Medical history questions predictive of myocardial infarction. Results from the Kaiser-Permanente epidemiologic study of myocardial infarction

Dyspnea in 70-year-old people

In the population study "70-year-old people in Göteborg" 45.5% of the probands were found to have an increased exertional dyspnea or to be short of breath at the medical examination. We have found it interesting to estimate to what extent a subjective experience of dyspnea at the age of 70 is related to disease and whether it is available for treatment. Out of these probands, 64% of the males and 48% of the females suffered from cardiac failure or pulmonary disease, compared to 48% of males, and 24% of females without dyspnea. Among dyspnoic probands without cardiac failure and pulmonary disease, ischemic heart disease was significantly more common than in probands without dyspnea. Probands with dyspnea but without cardiopulmonary disease felt less healthy and were more tired than others, although an objective health screening showed no difference between the two groups. They also had a significantly lower peak flow rate. A dyspnea that was not statistically related to disease was found in 30% of the males and 43% of the females. During a 5-year follow-up there was no statistically significant difference in mortality between dyspnoic probands without cardiopulmonary disease and others.

Cardiovascular evaluation of young patients with varicocele

OBJECTIVE

To evaluate cardiovascular risk factors and demographic parameters in patients with varicocele.

DESIGN

Although some pathophysiologic hypotheses have been suggested to explain the etiology of varicocele, the exact mechanism underlying varicocele is not yet known. The coexistence of arterial and venous system pathologic conditions has been reported recently, including varicosities of the coronary venous system and leg veins. Cardiovascular risk factors have not been evaluated previously in patients with varicocele. In addition to the presence of cardiovascular risk factors and demographic parameters, we assessed the prevalence of peripheral varicose veins in patients with and without varicocele.

PATIENT(S)

Study groups consisted of 52 patients with varicocele and 100 patients without varicocele younger than 50 years old.

RESULT(S)

There were no statistically significant differences between the two groups with respect to presence of hypertension, diabetes mellitus, hyperlipidemia, family history of coronary artery disease, body mass index, age, and height. The weight and presence of peripheral varicose veins in the patients with varicocele were significantly higher than in those without varicocele. It was found that presence of peripheral varicose veins was independently and positively associated with varicocele.

CONCLUSION(S)

We have demonstrated that varicocele is not associated with cardiovascular risk factors or demographic parameters. However, the presence of peripheral varicose veins is positively associated with varicocele, suggesting a possible common pathologic step.

Are Varicose Veins a Marker for Susceptibility to Coronary Heart Disease in Men? Results from the Normative Aging Study

Clinical observations suggest that varicose veins (VV) are less frequent in patients undergoing infrainguinal bypass surgery for femoral artery occlusive disease. While some previous studies support this relationship, others report that VV are more prevalent in coronary heart disease patients (CHD). This study used the Normative Aging Study (NAS) population to examine the association between VV and symptomatic CHD. The incidence of CHD over 35 years of follow-up was determined in the 2280 initially healthy male volunteers enrolled in the NAS. The incidence of CHD in the VV population and the subjects without VV were compared using Kaplan-Meier survival curves and the log-rank test. A time-dependent proportional hazards regression method was used to further explore the relationship between VV disease and subsequent development of CHD after adjusting for other cardiovascular risk factors. A total of 569 subjects (24.9%) were diagnosed with VV prior to the development of symptomatic CHD, and 1708 (75.1%) were not. Over 35 years of follow-up, 98 subjects with VV developed symptomatic CHD (17.2%), while 363 of those without VV subsequently developed symptomatic CHD (21.2%). Kaplan-Meier survival curves suggested a reduced risk of symptomatic CHD for subjects with VV (p = 0.0001). Further exploration of this relationship in a proportional hazards multivariate model showed VV to be associated with a 36% decreased risk of symptomatic CHD after adjusting for other recognized cardiovascular risk factors. In the NAS population, men with VV were less likely to develop symptomatic CHD over the 35+ years of follow-up than were subjects without VV.

Mental precursors of myocardial infarction

Both cardiologists and psychiatrists have observed that the onset of myocardial infarction is often preceded by feelings of decreasing energy, general malaise, and minor depression. This paper describes these observations and tries to integrate the findings. It is proposed that the mental state preceding myocardial infarction can be best described as 'vital exhaustion'.

Chest pain and coronary heart disease mortality among older men and women in three communities

Angina pectoris is a manifestation of coronary heart disease, yet little is known from clinical or epidemiologic studies about its prognosis in older populations. We investigated the relation of uncomplicated angina symptoms to risk of coronary heart disease mortality within 3 years in a prospective study of 8,359 people aged 65 and older residing in three communities. From baseline (1981-1983) to the third year of follow-up (1984-1986), there were 245 deaths from coronary heart disease. Three classifications of chest pain were defined using the Rose Questionnaire: nonexertional chest pain, chest pain on exertion (including angina), and angina. Exertional chest pain was a strong, independent predictor of coronary heart disease death for older men and women. There were no differences in the prognostic implications of this symptom between the sexes; the relative risks being 2.4 (95% confidence interval, 1.4-4.4) in men and 2.7 (1.7-4.2) in women. The risk of coronary heart disease mortality for those reporting chest pain on exertion was at least as high as that for participants whose symptoms met the Rose Questionnaire criteria for angina. The association between exertional chest pain and coronary heart disease mortality was independent of other coronary risk factors. The relation was specific for deaths from coronary heart disease, as there was no association between exertional chest pain and noncoronary causes of death. Chest pain on exertion conveys important prognostic information about risk of coronary death in older populations, regardless of gender.

A questionnaire to assess premonitory symptoms of myocardial infarction

To test the hypothesis that feelings of vital exhaustion precede the onset of myocardial infarction, and to develop a short questionnaire to assess these feelings, a prospective study was done among 3877 males, aged 39-65 years. During a 4.2-year follow-up period, 59 fatal or non-fatal infarctions occurred. The mean score of future coronary causes as determined by a questionnaire assessing feelings of vital exhaustion was significantly higher than the mean score of a control group matched for age, blood pressure, cholesterol and smoking. Given the validity of the model, it was possible to reduce markedly the size of the questionnaire.

Simple prediction of 28-day mortality following an acute myocardial infarction

Upon admission to a drug study of 1,122 patients with myocardial infarction, twenty-seven questions relating to the patients' cardiac status were answered by the physicians. These questions were categorized into four groups of related items of signs and symptoms. Thus four scores could be completed: degree of infarction score, cardiogenic shock score, cardiac failure score, and overall-state-of-the-patient score. The scores were all found to be highly correlated with 28-day mortality. Also, since these scores can be easily and immediately determined at the bedside, or with standard tests, they are both convenient and accurate predictors of 28-day mortality following a myocardial infarction.

Migraine, headache, and survival in women

A population study of 1310 women aged 45-64 years determined the prevalence of headache and migraine in the preceding year. To investigate the hypothesis that women with migraine had a higher mortality rate, these women were followed up nearly 12 years later. Unexpectedly, the mortality was found to be higher in women without headaches. Women with headaches and migraine had a relative risk of dying of 0.72 (95% confidence interval 0.52-1.00) compared with those without headaches.

Prodromal characteristics as indicators of cardiac events in patients hospitalized for chest pain

In an effort to determine the usefulness of prodromata for predicting a myocardial infarction, a prospective analysis was made of 211 consecutive patients with chest pain who were admitted to the Stanford University Medical Center Coronary Care Unit. In their subsequent course, 91 patients had a myocardial infarction, 102 had a myocardial infarction ruled-out, and 18 had a noncardiac etiology for their chest pain. Prodromal chest pain in the previous six months had occurred in 65% of patients and unstable angina in 61%. Infarction versus noninfarction patient groups could not be identified on the basis of prodromal ill health, chest pain, unstable angina, typical versus atypical nature of the chest pain, or activity at the onset of pain. Complaints of preceding fatigue and increased perceived stress were common in both groups. Activity at the onset of the admission chest pain was strenuous in 15% of the infarction patients and 12% of the noninfarction patients. We conclude that prodromal symptoms are common in both infarction and noninfarction patients. Although chest pain probably remains the single most frequent identifier of a new cardiac event, it is common in noninfarction patients and cannot be used alone to predict infarction or death.