Approach to assessment of risk factors in mild hypertension

Criteria are urgently needed for the early detection of subjects with only mildly raised blood pressure who may be at high risk of developing the complications of hypertension. As a step towards the establishment of such criteria we have examined the association of certain possible "risk" factors-namely, x-ray evidence of cardaic enlargement, high serum cholesterol levels, effort pain, E.C.G. abnormalities, and high systolic blood pressure-with fatal or morbid endpoints in a five-year follow-up study of subjects whose diastolic pressure had been found initially to be between 95 and 114 mm Hg. The index group consisted of 22 patients in whom these endpoints occured. They comprised death from cardiovascular disease, clinical or E.C.G. deterioration, and either an increase in diastolic pressure of at at least 10 mm Hg or a diastolic pressure of 115mm Hg or both. The control group consisted of 22 subjects chosen at random from other respondents with the same range of diastolic pressures and the same age and sex distribution. "Any two or more" of the possible risk factors examined were found to occur significantly more often in the index group than in the controls, suggesting a possible approach to the early detection of high-risk subjects. The value of long-term studies along these lines and the urgent need for them are emphasised (Summary)

Rheumatic fever prophylaxis: a three-year study

An effective programme of secondary prophylaxis against rheumatic fever has been established in Barbados over the last three years. Relatively unsophisticated patients collaborated well over prolonged periods. Adequate secondary prophylaxis was acheived with monthly injections of benzathine penicillin, with a resultant decrease in the complication rate. A total of 84 admissions over 32 months from a population of some 60 000 children under the age 12 emphasises the need for registration and prophylactic treatment of children with rheumatic fever. The low yield in the survey schoolchildren between the ages of 5 and 11 and the large number of personnel required for the survey suggest that it might be extended to include older age groups. Automatic screening devices should be used when possible so that more may be screened. (AU)

Acute myocardial infarction in the University Hospital, Jamaica, 1968-70

During the years 1968, 1969 and 1970, 111 patients with acute myocardial infarction were admitted to the University Hospital, Kingston, of which 35 were confirmed at post mortem. A history of diabetes or hypertension was given by 85.0 percent of the women and 72.5 of the men. The mortality rate of ward patients without a history of diabetes was 21.1 percent compared with 59.0 percent of those with diabetes. The relative number of cases of myocardial infarction admitted to the University Hospital had increased since the last observations were made 10 years ago. The incidence of myocardial infarction in Jamaica is likely to increase with the rising standard of living of the expanding urban population (AU)

Rheumatic fever and rheumatic heart disease in Barbados - abstract

This paper is a preliminary report based on the first 12 months of a rheumatic fever programme which is being carried out in Barbados. Data are presented on the natural history of the disease, the load of the disease on the community, the effectiveness of a programme of secondary prophylaxis and the prevalence of rheumatic heart disease among school children aged 5-11 years. In February, 1970, a rheumatic fever clinic was started at the Queen Elizabeth Hospital, to which patient diagnosed as having had rheumatic fever were referred. At the same time twice weekly visits to the paediatric ward to identify cases of rheumatic fever and weekly visits to primary schools were made. Sixty-one (61) patients were registered as having had documented evidence of previous acute rheumatic fever. Thirty-seven (37) of these had a residual valvulitis of which 23 were aged 12 years or less. The major valve affected was the mitral which was incompetent in 19 of 37 patients. Seventy-four (74) patients received monthly injection of penicillin. Information which is available on 71 of these patients showed that after 1 year 533 patient/month injections were received out of a possible total of 547. Nineteen (19) patients were admitted to the paediatric ward with definite first attack of acute rheumatic fever and 6 patients were admitted with a second or more attack. Prevalence of rheumatic heart disease among 3,882 primary school children aged 5-11 years was found to be per 1000. Preliminary analysis demonstrates the high degree of effectiveness of a recently instituted programme of secondary prophylaxis, the presence of chronic rheuamatic heart disease among children and the significant morbidity produced by rheumatic fever and rheumatic heart disease (AU)

Rheumatic fever and rheumatic heart disease in Barbados: detection and prophylaxis

The objectives of this study were to improve our methods of secondary prophylaxis of rheumatic fever and rheumatic heart disease in Barbados, to estimate the overall prevalence of these diseases and the relative load imposed by them on available health services, and to measure the yield, feasibility, and effectiveness of mass programmes for the detection and prophylactic management of rheumatic heart disease in schoolchildren. Improved methods of surveillance and follow up resulted in 97 percent adherence to therapy by patients on prophylactic penicillin. Thirty-four children, 27 with a first attack, were admitted with acute rheumatic fever, representing a 7 percent occupancy of children's medical beds during a twelve month period of the study. Out of a possible 3,942 schoolchildren aged 5-11 years, 3,882 (98 percent) were screened for rheumatic heart disease. Four cases (about 1 per 1,000) were discovered. (Summary)

Outpatient treatment trial of mild and severe hypertension

Not much is known about the feasibility or the advantages of treatment of subjects with only mild hypertension. There are also many unresolved problems in the out-patient management of hypertension of any severity. In this study an analysis is made of the results of a controlled treatment trial of 56 subjects with mild hypertension, 26 of whom were treated with active drug and 30 initially with placebo, and a treatment programme involving 81 patients with moderate or severe hypertension, all of whom received treatment with active drug. The drugs used in this study were bethanidine, debrisoquine, and guanethidine. Follow-up for 12 months or more was achieved in 87 percent of individuals admitted to the study with mild hypertension and in 80 percent with severe hypertension. Many subjects with only mildly raised blood pressure were found to have cardiac enlargement on chest x-ray (up to 45 percent) and left ventricular hypertrophy on electrocardiogram (up to 51 percent). Rapid rates of rise of blood presure were observed in many placebo-treated subjects; but good blood pressure control was achieved in 63 out of 104 patients (61 percent) receiving active drug in both the mild and the severe hypertension groups. The drugs used showed approximately equal effectiveness in controlling blood pressure (AU)

Pathology of idiopathic cardiomegaly in Jamaica

Twenty-one cases of idiopathic cardiomegaly which came to necropsy have been reviewed. Investigations included injection and x-ray studies, careful microscopical examination and skip serial sectioning of the conduction systems. The obvious feature was gross cardiomegaly in the absence of atheroma of the large coronary vessels and an associated fibrosis of the right and left bundle-branches. Three hearts showed thickening of the intramural vessels of 80æ to 400æ diameter. We suggest that such changes may be one of the causes of the ischaemic electrocardiographic findings reported in previous epidemiological surveys.(AU)

Prognosis of idiopathic cardiomegaly in Jamaica with reference to the coronary arteries and other factors

Clinical and epidemiological features of idiopathic cardiomegaly in Jamaica are reviewed, and the high community prevalence of the disorder is shown. The frequency occurrence of sudden or unexpected death in patients whose earlier electrocardiograms had shown repeated ventricular ectopic beats has been noted. Common electrocardiographic findings included a high rate of abnormalities usually regarded as indicative of coronary artery disease: cardiac arrhythmias, particularly multiple ventricular extrasystoles; and high voltage complexes characteristic of left ventricular hypertrophy. The differences and similarities between idiopathic cardiomegaly and coronary heart disease are shown. A possible role for intramuscular lignocaine in the control of the chronic ventricular ectopic rhythms is demonstrated. There is a statistically significant association between idiopathic cardiomegaly and positive serological tests for treponemal infection. The hearts are invariably hypertrophied at necropsy. In some hearts the smaller intramuscular coronary arteries show occlusive changes. Their possible nature and significance are discussed.(AU)

Immunological studies on leakage of heart antigens in Jamaican cardiomyopathies

Antibodies to cow-heart tissue were prepared in mice. These antibodies were used to demonstrate the presence of cardiac antigens in sera of patients with cardiac disease. Normal individuals gave positive reactions, but to a lesser extent (AU)

The pathology of idiopathic cardiomegaly in Jamaica - abstract

Since 1966 twenty-five cases of idiopathic cardiomegaly (ICM) have been examined at post mortem in the Pathology Department, University of the West Indies. Hearts were injected with micropaque and coloropaque and subsequently X-rayed to study the vasculature, including the microvasculature. Microscopic sections of various parts of the heart together with skip sectioning of the conduction system were done. Microscopically the hearts were heavy and dilated, with no abnormality of the valves or coronary vessels. Half of the hearts had thrombi (mostly small) in one or more of the four chambers, but endocardial thickening was minimal. Microscopically the changes in the myocardium were non-specific but twenty of the twenty-five hearts showed some pathology in the conduction system particularly the left bundle branch. Four of the hearts showed thickening of the intramural vessels of the interventricular septum. The microvascular pattern of ICM is different from that of the normal heart and also different from the atherosclerotic and hypertensive hearts (AU)

The prognosis of idiopathic cardiomegaly in Jamaica with reference to the coronary arteries and other factors: clinical aspects - abstract

The mode of death, and the factors which appear to influence the prognosis of idiopathic cardiomegaly have been examined. In more than half the deaths in patients with idiopathic cardiomegaly, death was sudden or unexpected. Electrocardiograms recorded on patients with idiopathic cardiomegaly showed a high rate of abnormalities commonly regarded as indicative of coronary artery disease (36 percent in men and 50 percent in women), a high prevalence of cardiac arrhythmias, particularly multiple ventricular extrasystoles; and high voltage complexes characteristic of left ventricular hypertrophy. Fifty seven per cent of patients whose death was unexpected or sudden, showed multiple ventricular ectopic beats. The differences and similarities between idiopathic cardimegaly and coronary heart disease have been shown. It is concluded that the background of some cases of idiopathic cardiomegaly may be myocardial ischaemia occurring at a gradual and insidious pace, and probably diffusely involving a smaller category of coronary vessel. A possible role for intramuscular Lignocaine in the control of the chronic ventricular ectopic rhythms has been demonstrated. There was a statistically significant association between idiopatic cardiomegaly and positive serological tests for treponemal infection (AU)

Acute myocardial infarction in the University Hospital, Kingston, Jamaica - abstract

An attempt was made to estimate the number of cases of acute myocardial infarction occurring during 1968 and 1969, both in wards and in the Casualty Department. The diagnosis of definite myocardial infarction was based on post-mortem evidence or on unequivocal serial changes in ECG patterns. Patients suffering from a possible myocardial infarction or had a typical history, equivocal ECG patterns of infarction or ischaemia and suggestive evidence from ESRs, wbc counts and serum transaminase estimations. In the two years 26 men (mean age 58.9 years) fulfilled the criteria of a definite myocardial infarction. Of these 15 died and 13 were proved at post mortem. 5 died or were brought in dead to Casualty. Of 22 for whom histories were available 14 (64 percent) were known diabetics or gave a history of hypertension. 17 men (mean age 57.9 years were diagnosed as having a possible myocardial infarction. One died. 13(77 percent) were diabetic or hypertensive. 19 women (mean age 63.9 years) had definite myocardial infarction. 26 died and 14 were proved at post mortem. 4 died or were brought in dead to Casualty. Of 15 for whom histories were available, 12(75 percent) were diabetic or hypertensive. The results suggest that acute myocardial infarction is less common than in cities in North America and Europe. It is relatively rare in younger age groups and is frequently associated with diabetes or hypertension. It must be remembered, however, that in Kingston the more affluent members of the population, in whom myocardial infarction may be more common, may tend to be admitted to private hospitals. Many difficulties are encountered in making a retrospective study of acute myocardial infarction from hospital records. A prospective study in which all hospital departments co-operate is essential for an accurate investigation (AU)

A clinical follow-up and further observations on veno-occlusive disease of the liver - abstract

A study has been made of 82 Jamaican patients suffering from veno-occlusive disease of the liver (V.O.D.). Seventy-three have been followed up for periods from 6 months to 5 years. The clinical picture is described and an attempt is made to outline the clinical natural history. In addition to previous reports of the syndrome from Jamaica, three cases have been reported recently from Barbados. The prognosis, incidence, morbidity and mortality of the condition have been considered. The aetiology is unknown; but it does not appear to be primarily or entirely nutritional. The possibility that V.O.D. is produced by the action of plant toxins with special reference to "bush teas" which are widely used in Jamaica is considered. The three cases from Barbados were all associated with the use of Crotalaria retusa, a known hepato-toxin in animals; and Senecio, another outstanding herbal hepato-toxin, is commonly used in Jamaica. The histological features will be presented by Dr. Bras (AU)