Cholesterol and violent behavior.

Despite significant decreases [corrected] in the incidence of myocardial infarction, reduction of total mortality as a result of cholesterol-lowering programs has not been demonstrated. This puzzling outcome has led to several hypotheses linking cholesterol levels and mortality due to accidents, suicide, and homicide. We review the proposed explanations for increased mortality due to violent deaths. We discuss the available evidence and conclude that while there are some intriguing findings based on the well-established relationship between violent behavior and serotonin activity, the necessary link between cholesterol, serotonin, and violence has not been demonstrated. The complexity of the observed violent behaviors and their multiple determinants defies a simple explanation at the present time.

Health maintenance activities of physicians and nonphysicians.

Studying the health maintenance attitudes and behaviors of physicians (MDs) as patients provides information about health maintenance care in a group of individuals where preventive care might flourish. The present study reports the results of a survey of such attitudes and behaviors among 144 university-based MDs and 283 nonphysician doctoral faculty members (non-MDs) from two area universities regarding their personal health maintenance care in 1983. Respondents who reported having a personal MD (44% MDs, 74% non-MDs) were twice as likely to believe they should visit a physician regularly for health maintenance and three times as likely to actually visit a physician for health maintenance as those respondents without a personal physician. Both MDs and non-MDs described the need to visit the doctor more often than they actually reported doing so for health maintenance. However, MDs more often than non-MDs reported receiving the particular health maintenance procedures that are generally considered to constitute essential health maintenance care. A better understanding of health maintenance care by MDs and their non-MD colleagues provides insights into the use and misuse of clinical procedures in the asymptomatic adult.

Accurate patient diagnosis of acute porcine valve failure.

Spontaneous porcine bioprosthetic valve failure is usually of gradual onset. We report a case of acute porcine mitral valve rupture resulting in rapid hemodynamic decompensation. The patient perceived the moment of valvular failure as the abrupt onset of a vibrating sensation in his chest. As the number of patients with porcine bioprostheses continues to increase, acute valvular failure may become a more common clinical entity.

A new wrinkle to the earlobe crease.

Several studies had indicated that the earlobe crease may be a marker of coronary artery disease (CAD). This prospective study of 261 consecutive men undergoing coronary arteriography was carried out to evaluate the association of the earlobe crease with the presence and extent of CAD. A positive earlobe crease was detected in 67% of this population. When examining the presence of CAD in men with (n = 175) and without (n = 86) an earlobe crease, 85% of those with and 85% of those without an earlobe crease showed some degree of CAD. Since the prevalence of an earlobe crease increased with advancing age, we examined the age-specific prevalence rates of CAD in men with and without an earlobe crease and found no significant differences in those rates. A similar lack of association between earlobe crease and CAD was seen when we simultaneously controlled for other potentially confounding factors. We conclude that the reported association between earlobe crease and CAD is due to the fact that the prevalence of earlobe crease and CAD each increase with age.

Acute spontaneous failure of a porcine aortic valve.

The performance of the porcine bioprosthetic heart valve has been well characterized in terms of thrombogenicity, susceptibility to infection, and hemodynamic characteristics. There has been some concern about the frequency and mechanism of late dysfunction of this valve. To date, cases of valve failure have been progressive and gradual. We saw a case of acute, catastrophic, spontaneous failure of a porcine bioprosthetic heart valve. We suggest that in the differential diagnosis of acute aortic insufficiency acute spontaneous failure of a porcine aortic prosthesis be included.

The increased use of diagnostic procedures in patients with acute myocardial infarction. A community-wide perspective.

As part of a community-wide study examining time trends in the incidence and case-fatality rates of 3263 patients hospitalized with validated acute myocardial infarction (MI) during the years 1975, 1978, 1981, and 1984, we examined changes over time in the use of various noninvasive and invasive diagnostic tests during hospitalization for acute MI. In terms of the noninvasive procedures, exercise testing before hospital discharge increased from only 0.1% of patients in 1975 to 40.3% in 1984, while use of echocardiography (2.5%, 1975; 15.3%, 1984), Holter monitoring (1.0%, 1975; 34.0%, 1984), and radionuclide ventriculography (2.6%, 1975; 52.7%, 1984) also increased dramatically. Concerning the invasive procedures, use of coronary arteriography in patients with acute MI increased from 3.1% in 1975 to 9.8% in 1984. A more striking increase was noted in the use of pulmonary artery catheterization (7.2%, 1975; 19.9%, 1984). Examination of patient characteristics associated with the use of these tests demonstrated that the increased use of these diagnostic procedures was not due to changes in the clinical characteristics of patients hospitalized with acute MI; rather, it was the result of changes in physician practice patterns. If the practice patterns seen in this community-based study are similar to those seen throughout the United States, the charges for these diagnostic tests in 1984 are estimated to approach 600 million dollars. Given current interest in cost-containment and evaluation of clinical practices, these results suggest the need for further observational studies and clinical trials to assess the cost-effectiveness of these diagnostic tests. To assess the cost-effectiveness, it will be necessary to determine if the use of these tests improves the short-term or long-term prognosis of patients hospitalized with acute MI.

Occult malignant neoplasm in patients with deep venous thrombosis.

An association between venous thrombosis and cancer was first suggested by Armand Trousseau and subsequently confirmed by multiple postmortem studies. In a previous study, patients with pulmonary embolism, as assessed by pulmonary angiography, were at significantly increased risk of occult cancer with a comparison group of patients without pulmonary embolism. This nonconcurrent prospective epidemiologic study extends these findings by demonstrating a significantly increased risk of occult cancer in patients with deep venous thrombosis (DVT) confirmed by impedance plethysmography as compared with those with suspected DVT in whom the diagnosis was ruled out. Differences in the incidence of malignant neoplasms were greatest within the first two years after the diagnosis of DVT, and patients younger than 50 years with venous thrombosis were at particularly increased risk of occult cancer (relative risk, 19.0). These findings indicate that all patients with DVT or pulmonary embolism should have an appropriate diagnostic workup and careful follow-up, particularly with regard to the risk of occult cancer.

Pulmonary embolism from a venous thrombus located below the knee.

A patient with bronchogenic carcinoma developed acute thrombophlebitis below the knee followed by pulmonary embolism. Sequential nuclear venograms, perfusion lung scans, bilateral impedance plethysmography, and the patient's clinical course indicated that the below-knee thrombus had embolized in its entirety, causing clinically significant disease. This case demonstrates that below-knee thrombi are not always benign and, in certain circumstances, merit anticoagulation.

The clinical implications of bilaterally abnormal impedance plethysmography.

Although impedance plethysmography (IPG) is a test of recognized value in the diagnosis of acute proximal deep venous thrombosis (DVT), its meaning in patients with bilaterally abnormal IPGs is unclear. Consequently, we sought to determine the clinical significance of the bilaterally abnormal IPG in hospitalized patients. In a five-month prospective study, 19% (81/425) of all IPGs done at our institution were bilaterally abnormal (55% of all abnormal IPGs). Acute proximal DVT was found in 26% (14/53) of patients with bilaterally abnormal IPGs who underwent further diagnostic testing. Thirty-five percent of the patients with DVT were found to have either bilateral lower extremity DVT or clots in the inferior vena cava. A numerical score, the venous function index (VFI), was computed for the 101 legs for which further definitive diagnostic evaluations for DVT had been completed. The mean VFI of seven for legs with acute proximal DVT was significantly less than the mean VFI of 13 for legs with no DVT. Fifty percent of legs with a VFI less than or equal to five had DVT, whereas only 7% of legs with a VFI greater than 15 had DVT. The bilaterally abnormal IPG is a common clinical occurrence, is frequently associated with acute DVT, and the VFI is helpful in discriminating legs with acute proximal DVT from normal legs in patients with a bilaterally abnormal IPG.

Superior vena cava syndrome. Its association with indwelling balloon-tipped pulmonary artery catheters.

The placement of flow-directed pulmonary artery catheters has become a routine procedure in hospitals throughout the country. There have been scattered reports of complications associated with their placement, but in general, if it is done under proper conditions, it is associated with low morbidity and mortality. Recently, there have been questions raised regarding the thrombogenicity of these catheters. We report three cases of superior vena cava syndrome associated with the use of indwelling pulmonary artery catheters that we have encountered and a review of experience of others.

Physician attitudes toward cost containment. The missing piece of the puzzle.

A survey of 720 physicians practicing in central and western Massachusetts was undertaken to examine their attitudes toward cost-containment measures. The majority of physicians felt that major techniques (58%), major procedures (57%), inappropriate ordering of diagnostic tests (48%), and malpractice concerns (47%) were very important contributors to increasing health care costs. Physician age, practice affiliation, and specialty area were related to the perceived importance of these factors. In addition, while there was a uniform lack of prior training in cost-containment measures, 48% of all physicians felt that courses in cost-containment techniques would be worthwhile. These results suggest a variety of concerns and issues that need to be considered when attempting to modify the cost-containment attitudes and practices of physicians.

A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study.

A community-wide study was conducted in 16 short-stay hospitals in metropolitan Worcester, Mass, to examine the incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism in patients hospitalized between July 1, 1985, and December 31, 1986. The average annual incidence of deep vein thrombosis alone was 48 per 100,000, while the incidence of pulmonary embolism with or without deep vein thrombosis was 23 per 100,000. The incidence rates of deep vein thrombosis and pulmonary embolism increased exponentially with age. The in-hospital case-fatality rate of venous thromboembolism was 12%. Among patients discharged from the hospital, the long-term case-fatality rates were 19%, 25%, and 30% at 1, 2, and 3 years after hospital discharge. Extrapolation of the data from this population-based study suggests that there are approximately 170,000 new cases of clinically recognized venous thromboembolism in patients treated in short-stay hospitals in the United States each year, and 99,000 hospitalizations for recurrent disease. Because of the silent nature of this disease and the low rate of autopsy in the United States, the total incidence, prevalence, and mortality rates of venous thromboembolism remain elusive.

Feasibility and safety of emergency interhospital transport of patients during early hours of acute myocardial infarction.

The transfer of patients with acute myocardial infarction from community hospitals to tertiary care facilities for further intervention has become increasingly more frequent due to the emerging role of thrombolytic therapy and percutaneous transluminal coronary angioplasty. To assess the feasibility and safety of early transfer, a prospective analysis of 57 patients who were transported by ground ambulance or helicopter to the University of Massachusetts Medical Center, Worcester, for acute intervention during the early hours of myocardial infarction was conducted. Before transport, the majority (46 [81%]) of patients were having chest discomfort, 13 (23%) were hypotensive, and 12 (21%) were electrically unstable (defined as high-grade ventricular ectopia or nonsustained ventricular tachycardia). During transport, the majority (41 [72%]) continued to have some chest discomfort; however, only two (4%) remained hypotensive. Although five patients (9%) were electrically unstable during transport, the instability was considered noncritical. The distance traveled or the mode of transportation did not adversely impact on these clinical complications. All patients survived transport, and 53 patients (93%) were eventually discharged from the receiving hospital.

Serum estradiol levels in male cigarette smokers.

Serum estradiol levels were compared in smoking and nonsmoking men in two separate samples. Sample I consisted of 41 young adult male volunteers ranging in age from 18 to 24 years. Twenty-three men smoked an average of 24.5 +/- 6.9 cigarettes daily. The duration of smoking averaged 5.2 +/- 2.2 years. Sample II consisted of 35 husbands who had been evaluated for infertility; they ranged in age from 19 to 49 years. Eighteen men smoked an average of 21.6 +/- 7.9 cigarettes daily. The duration of smoking averaged 11.5 +/- 4.5 years. Age, height, and weight did not differ significantly between smokers and nonsmokers within either group. Serum estradiol levels were significantly elevated in smokers compared with nonsmokers in both groups (p less than 0.001 and p less than 0.0001 in Samples I and II, respectively). No significant correlations were found between serum estradiol levels and the number of cigarettes smoked daily, or with the duration of smoking in either sample. The differences in serum estradiol levels between smokers and nonsmokers could not be attributed to the differences in marijuana and alcohol use that existed between the smokers and nonsmokers in each sample. The recent reports of elevated serum estradiol levels as a possible risk factor in coronary heart disease are discussed in view of the known relationship of cigarette smoking to coronary heart disease.

Serum estradiol and coronary artery disease.

Serum estradiol levels were measured in 300 men undergoing coronary angiography. Among these men, there were no significant differences in the serum estradiol levels between patients with (mean, 26.4 pg/ml) and those without (mean, 30.9 pg/ml) angiographically confirmed coronary artery disease. There were no significant differences in any of the established coronary risk factors when patients were subdivided according to the presence or absence of coronary artery disease or according to the extent of disease. In addition, no significant correlation was noted between mean serum estradiol levels and the extent of coronary artery disease as classified by the number of obstructed coronary vessels. A matched-pairs analysis was carried out in which patients who had normal coronary arteries were matched with those who had coronary artery disease on the basis of age, cigarette smoking, prior history of myocardial infarction, and body mass index. The mean serum estradiol level in the patients with coronary artery disease was 28.7 pg/ml, and the mean estradiol level was 31.4 pg/ml for the matched patients with normal coronary arteries. In addition, when serial (three) estradiol determinations were carried out in 100 patients, no association was observed between degree of estradiol variability and the occurrence and/or extent of coronary artery disease. The results of this observational study fail to support an association between serum estradiol levels and the presence or degree of coronary artery disease in men as documented by coronary angiography.

Serum estrogen levels in men with acute myocardial infarction.

Serum estradiol and serum estrone levels were assessed in 29 men in 14 men in whom myocardial infarction was ruled out; in 12 men without apparent coronary heart disease but hospitalized in an intensive care unit; and in 28 men who were not hospitalized and who acted as control subjects. (The 12 men who were hospitalized but who did not have coronary heart disease were included to control for physical and emotional stress of a severe medical illness.) Ages ranged from 21 to 56 years. Age, height, and weight did not differ significantly among groups. Blood samples were obtained in the patient groups on each of the first three days of hospitalization. The serum estrone level was significantly elevated in all four patient groups when compared with that in the control group. Estrone level, then, did not differentiate patients with and without coronary heart disease. Serum estradiol levels were significantly elevated in the groups with myocardial infarction, unstable angina, and in the group in whom myocardial infarction was ruled out. However, estradiol levels were not significantly elevated in the group in the intensive care unit without coronary heart disease when compared to the level in the normal control group. Serum estradiol levels, then, were elevated in men with confirmed or suspected coronary heart disease but were not elevated in men without coronary heart disease even under the stressful conditions found in an intensive care unit. Serum estradiol levels were significantly and positively correlated (p less than 0.03) with serum total creatine phosphokinase levels in the patients with myocardial infarction. The five patients with myocardial infarction who died within 10 days of admission had markedly elevated serum estradiol levels. The potential significance of these serum estradiol elevations is discussed in terms of estradiol's ability to enhance adrenergic neural activity and the resultant increase in myocardial oxygen demand.

Valvular heart disease, infected valves and prosthetic heart valves.

The major causes of systemic embolism from valvular heart disease (mitral, aortic and mitral valve prolapse), prosthetic valves (both mechanical and tissue valves) and infected valves (endocarditis) are reviewed from the standpoint of their incidence and complications. Recommendations for therapy with anticoagulants or other antithrombotic therapy are set forth following the guidelines recently provided by the Second American College of Chest Physicians Conference on Antithrombotic Therapy. Adherence to these recommendations can significantly decrease the risk of systemic embolism in patients with these valvular heart problems.

Frequency of painless myocardial ischemia during exercise tolerance testing in patients with and without diabetes mellitus.

To evaluate the frequency of painless myocardial ischemia, all patients with positive exercise tolerance test responses (at least 2 mm of ST depression) from 1983 to 1985 were examined. Of the 211 patients with exercise-induced ischemia, 101 (48%) did not have pain during the ischemic period; 26 (12%) had diabetes mellitus, 24 of whom (92%) had type II diabetes mellitus. Lack of pain was not correlated with age, gender, history of cigarette smoking, systemic hypertension, past acute myocardial infarction, coronary artery bypass grafting, use of beta-blocking or calcium-channel blocking drugs, number of narrowed coronary arteries or average calculated ejection fraction at cardiac catheterization. Patients with painless myocardial ischemia were less often taking nitrates (39% vs 55%, p less than 0.05) and reported prior episodes of chest pain less often (50% vs 82%, p less than 0.01) than control subjects. There was no difference in the frequency of painless myocardial ischemia between patients with and without diabetes mellitus (54% vs 47%). Duration of exercise was shorter in patients with diabetes mellitus and in patients who had pain with myocardial ischemia. No significant difference in age, gender, use of nitrates, beta-blocking or calcium-channel blocking drugs, history of myocardial infarction, angina pectoris or cigarette smoking was found between diabetic and nondiabetic patients. Systemic hypertension was more common in diabetic patients. Thus, painless myocardial ischemia is common in our patients with positive exercise tolerance test responses, but its frequency is similar in diabetic and nondiabetic patients.

Outcome after cardiac arrest during acute myocardial infarction.

A community-wide study of acute myocardial infarction (AMI) was conducted in all 16 acute-care general hospitals in the Worcester, Massachusetts, metropolitan area during the years 1975, 1978, 1981 and 1984. The in-hospital and long-term prognoses of 667 patients with AMI complicated by cardiac arrest (CA) was compared with that of 2,596 AMI patients without CA. The incidence of CA complicating AMI was similar (21%) during each of the 4 study years. Among patients with AMI who had CA, 36% had CA within the first day of hospitalization and 48% within the first 2 days. The in-hospital case-fatality rate was much higher for AMI patients with CA (78%) than for those without CA (4%) (p less than 0.001). For patients discharged alive from the hospital, a trend toward a higher mortality rate was seen at 1 and 2 years after hospital discharge for patients with CA; however, long-term survival rates were not significantly different between AMI patients with and without CA. When time of occurrence of CA relative to in-hospital survival was examined, patients with early CA (within 1 day or within 2 days of hospital admission) had a significantly greater in-hospital survival (39% and 34%) than did those with late CA (after 1 day or after 2 days) (13% and 12%). Similarly, patients discharged from the hospital after early CA had a significantly better chance of long-term survival than patients discharged after late CA.

Peak creatine kinase as a measure of effectiveness of thrombolytic therapy in acute myocardial infarction.

As part of the National Heart, Lung, and Blood Institute multicenter Thrombolysis in Myocardial Infarction Trial, the time to peak plasma creatine kinase (CK) activity as a marker of reperfusion in 272 patients with validated acute myocardial infarction was analyzed. Patients were treated with either tissue-type plasminogen activator or streptokinase by intravenous administration. All patients underwent acute coronary angiography. The infarct-related artery was identified and thrombolytic therapy administered. Reperfusion at 90 minutes was documented by angiography. CK was determined before institution of therapy and every 4 hours thereafter for the first 24 hours. Patients were classified into 3 groups for comparative purposes: group 1--occlusion with no reperfusion (n = 119); group 2--occlusion with reperfusion (n = 98); and group 3--subtotal occlusion (n = 55). Early (within 4 hours after treatment) and late (more than 16 hours after treatment) peaking of CK differentiated patients with drug-induced perfusion from those without reperfusion. Although peak CK between 5 and 11 hours after drug treatment did suggest perfusion through the infarct-related artery, it did not differentiate between drug-induced and spontaneous reperfusion. Clinically, early peak CK is a useful noninvasive means of assessing coronary artery patency. However, in clinical trials assessing drug therapy, the use of peak CK may overestimate drug effectiveness by including patients with spontaneous reperfusion.