311
STEPWISE ANALYSIS IN 25 PATIENTS WHO DIED WHILE AWAITING CABS AND IN 50 MATCHED CONTROLS
OR
=
odds ratio, CI
=
confidence interval
compared with 50 controls who had CABS in the same year, matched for age, gender, type of surgery, and priority rating. A stepwise logistic regression of clinical, angiographic, and haemodynamic variables in all 75 patients identified six independent variables predictive for early death after assignment to a waiting list for CABS (table). We were surprised that the presence of unstable angina before angiography and/or severity of coronary artery disease were not the strongest predictors for early mortality; the functional characteristic of a positive exercise test with short duration proved a much stronger predictor. It was also noteworthy that the use of coumarins constituted an independent risk, unrelated to site of infarction and/or impaired left ventricular function. Furthermore impaired left-ventricular function, except that shown by cardiac enlargement on chest radiography, was not associated with early death whereas it is known to be associated with later mortality.3 Thus our results have shown that, even in the short-term while waiting for CABS, these characteristics are independent predictors of death. These indicators may contribute important additional information in the assessment of priorities for treatment in patients at high risk while waiting for CABS. Since our selection criteria were not much different from those Naylor and colleagues propose, one can expect similar findings from studies in which their scoring system is used. feel that their proposed sequence of major factors affecting urgency ranking should be reconsidered.
Therefore,
we
Departments of Cardiology and Cardiovascular Surgery, St Antonius Hospital Nieuwegein, 3435 CM Nieuwegein, Netherlands; and Department of Clinical Epidemiology, Erasmus University, Rotterdam
1.
MAARTEN J. SUTTORP J. HERRE KINGMA EGBERT M. KOOMEN JAN G. P. TIJGSSEN JO A. M. DEFAUW SJEF M. P. G. ERNST
Suttorp MJ, Kingma JH, Koomen EM, et al. Short term mortality in patients selected a case-control study. Am J Coll Cardiol 1990; 15: 116A (abstr). European Coronary Surgery Study Group. Long-term results of prospective randomized study of coronary artery bypass surgery in stable angina pectoris. Lancet 1982; ii: 1173-80. Passamani E, Davis KB, Gillespie MJ, Killip T. A randomized trial of coronary artery bypass surgery: survival of patients with a low ejection fraction. N Engl J Med 1985;
for coronary artery bypass surgery:
2.
3.
312: 1665-71.
Thrombolytic therapy in suspected myocardial infarction SiR,—The practice of starting thrombolysis immediately after the of symptoms of suspected acute myocardial infarction is gaining acceptance. This can lead to therapy beginning before the patient reaches hospital. We wish to add a note of caution. A 49-year-old man collapsed at work. An ambulance was called
onset
and he was taken to the emergency department of our hospital. There he complained of epigastric pain. The patient was alert (blood pressure 115/80 mm Hg, heart rate 95/min) and in severe pain which did not respond to oral nitroglycerine but was alleviated by intravenous nitroglycerine. An electocardiograph showed raised ST levels and high T waves in leads V2-V4 as well as some supraventricular premature beats and ventricular ectopic beats. Creatinine kinase, creatinine kinase-MB, glutamic oxaloacetic transaminase, and lactic dehydrogenase levels were normal. A myocardial infarction was suspected and thrombolytic therapy
discussed. To exclude cerebral haematoma following his collapse computed tomography was done, with normal results. After his transfer to the medical department (about 3 h after the incident) the patient’s enzymes were still normal; however, the red blood cell count was 3xx 10/1 and haemoglobin was 10-0 g/dl. Thrombolytic therapy was ruled out. The cause of the anaemia turned out to be a bleeding ulcer at the pylorus. Electroardiograph findings returned to normal after one day and there was no evidence of coronary heart disease. The patient, who had not had any previous gastric or duodenal complaints, recovered uneventfully on a standard anti-ulcer regimen. In our opinion it is not always easy, even for an experienced physician, to distinguish between myocardial infarction and other diseases with similar patterns of pain and clinical findings. If early thrombolytic therapy becomes standard practice we will have to expect a number of "mistreatments" with - possible fatal consequences. University Medical Clinic 1, A-1090 Vienna, Austria
WOLFGANG BASE PETER SIOSTRZONEK
Hughes Day revisited SiR,—In the Wizard of Oz Dorothy exclaims: "Toto, I do not think in Kansas any more". Her statement is often used to reflect "future shock" when conditions around us change rapidly. Future
we are
shock for coronary care started in Kansas some twenty-five years ago when Hughes Day put together the first coronary care unit in a community hospital, thereby initiating more than two decades of coronary care. Progress has seemed to beget progress, as it does when one is focusing and spending the time on a problem. Cardiopulmonary resuscitation was the foundation for these advances. However, despite the excitement over thrombolysis we seem to be reaching a plateau or a point of diminishing return on our progress curve, because we lack ways to recruit the community. What we need is another Hughes Day to gear us up another notch-to complete the loop in the community just as has been done within hospitals over the past twenty-five years. Educating the community does not seem to be enough. What is lacking is the means to change the behaviour of the community and to re-programme society so that early cardiac care is linked to the
hospital. Thrombolytic therapy can only help those who come into the system early. Perhaps even more important is protection for those patients with prodromal symptoms. There are 6700 hospitals in the United States. Should not such hospitals serve as early cardiac care centres committed to educating the community about early cardiac care, introducing behavioural modification changes, and setting up user-friendly transport arrangements and check-up systems in hospital emergency rooms. Such a link between patients in need and hospitals with the means to provide early cardiac care could be the quantum leap required. Hughes Day was a clinician in a community hospital who brought logic and simplicity to bear in setting up the first coronary care unit. Quarter of a century ago, coronary care units developed overnight because that made sense. The same should apply to early cardiac care centres. Exacting standards of scientific proof may take years to meet, at the expense of human suffering. Paul Dudley White Coronary Care System, Saint Agnes Hospital, Baltimore, Maryland 21229, USA
RAYMOND D. BAHR
Oestrogens, arterial status, and postmenopausal women SIR,-Dr Bourne and colleagues (June 16, p 1470) report a coefficient of variation for measurement of uterine artery pulsatility index (PI), with transvaginal ultrasound in non-pregnant women. However, further data are required before conclusions about the arterial effects of transdermal oestradiol can be drawn from this uncontrolled study. Serum oestradiol concentrations should be measured, since these are highly variable following the application of ’Estraderm TTS’
STEPWISE ANALYSIS IN 25 PATIENTS WHO DIED WHILE AWAITING CABS AND IN 50 MATCHED CONTROLS
OR
=
odds ratio, CI
=
confidence interval
compared with 50 controls who had CABS in the same year, matched for age, gender, type of surgery, and priority rating. A stepwise logistic regression of clinical, angiographic, and haemodynamic variables in all 75 patients identified six independent variables predictive for early death after assignment to a waiting list for CABS (table). We were surprised that the presence of unstable angina before angiography and/or severity of coronary artery disease were not the strongest predictors for early mortality; the functional characteristic of a positive exercise test with short duration proved a much stronger predictor. It was also noteworthy that the use of coumarins constituted an independent risk, unrelated to site of infarction and/or impaired left ventricular function. Furthermore impaired left-ventricular function, except that shown by cardiac enlargement on chest radiography, was not associated with early death whereas it is known to be associated with later mortality.3 Thus our results have shown that, even in the short-term while waiting for CABS, these characteristics are independent predictors of death. These indicators may contribute important additional information in the assessment of priorities for treatment in patients at high risk while waiting for CABS. Since our selection criteria were not much different from those Naylor and colleagues propose, one can expect similar findings from studies in which their scoring system is used. feel that their proposed sequence of major factors affecting urgency ranking should be reconsidered.
Therefore,
we
Departments of Cardiology and Cardiovascular Surgery, St Antonius Hospital Nieuwegein, 3435 CM Nieuwegein, Netherlands; and Department of Clinical Epidemiology, Erasmus University, Rotterdam
1.
MAARTEN J. SUTTORP J. HERRE KINGMA EGBERT M. KOOMEN JAN G. P. TIJGSSEN JO A. M. DEFAUW SJEF M. P. G. ERNST
Suttorp MJ, Kingma JH, Koomen EM, et al. Short term mortality in patients selected a case-control study. Am J Coll Cardiol 1990; 15: 116A (abstr). European Coronary Surgery Study Group. Long-term results of prospective randomized study of coronary artery bypass surgery in stable angina pectoris. Lancet 1982; ii: 1173-80. Passamani E, Davis KB, Gillespie MJ, Killip T. A randomized trial of coronary artery bypass surgery: survival of patients with a low ejection fraction. N Engl J Med 1985;
for coronary artery bypass surgery:
2.
3.
312: 1665-71.
Thrombolytic therapy in suspected myocardial infarction SiR,—The practice of starting thrombolysis immediately after the of symptoms of suspected acute myocardial infarction is gaining acceptance. This can lead to therapy beginning before the patient reaches hospital. We wish to add a note of caution. A 49-year-old man collapsed at work. An ambulance was called
onset
and he was taken to the emergency department of our hospital. There he complained of epigastric pain. The patient was alert (blood pressure 115/80 mm Hg, heart rate 95/min) and in severe pain which did not respond to oral nitroglycerine but was alleviated by intravenous nitroglycerine. An electocardiograph showed raised ST levels and high T waves in leads V2-V4 as well as some supraventricular premature beats and ventricular ectopic beats. Creatinine kinase, creatinine kinase-MB, glutamic oxaloacetic transaminase, and lactic dehydrogenase levels were normal. A myocardial infarction was suspected and thrombolytic therapy
discussed. To exclude cerebral haematoma following his collapse computed tomography was done, with normal results. After his transfer to the medical department (about 3 h after the incident) the patient’s enzymes were still normal; however, the red blood cell count was 3xx 10/1 and haemoglobin was 10-0 g/dl. Thrombolytic therapy was ruled out. The cause of the anaemia turned out to be a bleeding ulcer at the pylorus. Electroardiograph findings returned to normal after one day and there was no evidence of coronary heart disease. The patient, who had not had any previous gastric or duodenal complaints, recovered uneventfully on a standard anti-ulcer regimen. In our opinion it is not always easy, even for an experienced physician, to distinguish between myocardial infarction and other diseases with similar patterns of pain and clinical findings. If early thrombolytic therapy becomes standard practice we will have to expect a number of "mistreatments" with - possible fatal consequences. University Medical Clinic 1, A-1090 Vienna, Austria
WOLFGANG BASE PETER SIOSTRZONEK
Hughes Day revisited SiR,—In the Wizard of Oz Dorothy exclaims: "Toto, I do not think in Kansas any more". Her statement is often used to reflect "future shock" when conditions around us change rapidly. Future
we are
shock for coronary care started in Kansas some twenty-five years ago when Hughes Day put together the first coronary care unit in a community hospital, thereby initiating more than two decades of coronary care. Progress has seemed to beget progress, as it does when one is focusing and spending the time on a problem. Cardiopulmonary resuscitation was the foundation for these advances. However, despite the excitement over thrombolysis we seem to be reaching a plateau or a point of diminishing return on our progress curve, because we lack ways to recruit the community. What we need is another Hughes Day to gear us up another notch-to complete the loop in the community just as has been done within hospitals over the past twenty-five years. Educating the community does not seem to be enough. What is lacking is the means to change the behaviour of the community and to re-programme society so that early cardiac care is linked to the
hospital. Thrombolytic therapy can only help those who come into the system early. Perhaps even more important is protection for those patients with prodromal symptoms. There are 6700 hospitals in the United States. Should not such hospitals serve as early cardiac care centres committed to educating the community about early cardiac care, introducing behavioural modification changes, and setting up user-friendly transport arrangements and check-up systems in hospital emergency rooms. Such a link between patients in need and hospitals with the means to provide early cardiac care could be the quantum leap required. Hughes Day was a clinician in a community hospital who brought logic and simplicity to bear in setting up the first coronary care unit. Quarter of a century ago, coronary care units developed overnight because that made sense. The same should apply to early cardiac care centres. Exacting standards of scientific proof may take years to meet, at the expense of human suffering. Paul Dudley White Coronary Care System, Saint Agnes Hospital, Baltimore, Maryland 21229, USA
RAYMOND D. BAHR
Oestrogens, arterial status, and postmenopausal women SIR,-Dr Bourne and colleagues (June 16, p 1470) report a coefficient of variation for measurement of uterine artery pulsatility index (PI), with transvaginal ultrasound in non-pregnant women. However, further data are required before conclusions about the arterial effects of transdermal oestradiol can be drawn from this uncontrolled study. Serum oestradiol concentrations should be measured, since these are highly variable following the application of ’Estraderm TTS’
