related, albeit weakly, to the development of coronary heart disease.

Six hundred and eighty four patients (629 men), all aged under 60 years, who had survived for 28 days after a first acute myocardial infarction were studied to determine the influence of the site of infarction on long term prognosis. The infarct site was not significantly related to age nor to extent of infarct at the time of the acute episode. Mechanical complications were more common in patients with anteroseptal infarctions, while atrioventricular conduction disturbances were more commonly found in those with inferior infarction. The site of infarction was not related to smoking habits or angina before the infarction or at 2 year follow up. Life table methods did not show any relation between infarction site and morbidity or mortality either two years or 15 years after the initial infarction.

Two otherwise comparable groups of patients, 27 of whom were non-smokers and 20 of whom smoked in excess of ten cigarettes per day, had serial fetal biparietal diameter measurements taken throughout pregnancy; from 21 weeks onwards, the fetal biparietal diameters increased significantly more slowly (p0.01) in mothers who smoked.A comparative study was conducted to determine whether fetuses of mothers who smoke show a slower growth of the biparietal diameter (BPD) as measured serially by ultrasound. 20 smokers of more than 10 cigarettes daily and 27 nonsmokers had the measurements taken throughout their pregnancies. In all respects other than the smoking characteristic, the 2 groups were comparable. From 21 weeks on, the BPD increased significantly more slowly (at a P .01 significance) in mothers who smoked. The average weekly BPD gain was 2.65 mm for the nonsmokers and 2.60 mm for the smokers. Birthweight for the infants of the nonsmokers was significantly higher. It is not clear whether the growth-retarding effects of smoking extend into postnatal life.

Nine hundred and seventy eight patients admitted with a first myocardial infarction or episode of unstable angina were studied to determine for how long after they gave up smoking did the risk in ex-smokers continue to resemble those of current smokers. Logistic regression was used to calculate a score, based on a combination of age, cholesterol, and hypertension, that separated current smokers from lifetime non-smokers. When this function was applied to ex-smokers, only those who had given up at least 15 years before the attack had a risk factor profile similar to that of non-smokers. Those who had given up less than five years before the ischaemic attack had a significantly higher level of other risk factors than current smokers; those who had stopped for between five and 15 years had levels similar to those of current smokers. Ex-smokers are at higher risk of acute coronary disease for at least 15 years after stopping, but some immediate reduction in risk is possible.

A total of 586 men who survived an initial attack of unstable angina or myocardial infarction have been followed for up to 15 years. A policy of early mobilization and sustained risk factor advice was employed. A conservative approach to treatment was adopted during the acute and follow-up stages. Drugs were employed only for symptomatic reasons, and only two patients proceeded to coronary artery bypass surgery. Survival at 5, 10, and 15 years was 80%, 61%, and 43%. Older patients and those with more severe initial attacks had a higher mortality, but these factors did not relate to combined fatal and nonfatal recurrence of myocardial infarction. Of 22 studies reviewed, 18 report a higher mortality than does our study. Four studies, none strictly comparable, report a similar 5-year mortality. A conservative approach to management does not appear to be harmful and may be beneficial.

This is a study of the relationship between the site of infarction and both risk factors and in-hospital outcome in 745 consecutive patients admitted with a first myocardial infarction. Patients with anterior infarctions were significantly more likely never to have smoked than patients with inferior infarctions. They had a higher prevalence of hypertension and a higher mean cholesterol level. In hospital prognosis was worse in anterior infarctions, with significantly higher rates of death and complications. Atrioventricular blocks were more common in inferior infarctions. Non-Q-wave infarctions had a lower incidence of complications than Q-wave infarctions. There was no difference in risk factor levels between Q-wave and non-Q-wave infarctions. Anterior and inferior infarctions were of similar size. Non-Q-wave infarctions were significantly smaller. A logistic regression showed a negative relationship between in-hospital mortality and smoking, and a positive one with peak cardiac enzyme levels. Any effect of site of infarction on mortality was eliminated when corrected for these factors. Our data indicate that the adverse prognosis associated with anterior myocardial infarction is related to differences in aetiology rather than to infarction size.

A total of 213 male patients who survived an initial episode of acute coronary inusfficiency or myocardial infarction for 28 days have been followed for 5 years. The effect of age, weight, severity of infarction diastolic blood pressure, serum cholesterol, and cigarette smoking at the time of the initial attack on postinfarction morbidity and death was examined. Only severity of infarction adversely influenced the long-term mortality rate; none of the factors studied was related to subsequent morbidity. The effect of subsequent cigarette smoking on morbidity and death was noted over the 5 year period. Smoking did not affect subsequent morbidity but there was an increased death rate among those who continued to smoke. This effect of smoking was independent of the severity of infarction. Improved long-term survival may be predicted for patients who stop or markedly reduce cigarette smoking.

We studied the impact of a first myocardial infarction or episode of unstable angina on four areas of subjective health: wellbeing, perceived functional status, body confidence and emotional symptoms. A questionnaire in which the patient was asked to compare status before and after hospital admission was given to 61 cardiac patients attending follow-up rehabilitation clinics.Worries about health and fears of straining oneself were common in the 24 patients surveyed less than 3 months from discharge. But in patients over 3 months from discharge, sense of wellbeing was significantly improved post-infarction compared with pre-infarction: 86% of patients noting a change reported an improvement. Perceived family role performance was significantly improved, while confidence in work performance and general competence remained unchanged. The prevalences of depression, anxiety and worry were unchanged from pre to post attack, patients in whom these symptoms developed being off-set by patients who lost symptoms.Previously-reported adverse sequelae of acute coronary disease may exaggerate the extent of the problem. Restriction of studies to neurotic symptoms and failure to compare pre and post attack periods may fail to elicit improvements in quality of life associated with rehabilitation and secondary prevention programmes.Running Title: Subjective health in post-coronary patients

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.

The routine measurement of electrocardiographic time intervals is a laborious task. Heart rate, PR interval, QRS duration, QT interval and mean frontal QRS axis were measured independently in fifty consecutive out-patient electrocardiograms by two cardiologists and a medical student. Between and within observer variations were small. These measurements were compared with those of a commercially available computer assisted electrocardiograph. Correlation between the cardiologists and the computer for all measurements was very high. No systematic bias was detected. Some disagreement was noted for longer QT intervals.

Forty-eight patients under 65 years were included in a double blind study comparing the lipid-lowering effect of clofibrate with that of beta-pyridylcarbinol combined with clofibrate. Over 4 months there was no significant difference in the lipid-lowering effect of either regime. A mean reduction of triglyceride of approximately 30% and of cholesterol of 18% was observed. Both drugs caused significantly greater reductions than placebo. No serious side-effects were noted.

One hundred one patients with unstable angina were treated conservatively without the routine use of beta receptor blocking agents, calcium antagonist drugs, anticoagulant agents or nitrates. Only two patients underwent arteriography and coronary arterial bypass surgery during hospitalization and one patient during the 1st year of follow-up study. The 28 day mortality rate was 4 percent and the total 1 year cardiac mortality rate 10 percent. Two patients died from carcinoma. The incidence rate of nonfatal myocardial infarction was 9 percent during the first 28 days and a further 3 percent for the 1st year. These results compare favorably with the immediate and 1 year prognosis reported from other studies using different treatment procedures, including modern intensive drug treatment and coronary arterial bypass surgery. Various factors studied during the acute stage of unstable angina were assessed in an effort to predict the immediate and long-term outcome. Only persistence of pain after admission to the hospital was found a significant indicator of an adverse prognosis. Modern medical treatment of unstable angina with beta receptor blocking agents, calcium antagonist drugs, anticoagulant agents, nitrates and antiarrhythmic agents is critically examined. The paucity of proper randomized controlled studies confirming the value of medication is underlined. There is little evidence to show that aggressive or intensive medical or surgical treatment is superior to a conservative approach to management in the coronary care unit. This approach includes bed rest until the pain has resolved, symptomatic drug treatment only, the minimal use of invasive investigations and careful risk factor intervention.

Between 1961 and 1975 the proportion of cigarette smokers among male patients with acute coronary heart disease showed a progressive decline from 87.1 to 66.1%. There was a corresponding increase in the proportion of ex-smokers and non-smokers. Factors which might have accounted for this trend were examined. Changing diagnosis, altered prevalence of other risk factors and social class changes in patient referral would not appear to have accounted for the observed smoking trends. It is suggested that the observed trends in cigarette-smoking habits may be real and that they may represent a change in the epidemiological pattern of coronary heart disease in Ireland.

One hundred patients admitted to coronary care with unstable angina were followed for a period of 1 year. A conservative approach to treatment was adopted. Routine beta blockers, calcium antagonists, and anticoagulants were not employed. Patients with persistent pain following admission were treated with nitrates only and with symptomatic treatment. One death and nine nonfatal infarctions occurred within the first 28 days after admission. A total of eight deaths, 14 nonfatal infarctions, and three readmissions for unstable angina occurred during the follow-up period of 1 year. Of the various initial factors studied, persistence of pain and the magnitude and extent of ECG ST-T changes were the only predictors of an unfavorable outcome. Non-smokers and those with a previous history of angina on effort had a significantly higher incidence of persistence of pain. The withdrawal of beta blockers on admission and the late administration of beta blockers to those with persistent pain did not appear to influence outcome.

Information about the cigarette smoking habits at the time of death was available for 261 male decedents who had survived a previous bout of confirmed unstable angina or myocardial infarction. The cause and mode of death were known for 259 of these subjects. Smoking habits at time of death did not appear to affect the mode or cause of death. Previous reports of a higher ratio of sudden death compared to deaths from myocardial infarction in smokers compared to non-smokers were not confirmed by us. A previous report of a high incidence of suicide and accidental death in healthy subjects who stopped smoking was not confirmed amongst these survivors of a coronary event. No case of suicide and only one accidental death was noted amongst 87 of 282 subjects who had stopped smoking after a coronary attack.

Three hundred and sixty-four men who survived a first episode of acute coronary insufficiency or myocardial infarction for 28 days were admitted to a coronary heart disease secondary programme between 1 January 1961 and 31 December 1971. Of these, 252 have been followed for at least 4 years. The 4-year mortality was 13.5 per cent (34 patients). The average mortality was 3.4 per cent but an excess of deaths occurred during the first year of follow-up. Of 11 characteristics measured during the acute attack, only severity of the attack was significantly associated with poor 4-year survival. Cigarette consumption after infarction was significantly less among those surviving the 4-year period when compared with decedents. Follow-up systolic and diastolic blood pressure levels were significantly lower among decedents. No significant differences were noted in serum cholesterol levels and in mean weight, The presence of post-infarction angina did not affect the prognosis.

Summary and Conclusions One hundred and seventeen survivors of a first attack of acute coronary heart disease had blood carboxy-haemoglobin levels checked and smoking histories recorded. All were participants in a longterm follow-up and secondary prevention programme. At last follow-up, four to eighteen years after the initial attack, 35 stated that they were still smoking, 57 claimed to be ex-smokers, 6 were non-smokers and 19 were pipe or cigar smokers. Thirty-one of the 35 current smokers had a COHb concentration which exceeded 1.6 %. Five of the ex-smokers had concentrations between 1.6 and 2.3%. There was a low and possibly zero deception rate amongst the ex-smokers. This may reflect a high degree of rapport achieved between patients and medical staff during an exceptionally long and regular follow-up period.

One hundred women with classical coronary heart disease were studied in an attempt to identify etiological factors. Three dominant factors were hypertension, cigarette smoking, and hypercholesterolemia. Cigarette smoking and hypertension were present together or separately in 80 to 90% of the patients. Four patients were diabetics; six had grossly abnormal serum cholesterol levels; and there was one case each of associated myxedema, aortic stenosis, and postoperative hypotension. Comments are made about the role of family history, obesity, hypercholesterolemia, abnormal glucose tolerance, exercise and dietary experience, and the influence of the menopause. It is believed that the proper control of hypertension in the population and the elimination of cigarette smoking would cause an appreciable or even dramatic reduction in the incidence of precocious and middle-aged coronary heart disease in women.

Thirty-five patients with acute coronary insufficiency and 180 patients with myocardial infarction received coronary care over a period of 18 months. Arrhythmic complications were unusual in patients with acute coronary insufficiency and other serious complications did not occur. One death (3%) occurred among patients with acute coronary insufficiency compared to 36 (20%) of patients with myocardial infarction. The management of patients with acute coronary insufficiency in a coronary care unit is discussed.

The effects of maternal age, parity, and cigarette smoking on baby weight are reported in 10,692 mothers. Maternal age and parity have no significant effect, but cigarette smoking is associated with a highly significant reduction in baby weight. The effect of smoking is dose-related up to a consumption of 10 to 12 cigarettes per day. Some possible mechanisms of the action of cigarette smoking are reviewed. The adverse effect of increased carboxyhemoglobin in the fetal blood in the earlier months of pregnancy is considered as a possible cause of later retarded fetal growth and development.

135 eases of bundle branch block have been studied over a period of 5 years. Details of age, sex and aetiological background of both types of BBB are presented and current views on pathogenesis are briefly examined.

Problems in the elucidation of the causes of coronary heart disease are discussed. The author refers in detail to the prospective and retrospective epidemiological techniques. The author contends that the retrospective approach is neglected by workers in the coronary heart disease research field. The reasons for this neglect are discussed and suggestions are put forward to ensure the acceptability of the retrospective approach. Results from a comprehensive retrospective study are reported by the author and compared with results from prospective studies. A special note is made of Ireland’s suitability for epidemiological studies.