Underuse of beta-blockers following myocardial infarction: a tale of two cities.

AIMS: To measure factors associated with underuse of beta-blocker therapy after myocardial infarction (MI). METHODS: The Newcastle and Perth collaborating centres of the World Health Organization (WHO) MONICA project (to MONItor trends and determinants of Cardiovascular disease) systematically evaluated all patients admitted to hospital in their respective regions with possible MI. A total of 1766 patients in Newcastle and 4,503 patients in Perth, discharged from hospital after confirmed MI from 1985 to 1993, were studied. Rates of beta-blocker use before and after hospital discharge were evaluated and correlates of beta-blocker use determined. RESULTS: Beta-blocker use was similar in Newcastle and Perth before MI (21% of patients in each centre). During hospital admission, beta-blocker therapy was initiated nearly twice as frequently in Perth compared with Newcastle (66 vs 36%, respectively) and more patients were discharged from hospital on beta-blockers in Perth (68%) than in Newcastle (45%). The main factors associated with underuse of beta-blockers in multivariate analysis were geographical centre (odds ratio (OR) for Newcastle compared with Perth 0.3; 95% confidence interval (CI) 0.3-0.3), a history of previous MI (OR 0.6, 95% CI 0.5-0.7), admission to hospital in earlier years (OR 0.4, 95% CI 0.3-0.4 for years 1985-87 compared with years 1991-93), diabetes (OR 0.6, 95% CI 0.5-0.8) and the concomitant use of diuretics (OR 0.5, 95% CI 0.4-0.6) and calcium antagonists (OR 0.6, 95% CI 0.5-0.8). CONCLUSIONS: Underuse of beta-blockers after MI was strongly related to hospital prescribing patterns and not to community use of beta-blockers. Underuse occurred in patients with diabetes and in patients with left ventricular dysfunction, patients who stand to benefit most from beta-blocker use following MI.

Australian doctors' beliefs and practice regarding Helicobacter pylori.

OBJECTIVE: To determine beliefs and behaviours of Australian doctors regarding Helicobacter pylori. DESIGN: Anonymous reply-paid postal survey mailed in December 1995 and again in March 1996. SUBJECTS: All members on the mailing lists of the Gastroenterological Society of Australia Endoscopy Section (n = 397) and the Australian Society of Infectious Diseases (n = 264; those without medical qualifications were asked not to reply), and 400 general practitioners (GPs) randomly selected from the Royal Australian College of General Practitioners. MAIN OUTCOME MEASURES: Differences between specialist groups in belief in a causative association between H. pylori and peptic disease and in use of eradication therapy and pre- and post-treatment testing for H. pylori. RESULTS: 92.6% of doctors believed H. pylori causes duodenal ulcer, with GPs significantly less likely to believe than gastroenterologists (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.00-0.81). In duodenal ulcer, 93.4% of doctors believed H. pylori eradication therapy should be given, but fewer (83.4%) claimed to give it "always or mostly", with GPs less likely to report giving it than gastroenterologists (OR, 0.06; 95% CI, 0.02-0.19). For non-ulcer dyspepsia, gastrointestinal surgeons were more likely than gastroenterologists to believe in a causative link with H. pylori (OR, 5.6; 95% CI, 3.0-10.7) and in a need for eradication therapy (OR, 3.6; 95% CI, 1.7-7.7). Most doctors (79.3%) believed in confirming the presence of H. pylori before eradication therapy in duodenal ulcer. Only 51.6% believed post-eradication testing necessary (45.5%), yet 79.1% reported performing it. CONCLUSIONS: Significant differences exist between specialist groups in beliefs and self-reported behaviours regarding H. pylori.

Declining rates of coronary heart disease in New Zealand and Australia, 1983-1993.

The authors report the results of 10 years of monitoring of trends in the rates of major nonfatal and fatal coronary events and in case fatality in Auckland, New Zealand, and in Newcastle and Perth, Australia. Continuous surveillance of all suspected myocardial infarctions and coronary deaths in people aged 35-64 years was undertaken in the three centers as part of the World Health Organization's Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Project. For nonfatal definite myocardial infarction, there were statistically significant declines in rates in all centers in both men and women, with estimated average changes between 2.5% and 3.7% per year during the period 1984-1993. Rates of all coronary deaths also declined significantly in all three populations for both men and women. In absolute terms, there was, in general, a greater reduction in prehospital deaths than in deaths after hospitalization. Although 28-day case fatality remains high at between 35% and 50%, in the Australian centers it declined significantly by between 1.0% and 2.9% per year, and in Auckland there was also a small decline. However, since most deaths occur outside the hospital in people without a previous history of coronary heart disease, an increased emphasis on primary prevention is necessary.

A case-control study of traffic risk factors and child pedestrian injury.

BACKGROUND: Pedestrian injuries in children constitute an important cause of mortality and morbidity. Specific hazards which contribute to these injuries need to be identified to enable the development of preventive strategies. METHODS: A population-based case-control study was conducted in which 40 aspects of traffic and road environment that contribute to the likelihood of childhood pedestrian injury were examined. The factors of interest were measured at 100 places of injury and 200 control sites between December 1991 and December 1993. RESULTS: The volume of traffic (odds ratio [OR] = 2.16 for an increase of 100 vehicles per hour) in combination with the proportion of vehicles exceeding the speed limit (OR = 1.04) for each 1% increase in average speed, and the presence of footpaths (OR = 11.0) were associated with significant increase in the risk of injury. A graded inverse relationship was present between socioeconomic status and the odds of pedestrian injury. CONCLUSIONS: These findings have obvious implications for public health as features of the physical environment are potentially modifiable.

Trends in the home management of non-fatal acute myocardial infarction in Perth, Western Australia between 1984 and 1993.

BACKGROUND: Trends in the incidence of acute myocardial infarction (AMI) that are based on admissions to hospital would be misleading if the proportion of non-fatal infarctions treated at home changed over time. AIM: To estimate trends in the management at home of cases of non-fatal AMI in Perth between 1984 and 1993 in order to determine if the number of such cases has remained consistently small and can be neglected in studies of the incidence of AMI. METHODS: In 1989, 251 general practitioners in Perth responded to a postal questionnaire asking about management of cases of AMI at home in the preceding 12 months. In 1993, 288 general practitioners and 174 physicians responded to the same questionnaire. RESULTS: We estimate that 1.5% of all patients less than 65 years of age diagnosed with non-fatal AMI were managed at home in 1989. The corresponding figure for 1993 was 4.1%. A previous study in Perth in 1984 found that 3.9% of cases of non-fatal AMI in patients less than 65 years of age were managed at home. CONCLUSION: The management at home of cases of non-fatal AMI in people of working age in Perth has remained at a negligible level from 1984 to 1993. Thus a register based on admissions to hospital for AMI will accurately reflect trends in AMI in people of working age.

Prevalence of depression after stroke: the Perth Community Stroke Study.

BACKGROUND: The Perth Community Stroke Study (PCSS) was a population-based study of the incidence, cause, and outcome of acute stroke. METHOD: Subjects from the study were assessed initially, by examination and interview, and at four- and 12-month follow-ups to determine differences in prevalence of depression between the sexes and between patients with first-ever and recurrent strokes. RESULTS: The prevalence of depressive illness four months after stroke in 294 patients from the PCSS was 23% (18-28%), 15% (11-19%) major depression and 8% (5-11%) minor depression. There were no significant differences between the sexes or between patients with first-ever and recurrent strokes. With a non-hierarchic approach to diagnosis of those with depression, 26% of men and 39% of women had an associated anxiety disorder, mainly agoraphobia. Nine per cent of male and 13% of female patients interviewed had evidence of depression at the time of the stroke. Twelve months after stroke 56% of the men were still depressed (40% major and 16% minor), as were 30% of the women (12% major and 18% minor). CONCLUSION: The prevalence of depression after stroke was comparable with that reported from other studies, and considerably less than that reported from in-patient and rehabilitation units.

Anxiety disorders after stroke: results from the Perth Community Stroke Study.

BACKGROUND: The prevalence of anxiety disorders in 294 patients who survived to four months in the Perth Community Stroke Study (Perth, Australia), and a follow-up of these patients at 12 months, are presented. METHOD: Diagnoses are described both in the usual DSM hierarchic format and by a non-hierarchic approach. Adoption of the hierarchic approach alone greatly underestimates the prevalence of anxiety disorders. RESULTS: Most cases were of agoraphobia, and the remainder were generalised anxiety disorder. The prevalence of anxiety disorders alone was 5% in men and 19% in women; in community controls, it was 5% in men and 8% in women. Adopting a non-hierarchic approach to diagnosis gave a prevalence of 12% in men and 28% in women. When those who showed evidence of anxiety disorder before stroke were subtracted, the latter prevalence was 9% in men and 20% in women. CONCLUSION: One-third of the men and half of the women with post-stroke anxiety disorders showed evidence of either depression or an anxiety disorder at the time of the stroke. At 12 month follow-up of 49 patients with agoraphobia by a non-hierarchic approach, 51% had recovered, and equal proportions of the remainder had died or still had agoraphobia. The only major difference in outcome between those with anxiety disorder alone and those with comorbid depression was the greater mortality in the latter.

Predicting survival for 1 year among different subtypes of stroke. Results from the Perth Community Stroke Study.

BACKGROUND AND PURPOSE: Few studies have evaluated the factors influencing or predicting long-term survival after stroke in an unselected series of patients in whom the underlying cerebrovascular pathology is clearly defined. Moreover, the relative importance of risk factors for stroke, including sociodemographic and premorbid variables, has not been described in detail. METHODS: The study cohort consisted of 492 patients with stroke who were registered with a population-based study of acute cerebrovascular disease undertaken in Perth, Western Australia, during an 18-month period in 1989 and 1990. Objective evidence of the pathological basis of the stroke was obtained in 86% of cases, and all deaths among patients during a follow-up of 1 year were reviewed. RESULTS: One hundred twenty patients (24%) died within 28 days of the onset of stroke. Among the different subtypes of stroke, the 1-year case fatality (mean, 38%) varied from 6% and 16% for boundary zone infarction and lacunar infarction, respectively, to 42% and 46% for subarachnoid hemorrhage and primary intracerebral hemorrhage, respectively. Using Cox proportional-hazards analysis, a predictive model was developed on 321 patients with acute stroke (test sample). The best model contained five baseline variables that were independent predictors of death within 1 year: coma (relative risk [RR], 3.0; 95% confidence interval [CI], 1.1 to 8.4), urinary incontinence (RR, 3.9; 95% CI, 1.4 to 10.6), cardiac failure (RR, 6.5; 95% CI, 2.8 to 15.1), severe paresis (RR, 4.9; 95% CI, 1.6 to 15.5), and atrial fibrillation (RR, 2.0; 95% CI, 1.1 to 3.5). The sensitivity, specificity, and negative predictive value of this model for predicting death were 90%, 83%, and 95%, respectively. When applied to a second randomly selected validation sample of 171 events, sensitivity was 94%, specificity 62%, and negative predictive value 92%, indicating stability of the model. CONCLUSIONS: Although the case fatality, timing, and cause of death vary considerably among the different pathological subtypes of stroke, simple clinical measures that reflect the severity of the neurological deficit and associated cardiac disease at onset independently predict death by 1 year and may help to direct management.

Validation of a clinical classification for subtypes of acute cerebral infarction.

The validity of a clinical classification system was assessed for subtypes of cerebral infarction for use in clinical trials of putative stroke therapies and clinical decision making in a population based stroke register (n = 536) compiled in Perth, Western Australia in 1989-90. The Perth Community Stroke Project (PCSS) used definitions and methodology similar to the Oxfordshire Community Stroke Project (OCSP) where the classification system was developed. In the PCSS, 421 cases of cerebral infarction and primary intracerebral haemorrhage (PICH), confirmed by brain imaging or necropsy, were classified into the subtypes total anterior circulation syndrome (TACS), partial anterior circulation syndrome (PACS), lacunar syndrome (LACS), and posterior circulation syndrome (POCS). In this relatively unselected population, relying exclusively on LACS for a diagnosis of PICH had a very low sensitivity (6%) and positive predictive value (3%). Comparison of the frequencies and outcomes (at one year after the onset of symptoms) for each subgroup of first ever cerebral infarction in the PCSS (n = 248) with the OCSP (n = 543) registers showed uniformity only for LACI. For example, there were 27% of cases of TACI in the PCSS compared with 17% in the OCSP (difference = 10%; 95% confidence interval (95% CI) 4% to 16%) and 15% of cases in the PCSS compared with 24% in the OCSP were POCI (difference = 9%; 95% CI 3% to 15%). Case fatalities and long-term handicap across the subgroups were not significantly different between studies, but the frequencies of recurrent stroke were significantly greater for POCI in the OCSP compared with the PCSS. Although this classification system defines subtypes of stroke with different outcomes, simple clinical measures-level of consciousness, paresis, disability, and incontinence at onset-are more powerful predictors of death or dependency at one year. It is concluded that simple clinical measures that reflect the severity of the neurological deficit should complement this classification system in clinical trials and practice.

Spectrum of primary intracerebral haemorrhage in Perth, Western Australia, 1989-90: incidence and outcome.

In a population based register of stroke (n = 536) compiled in Perth, Western Australia during an 18 month period in 1989-90, 60 cases (11%) of primary intracerebral haemorrhage were identified among 56 persons (52% men). The mean age of these patients was 68 (range 23-93) and 46 (77%) events were first ever strokes. The crude annual incidence was 35 per 100,000, with a peak in the eighth decade, and a male predominance. Deep and lobar haemorrhages each accounted for almost one third of all cases. The clinical presentations included sudden coma (12%), headache (8%), seizures (8%), and pure sensory-motor stroke (3%). Primary intracerebral haemorrhage was the first presentation of leukaemia in two cases (both fatal) and it followed an alcoholic binge in four cases. 55% had a history of hypertension. 16 (27%) patients, half of whom had a history of hypertension, were taking antiplatelet agents, and one patient was taking warfarin. There were only two confirmed cases of amyloid angiopathy. The overall 28 day case fatality was 35%, but this varied from 100% for haemorrhages in the brainstem to 22% for those in the basal ganglionic or thalamic region. Other predictors of early death were intraventricular extension of blood, volume of haematoma, mass effect, and coma and severe paresis at onset. Although based on small numbers, these data confirm the heterogeneous nature of primary intracerebral haemorrhage, but they also suggest a different clinical spectrum of this type of stroke in the community compared with the experience of specialist neurological units.

Early identification of patients at low risk of death after myocardial infarction and potentially suitable for early hospital discharge.

OBJECTIVES: To find (a) whether data available shortly after admission for acute myocardial infarction can provide a reliable prognostic indicator of survival at 28 days, and (b) whether such an indicator might be used to identify patients at low risk of death and suitable for early discharge. DESIGN: Retrospective analysis of data collected on patients admitted to a coronary care unit for acute myocardial infarction. A validation sample was selected at random from these patients. SETTING: Coronary care units in Perth, Western Australia. SUBJECTS: 6746 patients aged under 65 and resident in the Perth Statistical Division who during 1984-92 were admitted to a coronary care unit with symptoms of myocardial infarction. MAIN OUTCOME MEASURES: Sensitivity and specificity of several models for predicting survival at 28 days after myocardial infarction, and detailed performance characteristics of a particular model. RESULTS: Patients with a pulse rate of 100 beats/min or less, aged 60 or under, and with symptoms typical of myocardial infarction, no past history of myocardial infarction or diabetes, and no significant Q wave in the admission electrocardiogram had a very high chance of survival at 28 days (99.2%). These patients made up one third of all patients studied. CONCLUSION: The prognostic index identifies patients very soon after admission who are at low risk of death and potentially eligible for early discharge from hospital or the coronary care unit. Computing the index does not need complex cardiac investigations.

Stroke incidence and case fatality in Australasia. A comparison of the Auckland and Perth population-based stroke registers.

BACKGROUND AND PURPOSE: Population-based studies are crucial for identifying explanations for the decline in mortality from stroke and for generating strategies for public health policy. However, the present particular methodological difficulties, and comparability between them is generally poor. In this article we compare the incidence and case fatality of stroke as assessed by two independent well-designed incidence studies. METHODS: Two registers of acute cerebrovascular events were compiled in the geographically defined metropolitan areas of Auckland, New Zealand (population 945,369), during 1991-1992 for 12 months and Perth, Australia (population 138,708), during 1989-1990 for 18 months. The protocols for each register included prospective ascertainment of cases using multiple overlapping sources and the application of standardized definitions and criteria for stroke and case fatality. RESULTS: In Auckland, 1803 events occurred in 1761 residents, 73% of which were first-ever strokes. The corresponding figures for Perth were 536 events in 492 residents, 69% of which were first-ever strokes. Both studies identified a substantial proportion of nonfatal strokes managed solely outside the hospital system: 28% in Auckland and 22% in Perth of all patients registered. The age-standardized annual incidence of stroke (all events) was 27% higher among men in Perth compared with Auckland (odds ratio, 1.27; P = .016); women tended to have higher rates in Auckland, although these differences were not statistically significant. In both centers approximately a quarter of all patients died within the first month after a stroke. There were significant differences in the prevalence of hypertension among first-ever strokes. CONCLUSIONS: These two studies emphasize the importance of identifying all patients with stroke, both hospitalized and nonhospitalized, in order to measure the incidence of stroke accurately. The incidence and case fatality of stroke were remarkably similar in Auckland and Perth in the early 1990s. However, there are differences in the sex-specific rates that correspond to differences in the pattern of risk factors.

Medical care and case fatality from myocardial infarction and coronary death in Newcastle and Perth.

Coronary mortality rates are significantly higher in Newcastle than Perth. In this paper we examine the extent to which this might be due to differences in medical treatment and case fatality. Population-based disease registers were used to identify all cases of non-fatal definite myocardial infarction (MI) and coronary death in people aged 25-64 years in the study populations between July 1988 and June 1990. Case fatality (at 28 days from onset of symptoms) was not significantly different between the centres. Thrombolytic therapy was used for one third of all hospitalised events in both centres. Other drugs of proven benefit were, however, used more often in Perth than in Newcastle. For example, during hospitalisation 74% of patients in Perth received beta-blockers compared with 41% in Newcastle (difference = 33%, 95% confidence interval (CI): 28%, 37%) and 85% of patients in Perth compared with 72% in Newcastle received aspirin (difference = 13%, 95% CI: 9%, 17%). Median lengths of stay in a coronary care unit (CCU) and total hospital stay were one day shorter in Perth. As case fatality was similar, the differences in mortality rates can be attributed mainly to differences in attack rates. Greater use of cardio-active drugs in Perth apparently did not result in improved short-term outcome although potential long-term benefits cannot be judged yet.

Ascertaining the true incidence of stroke: experience from the Perth Community Stroke Study, 1989-1990.

OBJECTIVE: To determine the age and sex specific incidence, and case fatality of stroke in Perth, Western Australia. DESIGN AND SETTING: A population-based descriptive epidemiological study. SUBJECTS: All residents of a geographically defined segment of the Perth metropolitan area (population 138,708) who had a stroke or transient ischaemic attack between 20 February 1989 and 19 August 1990, inclusive. MAIN OUTCOME MEASURES: Definite acute "first-ever-in-a-lifetime" (first-ever) and recurrent stroke classified according to standard definitions and criteria. RESULTS: During the 18-month study period, 536 stroke events occurred among 492 patients, 69% of which were first-ever strokes. The crude annual event rate for all strokes was 258 (95% confidence interval 231-285) per 100,000, and the overall case fatality at 28 days was 24% (95% CI, 20%-28%). The crude annual incidence for first-ever strokes was 178 (95% CI, 156-200) per 100,000; 189 (95% CI, 157-221) per 100,000 in males and 166 (95% CI, 136-196) per 100,000 in females. The corresponding rates, age-adjusted to the "world" population, were 132 (95% CI, 109-155) for males and 77 (95% CI, 60-94) for females. CONCLUSIONS: In contrast to mortality rates for ischaemic heart disease, the incidence of stroke in Australia appears little different from that for several other Western countries. For both males and females the incidence of stroke rises exponentially with increasing age. Although the sex-dependent difference in the risk of stroke is greatest in middle age, males are at greater risk of stroke even among the most elderly. To determine the incidence of stroke accurately, population-based studies of stroke need exhaustive and overlapping sources of case ascertainment. If only cases admitted to hospital had been used, we would have underestimated the rate of stroke among the most elderly by almost 40%. We estimate that approximately 37,000 people, about 50% of whom are over the age of 75, suffer a stroke each year in Australia.

Determining the incidence of different subtypes of stroke: results from the Perth Community Stroke Study, 1989-1990.

OBJECTIVE: To determine the incidence and case fatality of seven distinct subtypes of stroke in Perth, Western Australia. DESIGN AND SETTING: A population-based descriptive epidemiological study. SUBJECTS: All residents of a geographically defined segment of the Perth metropolitan area (estimated population 138,708 persons) who had a stroke or transient ischaemic attack between 20 February 1989 and 19 August 1990, inclusive. MAIN OUTCOME MEASURES: The following subtypes of stroke were classified according to standard clinical, radiological and pathological criteria: types of cerebral infarction, namely, large artery (thrombotic) occlusive infarction (LAOI), cerebral embolic infarction (EMBI), lacunar infarction (LACI) and boundary zone infarction (BZI); primary intracerebral haemorrhage (PICH); subarachnoid haemorrhage (SAH); and stroke of undetermined cause. RESULTS: Over the 18-month study period 536 stroke events were registered, of which 86% (95% confidence interval, 83%-89%) had a defined "pathological" diagnosis on the basis of computed tomographic scanning, magnetic resonance imaging or necropsy. Cerebral infarction accounted for 71% of cases (95% CI, 68%-75%), PICH 11% (95% CI, 9%-14%) and SAH 4% (95% CI, 2%-5%). The 382 cases of cerebral infarction included LAOI (in approximately 71%), EMBI (15%), LACI (10%) and BZI (5%). While the incidence of all subtypes of stroke increased with age, there were age and sex differences in their proportional frequency, management and prognosis: patients with PICH, SAH and EMBI were more likely to be admitted to hospital, and these conditions carried the highest early case fatality. Over all, the 28-day case fatality was 24% (95% CI, 20%-28%), but varied from 0 for LACI and BZI, to 37% (95% CI, 15%-59%) for SAH and 35% (CI, 23%-47%) for PICH. CONCLUSIONS: In this study, we found considerable differences in incidence rates, the effect of age and sex on incidence rates, and prognosis for the different subtypes of stroke. Hospital-based studies are likely to be selectively biased by emphasising strokes that are severe and require admission to hospital. These data have important implications in the design and evaluation of clinical trials of therapy for stroke.

Childhood pedestrian injuries in the Perth metropolitan area.

OBJECTIVE: To examine the characteristics of childhood pedestrian injuries in the Perth metropolitan area from 1980 to 1989. DESIGN: Retrospective descriptive study. SETTING: Perth metropolitan area, Western Australia. PARTICIPANTS: Child pedestrians aged 0 to 14 years who were injured during the period 1 January 1980 to 31 December 1989. MAIN OUTCOME MEASURES: An extensive database which reported fatal and non-fatal motor vehicle collisions was used to obtain details on the child pedestrian, the vehicle involved in the collision, and the environmental factors related to these injuries. RESULTS: A total of 1282 child pedestrian injuries were reported in the 10 year period. Children aged between 5 and 9 years, and were overrepresented among those injured. This study also demonstrated a similar proportion of injuries involving the 10-14 year age group. Injuries frequently occurred mid block, on local urban roads, between the hours of 3 p.m. and 7 p.m., and a greater than expected proportion of drivers involved in these collisions were in the under-21 age category. To describe the pattern of childhood pedestrian injuries we calculated both age-specific injury rates, and injury rates based on the number of registered motor vehicles. The latter revealed a greater than 20-fold variation between local government areas. CONCLUSIONS: Further analytical research, incorporating a measure of the child pedestrian's exposure to roads and traffic is required to identify those features in the individual and the environment which have a significant influence on the likelihood of a collision. Such research is required to institute effective preventive measures.

Predicting survival after stroke: experience from the Perth Community Stroke Study.

Survival is the most fundamental measure of the outcome from stroke, the magnitude of the burden being strongly reflected in case-fatality and survival rates. Although the literature is rich with follow-up studies examining survival after stroke, most are based on selected series of patients and factors which correlated with time to death have usually been determined in univariate analyses. We examined the factors associated with a high risk of death during the acute phase of stroke. Analyses were based on data from a population based study of acute cerebrovascular disease undertaken in Perth, Western Australia, during an 18 month period 1989-1990. Using logistic regression modelling techniques only 2 factors, severe loss of consciousness, odds ratio 14.7 [95% confidence limits (CL), 4.0-53.6], and severe paresis, odds ratio 7.2 [95% CL, 1.6-32.0], independently predicted death by 28 days after the onset of stroke. The implication is that 2 simple measures, level of consciousness and motor power, may help direct management. Furthermore, age is not an independent risk factor for death early after stroke. Therefore the elderly should not be denied therapy purely on the basis of their age.

The benefits of beta-blockade at the time of myocardial infarction.

Data from the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease (WHO MONICA) project, collected in Perth, are described. Patients taking a beta-blocker at the time of onset of myocardial infarction are a high-risk group, but univariate analysis of the data showed that the overall survival of patients on beta-blockers at 28 days was the same as for those not taking beta-blockers. A multiple logistic regression model analysis showed that the patients treated with beta-blockers had a survival advantage at 28 days, with a relative risk of death of 0.5. The mechanism of benefit is unclear. It does not appear to be an anti-arrhythmic effect, because beta-blockers did not affect survival in the first 24 h following a myocardial infarction, nor did they affect ventricular fibrillation. The effect may be due to a reduction in myocardial necrosis. Furthermore, an analysis of the incidence of coronary disease and type of drugs prescribed in Perth has indicated that beta-blockers may be contributing to a decrease in mortality due to coronary events.