Geographical variation and time trends in the attack rate of coronary heart disease in five Swedish cities.

Based upon community myocardial infarction (MI) records in five Swedish cities, geographical variation and time trends in the attack rate of fatal and non-fatal MI have been evaluated. During the study period 1975-1982, a total of 7699 events were registered among men and 1823 events among women. The mean annual mortality was highest in the north, and a declining gradient in mortality was observed from the northern to the southern part of the country. The out-of-hospital death rate was highest in the north, while no difference in in-hospital mortality was observed. However, the geographical variation in the morbidity of MI was less consistent. Changes over time generally followed the same pattern in all cities. The attack rate of fatal and non-fatal MI tended to decline among women and men aged 60-64 years. The pattern was less consistent among younger men. Among women aged 50-59 years the mortality remained unchanged, but the attack rate of non-fatal MI increased in all cities. This increase was not explained by inclusion of less severe infarctions. A considerable proportion, about 85%, were recorded as primary events, emphasizing the possible role of primary prevention in obtaining a decrease in the incidence of the disease. The results of this study support previous findings of an important regional difference in the mortality of MI in Sweden. However, the magnitude of the regional variation in the incidence of coronary heart disease might be overestimated if only the mortality pattern is studied.

Identification of cases of myocardial infarction: hospital discharge data and mortality data compared to myocardial infarction community registers.

Identification of incident myocardial infarction (MI) cases in a defined population using hospital discharge data and mortality data in combination has been suggested. This method of case identification was compared to that of use of MI community registers set up in accordance with principles adopted in a World Health Organization collaborative programme. The comparison comprised data for four Swedish cities over a number of years. On average 81% of incident hospital-treated cases below 65 years of age identified through MI community registers were found by the retrospective use of the method based on hospital discharge data and mortality data. Of hospital-treated cases identified by the latter method, 83% were also found by the MI community registers. For cases fulfilling the diagnostic criteria employed by the MI community registers this proportion would be higher, probably 87%-92%. Several reasons for cases being missed by either method were suggested by the results. According to the findings of this study, the case identification of the method based on hospital discharge data and mortality data seems to be somewhat less efficient compared to use of MI community registers. This may be of importance in descriptive epidemiological studies, but is of less significance in analytical studies. The relative efficiency of the former method could be improved by a more reliable system for the recording of hospital discharges. If supplemented by a validation procedure, it could yield sufficiently accurate data for many epidemiological applications at a fairly low cost.

Clinical efficacy of hydralazine in chronic heart failure: one-year double-blind placebo-controlled study.

In a placebo-controlled trial 62 patients with chronic congestive heart failure (CHF) (New York Heart Association class III) had hydralazine (149 +/- 11 mg daily) or placebo added to conventional therapy. During 12 months' follow-up 27 patients dropped out, 15 of 32 in the hydralazine group and 12 of 30 among the control subjects. The 1-year mortality rate was 28% in the hydralazine group compared to 27% in the control group. Symptomatic improvement was noted in both groups; however, it was gradually more pronounced in the actively treated group with a statistically significant difference between the two groups at month 12 (p less than 0.05). The hydralazine patients increased their exercise capacity 25%, from 53 +/- 3 watts at month 0 to 67 +/- 4 watts at month 12 (p less than 0.01). No improvement in exercise capacity took place in the placebo group. A significant improvement in chest x-ray examination was found with hydralazine (p less than 0.01) in contrast to a significant deterioration among the control subjects (p less than 0.05). Thus, we conclude that hydralazine used in chronic CHF has beneficial clinical effects during long-term treatment.

A controlled study of early discharge after uncomplicated myocardial infarction.

Out of 383 myocardial infarction (MI) patients aged below 70 years, 252 (66%) were judged after the third day in hospital to have had uncomplicated infarctions. These patients were allocated at random to two groups, one of which was given treatment for 8 days and the other for 15 days. No significant differences in mortality, morbidity or incapacity for work could be detected during the three-month period of follow-up. The findings thus support previous conclusions that early discharge from hospital after uncomplicated MI is not associated with greater risk for the patient than later discharge.

The Landry-Guillain-Barré syndrome and pregnancy.

The Landry-Guillain-Barré syndrome is considered rare in connection with pregnancy. In mild cases the course of the pregnancy is unaffected. In severe cases, with respiratory depression and bulbar symptoms, especially during late pregnancy, the syndrome entails an increased risk to both mother and foetus. Therapeutic abortion of cesarean section are not considered to be indicated. A pregnant woman developed the disease during the final trimester and gave birth to premature twins during respirator treatment. The mother and the infants survived.

Long-term treatment with beta-blockers after myocardial infarction.

162 patients discharged from hospital after mycardial infarction were randomly allocated to two groups, one received alprenolol 400 mg daily and the other served as the control. The period of follow-up was two years and all other treatment given was standardized. The two groups did not differ with respect to risk factors for myocardial infarction, the course of the acute infarct or treatment during follow-up. After two years one patient in the group treated with alprenolol had died suddenly as compared to nine in the control group. During the same period four fresh infarcts had occurred in the alprenolol group compared to 15 in the control group. Both these differences were statistically significant. Only four patients were obliged to discontinue beta-blocker treatment because of suspected side-effects. Long-term post-infarction treatment with beta-blockers appears to be an effective form of secondary therapy without serious side-effects.

Extreme digitalis intoxication.

A case of massive digoxin intoxication is described. The concentration of digoxin in plasma, 15.5 ng/ml, is one of the highest observed in an individual not having heart diease who survived the intoxication. During the first two days there was complete heart block but only moderate hyperkalaemia. The advantage of temporary pacemaker treatment under these conditions is emphasized.