Document 6406

Heart Attack :
Epidemiology and Risk Factors
Epidemiology ~ u n l r r a a u
s r i significant coronary artery diseaseU fualiu
~udmriirm 30 i)iihum 6 m m n i ~ I Z l ~ m
fiouh:innfi
asplrln, beta-blockers ~ S o u i r n
6x1 cardiovascular diseases (ischemic heart
'Iuliu~uni~inm<ihucoronary artery disease 6u
disease ua: stroke) f u l h r m ~ l i ~ ~ & ~ m u l h r ~ n f l $?u chronic Sable a n m a ~ ~ d i ~ ~ m >
d u 44u ooau.s~8ud+wia UAUIAI
a~?jou~ini
ia?a~cl&~ilr:iour: 4.13 sinni>anwuoq Proudfit
ua~:mflunuaunui~uiiu I A I a a r ~ d ~ : u i ~ i ~ u r :
t ~ ~ i h u n ' i i o i ~ s i i n65i i i)iiiioinnau&us:ii mro20 li.riour: 60 E m ~ i n ~ ~ r m r ~ ~ ~ ~ u f l ~ nary
~ ~ artery
~ o u disease
n i i u~:~>fIdui?usi?uua:IA'~~?s
n i ~ a m a ~ 6 i i ~ ? i u ~ ~ ~ ~ ~ ~ u ncoronary
i ~ ~ ~
~ ~ u iin@uGGni>Au
o ~ ~ : ~ u (ulnniiiourr
~ u ~ ~
angiograrn
f~u
? ~major
u ~coronary
u ~ arteries
A ~ ~niiu~$u
R ~ floq~iu
~ ~ ~
uou
D ~ ~ o ~ ~ I > : H ~fIA..
I ~ ~1968-1976 n718AA.IVD.1
~ i u ~ i i u u aleft
r main artery iiEm?ini>~iuEnInu
'lnhlufiom n i ~ g u p ua:nm"nw~?iuA'u~rAm~.~
i
ra7iumo~rrii~u
<our: 4.1. iouar 7. iour: 12.5
fiaam~H'Em~ini~r7~35mAI~u
coronary artery
ua: iourr 12.6 niuEii~uiurra:Em~ini~~~~~~
10 i!
&sees ama.rh:mrui~ua': 30 iaur: 24 ur:iourr
~riiKuiourr 62.9, iaur: 45.4. iaurr 23.4 urr
48.6 miu6iih' lm~:~;u?6~6Zj6m~ini~~u;aim~iu+our: 22.5 niu6ii&" d m ~ m ~ i n i ~ ~ 8 u % n I ~ u
bu~ud~:~n~unumounri~ur:3nm:Tu~~nn~~~I~d~~~
HAj9lnLiiA myocardial infarmon U$?U~.I~~I:
d~:mfldrii6*riRlui dud>: m ~ i + ~ ' EuInijr%f
~ r i ' l ~ l I j i l ~ F5
l : ddi5 ~ ~ U ~ > ~ U I N M ~ ~ ~ U
BULEU~n@ud~:rn~m:T~aonnri.r~~
ur:o~uSni~AI'
$?u coronmy heart disease srriifl sudden death
r r i o u ~ u ~ n i ~ ~ ~ u b u n ~ . r ~ m ~ i n i ~ ~ ~ u i a ?d?ul~~riiariouuiii~I>.~uuiuia
muaru~~w
En~in~~du%nl
H ~ B R ~ ~ D~ A ~
>
~
~
~
~
~
~
H
~
A
~ 50)
A
no9 ischemic heart disease riioqsindxain>lu
~~.muiu?rs:umnmi~Cu~uo~~ud~:7n
d . r : ~ n f l ~ ~ a i ~ i i r r ~ ~ n ~ ~ u n i ~ i i ~ ~ ~ n d ~ d u r~lndwounoi ~ u~ m
i i rmr I ~ w u innyuu>.rno.rI>~ua:ni?r
uir
I~nmaon~~o~filsuinGu
un>doui+l.rl luariudth7iii intensive care unit
&I
Epidemiology n e ~ ~ a ~ n a a c i l i ~ a c i l H ' a ~ ~
d o coronary mtery ii atherosclerasis
ui&
<ihud?u~~~s:ijoinn
a n m a pain 61du
typical angina s m u i n h r u i ~ i o u r r90 uo.r<d?u
$?u acute myocardial infarction ii6n>ini>
~ 3 u E n i i ~ i o u3015
r r ilsqU1VHiqsinii intensive care
unit
u~:~I>?~M~?uuI
beta-blockers. aspirin.
ua'?Em>inistAu-Zialu
I>urrunnrr~arlb'L6omn'i~~ua:
~'"RuLQuI~~~~I~
thrombolytic
therapy
d ~ ~ ~ f ~ ~(<70
f inl ) $dii ~myocardial
u
infarction
i ~ u a : 30 n o ~ ~ 1 h ~ d ~ i i i ~ ~ 7 UR:~R'%UI
~tlmul~)
t i t u ~ 4 ~ u m u a r i j m n n(mip
~ u ~ ~ckss I) u:
mutu 6 d?~u.rucimlniioini7q:a~~m7ld~~d
% ~ " m u 1 u 6 & h & ~ i n i i f n m n t o u acute
B n l u 35 5iLHkqinfim infarction A ~ ~ A ~ ~ . ~ < Q
-
infarction, low LVEF (4.40). mngestive heart
LUBQJOUA:9.0 [NNT 441)
d ~ : T u n M o u n i ~ i n w ~ : ~ ~7~ ~uin1R'ium<i
~iou
lvdw 7-12 d?l~qUCi: 13-24 d?~lI4&77d~V4:RA
~NL*&UR:
12.6 ( W ~ ~ D U A12.7
:
LUBQ~QUA:11.1
failure, residual ischemia left ventricular hyper-
(NNT
nophy, axrhythmas. aging (>70 years), diabetes
~DUR:
meUitus. dyslipidemia female gender
~ ~ r n r i u u ~ o ~ i t f i stroke
l i i m ~U~?.IL?AI
35
myocardd
ihTuu8iKdiiuamonn~fin
infarction
recwrent mymardial infarctim ~ i l ~ d k m s m death
la
~ ~ f u ~ : u : ~ u u ~ : ~ :d~:nouWR'?u"
u:u~~~u
UR:
large
hyper-
20 ( m i o u ~ :11.3
-
66)) u ~ r i o u a r4.7 ( q i n i o u ~ : 10.5
(NW
10.0
-
mfii im
200)) RIuA'IRIU
LU~Q
1unt-u:
tension n i ~ 5 n ~ 7i ~ dcijqr;iidil-;9'~lis~Y77na~
w
LIT-mu 4
dovascular mo~ldity ua: m o M t y 16 %mu
n n m u q u u a ~ n ~ " u ~ u a l u ' ~ & nil lR.N.
' 1966
&n5&ujlom:a~
morbidity ua: m o d t y
so.r{hu infarction 1"$i
?~fiorn?lH' long term oral
tituilu7niiinn~H'hta-blocker u k infarction u h
anticoagulant
domiinnhrnd&nmu&mrii
infarction
aiunaafi total
mortality (four: 7.9 vs i o u ~ :10.0 (number needed
to treat [NNTI
- 48)). sudden death
(ioua: 3.6
LA:
~ l i f i i Y u n i ~ % ruonqin
n~
recurrent
$JQI~RR
stroke
~
u
~
D
~
myocardial
~
~
A
n17%
R ~
anIjarrhythmcs, calcium channel blockers b n u
i i l i d ~ : l u a r i ' ~n n r i i
coronary angioplasty l u
?hi
vs iouar 5.2 (NNT-63)). nonfatal re-infarction
$?u
(ioua: 5.7 vs i o u ~ :7.5 (NNT = 56))" (NNT AD
pain
~ m ~ u ~ ~ d s i o ~ ~ ~ ? u n i 7 i n wmorbidity
i ~ r r ' o ut ~i ~u )~
QI~IYUR:LU
mortality IR'H~'.IAU)
& ~ ~ t w i i u n ~ u ~ ul uui l ~ t w
Aumuara'?udu patency rate
n.n. 1974 i i ' u i i n n ~ n w i k t h : h ~ h antiplatelets
o~
n i 7 l u 5 ~ 1 G n i - 1thrombolytic therapy udBmini7
&d?ulW@D
aspm (75-325 m.) fu!$hu
myocar-
acute myocardial infarction
*
M
anginal
single ua: multivessel diseases szan
exercise tolerance in'Gniinn?nwi
TIO.~URQAL~DR~
lu5u~i~~::ni~~~u~5mlub~nuiuialu'um
dial infardon dolcu&4 infarction 3:aA myocar-
n i ~ mlate elective angioplasty ~u{1I?udEqiioini7
dial infarction stroke &a: vascular death u & n n
r5uHti7~nuAj~iiminfarction W u ~ l u n i ~ ~ ~ O I A ~ i
~ r n u i ? o u ' i ~ ~ o u d ~ m d . ~ d ~ uQUA:
~ ~ u14.7
a~qin
n n d u infarction Jimiolridi left ventricular ejec-
a a u B o i o u ~ : 11.4 (NNT = 31).
nonfatal infarc-
tion fraction tud?q7:u:~?ai3 d o u m m i i u n i m i
MNT = 72).
angioplasty n i u h 18-48 d ? h n h rnfaarcti~n~~
tion q i n <QUA: 4.2 LUBQ
AR
~ O U A : 2.8
RR
all cause mortality nm'our: 9.5 n i i o i o u r : 8.0
(NNT
-
67) uornin6 antiplatelets
&RA
vascular
occlusion rates no4 coronary artery w n i o u a r
27.3
L U ~ D ~ D U A 18.8
:
arteries du 7 (NNT
-
(NNT
-
12) &a: peripheral
11P2' d o u l u n.fl. 1980
De Wood n v j i thrombosis n ' i t H ' ~ E ~ n n q ~ 6 u t u
U A Q R L ~ ~ D Racute
~U
myocardial infarctionn 5uiin-n
~do~rliuu~tuuni~inwiAuui6uni~n'i
coronary
artery bypass graft f u [ I h u coronary artery disease
~ : ~ R ' d ~ : l u a u l u n i ~ ~ ~ a i n i ~ ~ 5 ~~ uI U~ .L i Eo nR
infarction ~ i u a : n ~ ~ m i u ~ i j o ~ ~ u u ~ ~ u u n i r n
huuilun-lciid~d?uii left main coronary artery
Su > ioua:
50-60 &IW
ii three-vessel disease
i ? u ~ u i i n i ~ a c l a ~ n o . r n i ~ n ' ileft
~ i u nventricle.
~~
CI intravenous thrombolytic therapy m l f i u n i ~
(d?udi! two-vessel disease ~ n u d u d . r ~ ~ u ~ i ) u n i - d
inwi
>ioua: 75 no4 left anterior descending a r t e g
acute myocardial infarction dyinpi7lu
7 l ~ f i ccontra-indication
~ u n i Y l ~ u(d7:mt-u
6
actors
riniimyuu~uaml~nmnnjlY
uonnnifRaiuqmou
ilss"udw 6o h"diiuarh~kknirnnju
i h j , d w h 7 am mrheart disease ti
~mnrjumu'~E~oniadaurilu~>nm5oiiJ~i~nninuin
nuu1&lurnmmilmiiu
na'ln~uu~uumfuvn?lj~&r h n n atherosdemnio'ty
roac plaque rilunuij~nindhR'~~nnur~uolu
d>mnsuwrirnii rdu aiakrZuEqGnn
{ ~ I ~ ? U $ L ~ U ~ ~ ? R ~ ~ ~ ~ > R H A D R L a
~m
~ ~
~ >
~m
~ a
~o
~ ~~6Um<~U~ q
~~
~ ~~1I 6~@
~ 9Zn i 71rbi?qr n
7 iid
$mkoy2ullsrmn~v?~uuaz~~5urdw~Aiu
n s i r ' d u d w a m n i > l i i m atheroderasis d u
onrii~wnmiuumndwrm~a'o~ii
i@nrianSurZu
il<udusdhKqno.r cardiovascular diseases TRU
ii~.rnunmaiuua:Impaired glucose tolerance test
ramnohh coronary heart disease, atherothromuinrrj7r~middmiru~mhz~nfl~Zv?n'ubotic stroke H3o peripheral Mscular diseases
Risk
2
A
~ R ? ~ ~ ~ R ? I U L < I ~ ~ & ~ ~ ~S P
~ hUR W
L ~ W L H ~ W 5&bY0+
fibrinogen
r & l u d % h d r o . r " diuannflnmn~
&ua:olau~wqjiimiu8~dfiurn>tiinheart attack
iBsnaiurdus~:r6u&riluni~~miu~iuauno~~~4u> m ~ % m a & ~ Y Vfibrinogen
jl
dii>:&@.rrmdu
ddii
i1~Lrdu~ddi~~~amu'sn~~~~~~
~ U ~ D U ~ I > L ~ ~ A ~ > R U R D A L Z ~ D A G ~ ~ ~ U R ~nab$
R U D I fibrinogen m l i l i i m atherosclerosis ua:
hliir~nsrhud atherosclerosis ro.nmao~r5io~rinu
thrombosis & C & ~ ~ A L W
r $ i h n bbfmogen ii
ua'a~~rii~ni~msi?u5on1~fiurnnno~
plaque RUI
U A ~ N ~ ~ U ~ A U
hemmtasis,
~ ~ U ~ ~ blood
~ O
theology,
mhuii thrombus formation qRfi E A acute
platelet aggregation Ua: endothelial function
obtmcfion l&umouni~5~~>n1mriiu'ijih4uiuldur~o~ d 4 ~ f i ~ ~ ~ ~ u i ? u n ' h ~ ~ ~ n 7 3 1 ~ 6
ddiK~uuu1A'~h
2 ntju" 6o
1.2 ModiTmble Physiological Risk Fac1. Atherogenic lisk factors
tors d>:nmAu
2. Thrombogenic lisk factors
Elevated LDL (low density lipoprotein)
and low HDL (high density lipoprotein)
1. Atherogenic Risk Factors
ZO~~=I<"L~UP~
&un'ud6u atherosclerotic vessels uu.fibr~u3 niu
i;o
1.1 Nonmdifiable Risk Factors dlrnou
ku
luJ~quiriimin3iurilu~uouiun'~l~uh
~rin:6~diimd~n~o~l~iiulihi~~~ul
atherosclerosis uar h e m attack
Hypertension
~dau~aiu<ul~Gm$~l~ii~:~J~~nfln
Age
~untjml~rain~oi~tiounjl
60 il mflniuii
atheroderotic events d>rul~RosMimosmfluQ9
n n u u m n m i ~ & r r i o u a ~ u i ~ ~45i niluclrqrwiniu
~i~
~unjud>zain>iu70 0 & 1 d ~ ~ ~ ~
uQ~oiquindoijouiinaiurdu~~~rr?lm~~nu~
k h 6 u6
0
sudden death ii9aiurrir)lounudnl"
~ ~ ~ ~ u L ~ w L ~ ~ u R W R ? ~ U ~ U
Diabetes Mellitus
u o n ~ i n l ~ n 1 m m w r ~ ~ u i l q 4 uath~du~
Genetic prediposition
erosclerosis uci? ujnuiiiiniar$du~aiu~du~n
Davldson3' ~hu.r7uuam~Anmo~uaiunn
coronary atherosclerosis uin6u6au~o hypenn-
anwilqa.xflA'aiiou 1n'uAo @iaiu~>uuo.r$aui
liimhn myocardial bfarcfion loynrdiimq6ounii
suhnemia & h u d l ~ ~ o ~ ~ h ~ f l ~ ~ n u
ua: low HDL
45 G ~ W ~ U ~ & ~ ~ R ~ > W ~ D R G D R H ~ ~ ~ ~
~ U ~ R 'nUn~n$nY8 n m ~ ~ n i ~ h u n m m i
dmlester01~
~uumurnr6&k~u~rir)lo~ntjuu~ivu~iivu~
uar
NIDDM n u i i ~ d a & ~ u Q ~ u a r n i u i i ~ m ~ i n i ~
obesity. hypertriglyceridemia
~ Y : ~ ~ N R ~ ~ L ~ ~ I ~ ~ ~ ~ ~ ' ~ ~ L ~~IH~U$?U
uLUIH?IU"
IDDM uh~151rdu.rdoaxormy events r6&urau
4 rmlurnmiu 8 rri71urnmr@qUU
1.3 Modifiable Behavioral Risk F a d o n
n l 5 ~ u ~ d
uonqinrituil77irdum atherosclerosis d
s17Riyu~~Caunujiiin&lk:6~1nCuHDL asw r6u
oiglyceride. LDL uc:l fibrinogen 5 s endothelial cell
dysfunclion platelets aggregation ~ i & unnn?u?u
Sedentary lifatyle
n~:u'~~~iin~n)iud~:u~nii~n?i
no.rni~~rioonrh&niuKuni~
riis athero~clerosis
u m i i n i ~ ~ n w u i n u i u d u ~ ~ ~dluriuinoqni~
ii~n~iu
hrirfimu&
rillni~r6&oMudwdiq 7 nm
atherosclerosis R'€IY:~u~%~u~uL~IR miu6uIais
n?iuhur6&uax:ciz1
HDL &olgtero~ asa.rY
luiwrn~~iiuhu
n i ~ o o n r i i ~ j n i ~ auomin
h~u~
~iunnasih"urduwoatherosclerosis ua:r6u HDL
carcholesterol uci?kiiuu?Tu'Ujionasdm~d~~y~rl
diovascular death ~R'n"~~unq'umui;ii?~mdni~
unr
mu6uhRm~.j[(iCIa1GG d~:nirni/~uqHiiiDIRnni~
l~uil?ViLh:UIN 1.7 rkmosnjun%eu L n n i ~ r i u
gimFi?uT~nnaosrPostr;~lqiin~iu8uriu~'I~um~.15~
ndu$xtn& myocardial Infarclionm nnoonrh&
R
J%
N
R
LIU
@
IU
~n~dqu~~~do~iiu~5un~un
~ I%
U ~~~uD W R R
(regress) coronary atherosclerosis
mn'liidmini~
riis corormy artery dsease L h r u l ~
lu{ihudii symptomatic mronary atherosclerosiss5
5 L~~IUA:~~IR sudden cardiac death m m i u " dlwk
2. Thrombogenic Risk Factors
idii coronary artery disease HSD myocardial infarcnu?uni~riis thrombus tu¶?lr?ain'ii
~mn~m
WDJ
i r plaque hduna'lndh6~ds:u'i1d
tion u h r i i ~ n q s ~ u n ? i ~ ~ d ~ ~ n ~ ~ n i ~ r i u rupture
~ u n ~ o n i ~infarction
~ i i n dlasa.r**' passive smok{nisriis heart attack tUd?sr?aiRjnii?iiilqjV
ncliuau'i.m'riotH'iis thrombus ~ i ~ u ~ s u u ~ 12 r i r
ers riiia?iurd~dq:L?Imcoronary events ~6uu'u1A?i9
rnrilk*
n $ P " Ao
n15&1qsi
2.1 Local vessel wall-related Factors
twrurd&biin~qnrjinniu?nrhathero2.1.1 Rheological Factors
genic risk factor umwuiin1~6~iina~nli~~iun'u
u j r ? ~ i i i i n n b u ~ n ?local
:
shear rate
~ ~ s @ & ~ c l : ~ o n ~ s i ~ n ? i ~iincnnjiu
~ u ~ : a ~ a uindiln~
~ ~ ~ 1 ~ platelets ~zauuarriisthrombus ~ I U ~ U
qin observahonal studies nVLmi~iu1ulT~ui~d
2.1.2 Degree of Plaque Damage
a A
h n a w i i m u k ~ ~ r i u n i ~ a s a m ~ COIO~~u%ni~
ujr7nhi damage 6wiisri8~expose tuowo
nary hem disease ~ ~ ~ u ~ ~ w I : ~ ~diq~ 7 1
~ i h~ intima
~ ~ il.rn~:&ua:dqr8julH'fis
u ~ ~ R ~ I u throm~ ~ ~
u d a a n o ~ n i ~ a n w ~ ~ 1 u t ~ u n ' u o u i u n ; ? l ~ r d o ~ bus
~ini~
n i ~ ~ l n w n ' t B C ~ ~ i i ~ i n ~ n r i i u ~ n o d q : ~ ~ ~ ~ a ~2.1.3
~ i i nResidual
i ~ ~ ~ Thrombus
~ Y I ~ Udsk M ~ Dprotective
factor 'dm atheroscle-
n h q l n n l~~ ~
~ I U ~ ~ ~ ~ U L ~ D A ~ ~
LBDR ujr7~hHtjino9 thrombus da8orjuia'q
rosis
~ I ~ & ~ ~ ~ W I U S I H ~ ~ ~ ' ~ V ~ U ~huurini~riisiur'l~Rbu~nu
U ~ ~ H ~ O ~ '
cholesterol ann
2.2 Systemic factors
iin~iukuKu8riunisriiRatherosclerosis TRU
9 q i n i i n i ~ r ~ & m o s q ~ ncoronary
i ~ n ~ ~heart disease ua: peripheral vasdular disease tunq'u
2.2.1 %&VOd
a
epinephrine L W M U L
~U~U
nnrii stress, circadian Mliation n j a n i ~ @ u y n ~
2.2.2 ~Km0~InUIU1ur~srn
Tsuram:~(ii~
d ~ : ~ i n ~ d i i r ~ ~ u i ~ ~ n ~ u cholesterol
6~67ua: lu
frsmi'u bpoprotein (a) ILp(a)l
~ i n i ~ ~ ~ ~ d ~ r ~ ~ ~ r i i ~ ~ r i u n ~ ~ 6 i i l J i u i ~ a i2.2.3
n 1 ~~ZR-U
n " ~Fibrinogen
~o9
nijsd-~nii~~'
ri&u
UI::
fador HI
-4
W
~ana?.rai~S~
1. Wolf PA D'Agastino RB. Belinger AJ. er aL
RoWihty of stroke: a risk profile from the
Flamtn-
mdy. Strdre 1991;22 312-8.
2 ~ o w l TP.
d %%son AV. W m h Y, er af.
Serum cholesterol, other risk factors. and
cardiovasdar disease in a Japanese cohort.
J Chrm Dis 1984,37:569-84.
3. Ueshima H. Tatara K Asakura S. Declining
mortality from ischemic heart disease and
changes in Fronary risk factors in Japan.
1956-1980. Am J Epidemfd 1987: 125: 62-
n.
4. G o l h I, Cook EF. The decline of ischemic
of
heart disease mortaiity rates: an anthe comparative efforts of medical intervention and changes in lifestyle. Ann Intern Med
1984:101: 825-36.
5. Pearson TA Jamison DT. 'Dejo-Gutierrez J.
Cardiovascular disease. In: Jamison DT, Mosley
WH. Measham AR Bobadilla JL.ed. Disease
control prlorities in developing countries.
Oxford Oxford University Ress for the World
Bank 1993:577-94.
6. Lopez AD. Assessing the burden of mortality
from cardiovascular diseases. World Health
Stat Q 1993:46: 91-96.
7. Chonghua Y. Zhaosu W. Yin* W. The changing pattern of cardiovascular diseases in
China. World Health Star Q 1993;46: 113-8.
8. Boedhi-Darmojo R. The pattern of cardiovascular disease in Indonesia. World Healrh
Star 0 1993;46: 119-24.
9. Reddy KS. CardioMscular diseases in India.
WOM ~ e a l t hStar Q 1993;46: 101-7.
10. Alwan AAS.Cardiovascular diseases in the
11. Nicholls ES. W g a A R m e p o HE. Cardio-
disease morWty in the Americas.
world ~ e a l t hStar Q 1993;46: 134-50.
vascular
12 Dianhmd GA Pornester JS. Anatysls of probability as an aid in the clinical diagnads of
coronary artery
disease.N Engl J Med 1979;
300:1350.
13. KaMel WB. Feinlieb M. Natural history of angina pectolis in the Framingham study: progress and mvival. Am J Cardio] 1972:29: 154.
14. Roudfit WL.. Bruschke AVO. Sones FM.Jr.
Natural h r y of obmctive coronary a r t q
W e : ten-year m d y of 601 nm-swgjcal
cases. h o g C a r d i o ~ Dis
c 1978;21: 53-78.
15. M S. D'Alonzo CA Immediate mortality and
five-year survival of employed men with a
firs myocardial infarction. N Engl J Med
1461: 270:915.
16. W O N - G .Fresco-C. Franzosi-MG. MaggI0~fPThrombolysis in acute myocardial infarction. Chest 1991:99(4 Suppl): 121s-127s.
17. Hessen SE. Brest AN. Risk profiling the
patient after acute myocardial infarction.
Cardivasc Clin 1989: 20: 283-318.
18. Lau J. AnEM. Jimenez-Wva J. et al.
Cumulative meta-analysis of therapeutic
trials for myocardial infarclim. N Engl J Med
1992;321. 248-54.
19. Yusuf S, Peto R Lewis J. Collin R Sleight P.
Betablockade during and after myocardial
infarction. an overview of randomized trials.
Prog Cardiovasc Dis 1985:27: 335-71.
20. Antiplatelet lblists' Collaboration. Collaborative overview of randomized hials of antiplatelet
therapy-I: prevention of death, myocardial
infarction. and stroke by proIonged antiplatelet
Eastern Mediterranean region World Health
therapy in various categories of patients.
Star 0 1993;46: 97-100.
BMJ 1994;308: 83-108.
ti= ovaview of randomized hials of anapatele4
29. Roberta WC. Potkin BN. Solus DE, er al.
Modes of death. frequency of healed and
therapy-11: maintenance of vascular graft or
acute myomdial infarcts. numbers of major
enerlal patency by antiplatelet therapy. BUI
1994; 3W 159-68.
22. De Wood MA Spores J. Notske R et el Prevalence of total m o w occlusion during the
early hours of namnural myocardial infarction N Engl J Med 1980;303:897-902.
23. MMnolfic Therapy Malisls' WTl C d a b
epicardlal coronary arteries severely nanowed
21. Anaplatelet ?liallsts' CoIkboration CoUabora-
by atherosclerotic plaque and heart weight in
fatal atherosderotlc coronary artery disease:
anabs of 889 patients studied at neuopsl.
J Am M Cardid 1990.15:9.
30. Lemer DJ, Kannel WB. P a m of c o r o w
heart disease morbidity and mortality in the
in suspected acute myocardial infarction:
sexes:a 26-yearfollow-up of the Ramingharn
population Am Heart J 1986;111: 385-90.
adhtaative owview of early mortality and
31. Davidson DM (ed). Preventive cardiology.
rative Group. Indimtiom for 6brinolfic therapy
major morbidity results horn all randomized
hials of more than 1M)O patients. lancet 1994;
m and Wlllbns. 1991;1-104.
32. Rissanen AM. Nikldla EA. C o r o ~ l yartery
disease and its risk factors in families of
343: 311-22.
24. Antiwa&ts
Baltimore. W
in the Secondary Prevention of
Events in Coronary Thrombosis (ASPECT)
young men with angina pectoris and conuols.
Br Heart J 1977;39: 875-83.
Research Group. Effect of long-term antico-
33. Nora JJ, Lortscha RH. Spangler RD. er al.
agulant treaunent on mortality and cardiow-
Genetic-epidemiolomc study of early-onset
cular morbidity after myocardial infarction.
ischemic heart disease. Circulation 1980;61:
Lancer 1994,343:499-503.
503-8.
25. Reeder GS. Gersh BJ. Modem management
of acute myocardial infarction. Curr Probl
Cardiol 1993;18:83-155.
26. Mehra A Faxon DP. Bailey SR.Clurent status
of percumeous transluminal monaty angioplasty. Curr hob1 Cardiol 1994; 19: 229-84.
27. Rutherford JD.Braunwald E. Chronic ischemic
heart disease. In: Braunwald E. ed. Heart
disease: a textbook of adioMscular medicine.
34. Chesebro JH. hster V. Elveback LR, et a1
Snong family history and cigarette smoking
as risk factors of coronary heart disease in
young adults. Br Heart J 1982;47: 78-83.
35. McKeigue PM. Miller GJ. Marmot MG. Coronary heart disease in South Asians overseas:
a review. J Clin Epidemiol 1989;42:597-609.
36. Hughes K. The epidemiolcgy of cardiwascula~
disease in the ethnic groups of Singapore.
Fourth edit. Philadelphia: W.B.Saunders
Southeas Asian Medical Infomation Center
Company.1992 1292-1364.
(SEAM'C). 1993;66: 1-157.
28. Fuster V, Badimon
L Badmon JJ.
er al. The
pathogen& of coronary artery and the acute
coronary syndromes. N Engl J Med 1992;326:
242-249.310-8.
37. Emst E. Resch KL. Fibrinogen as a cardiowcular risk factor: a rneta-analysis and review
of the literature. Ann htem Med 1993;118:
956-63.
38. KaMel WE. Hypertension and the risk of car-
47. Wilhemsen L. Cessation of smoking after
on mortality
ttlovascular dlsease. In: Lamgh JH Brennm
myocardial infarction: effects
BM.ed. Hypertension: Pathophysiology.
after ten years. Br Heart J 1988.49: 416-22.
48. Svendsen K, Kuller LH. Margin
diagnosis. and management. New York.
MJ. et al
R a m Prerr Lrd 1990. 101-17.
39. MacUahon S. Peto R Cutler J.et a1 Blood pressure. stroke. and coronary heart disease. Part
Effects of p a v e smoking in the Multiple
L Prolonged differences in blood pressure:
49. American Heart Association MedicaVScien-
prospective observational studies corrected
tihc Statement. special report Rational of the
dilution bias. Lancet 1990;
diet heart statement of the American Heart
for the rreg&on
Risk hctor Intervention ltial Am J bidemi01
1987;126: 783-95.
3-35: 765-74.
Assciation: report of the Nutrition Commit-
40. Rmven OM The role of insuHn resistan= and
tee. Circulation 1993;88: 3008-29.
50. Coate D.Moderate a
hyperhmbmda in coronary heart disease.
Merabolism 1992: 4l(suppl l) :16-19.
41. K
l
w JC. Donahue RP, Harris MI. et al.
Momhty among diabetics in a national health
sample. Am J Epidemiol 1988;128: 389.
42. Kannel WB. Contributions of the Eramingham
study to
?t?o
conquest of coronary artcry
disease. Am J Cardiol 1988;62: 1109-12.
43. Krolewskl AS. Wanam JH.Vakama P. er al.
Evolving nahual lustory of coronary artery d s ease in diabetes mellitus. Am J Med 1991;
W(s~ppl2A): 56s-61s.
44. Wlllet WC. Green A Stampfer MJ. et al. Relative and absdute excess risks of coronary heart
disease among women who smoke cigarettes.
N Engl J Med 1987;317: 1303-9.
45. Schatzkin A Cupples LA. Heeren T. er al
. ...
g and coronary heart
disease mortality: evidence from NHANES
I and the NHANES I follow-up. Am J Fllbl
Health 1993; 83: 888-90.
51. Report of a WHO Study Group. Diet. nunition
and the prevention of chronic disease. WHO
Bchnid Report Series 797. Geneva. WHO
1990.
52. Report of WHO Expert Cornmitt&. Prevention
in childhood and youth of adult cardiovascular
diseases: time for action. WHO Technical
Report Series 792. Geneva. WHO. 1990.
53. Berlin JA Colditz GA A meta-analpis of physical actlvity in the prevention of coronary h e m
disease. Am J Epidemid 1990; 132: 612-28.
54. O ' C o ~ o rGT. Buring JE. Yusuf S. et al. An
overview of randomized trials of rehabhtation
Sudden death in the Framin-gham Heart
with exercise after myocardial infarction.
Study. Am J Epidemiol 19W. 120: 888-99.
Circulation 1989;80: 234-44.
46. Vlietstra RE. Kronmal RA, O b e m A et al.
patients with angiographicaly demonstrated
55. Hambrecht R. Various intensities of leisure
time physical activity in patients with coronary a r t w disease: effects of cardiorespira-
mrmary artery disease. Report from the CASS
tory fitness and progression of coronary
regisrry. J A M A 1986: 255: 1023-7.
atherosclerotic lesions. J AM CoU Cardiol
Effects of dgarette smoking on survival of
1993: 22: 468-77.
66. Badimon L Eadimon JJ. W e n M. et a1
Vessel wall-related risk factors in acute
v a s o h events. L h p 1991: 4Z&mppL5):1-9.
W. stmy HCBs
d
m~
g
9 ~ W I:IS~Z.
c
rosis.Cluestopa~komserial~
narY arMOQ@Iy. Br Heart J 1984 OcZ: 52:
of athero-
n
~
dmnmIyormgadults.Atberasderosls 1989:
n
~
58. Sngh-RN. Rogr&on of anonary atheroscle-
~
i
61-61.
~
o Fu
fsta VBadimon
~
59.
LBadimon .I. et aL The
pe~ofcoronaryartewdlseeseand
a m corcaw ~ ~ ~ d r o m
(first
e ~01. the
two perts). N EngI J Med 1992 326: 242-50.
th