1. No category

Title
Author(s)
Acute myocardial infarction in the Chinese in Hong Kong
Woo, Kam-sang.; 胡錦生.
Citation
Issue Date
URL
Rights
1988
http://hdl.handle.net/10722/27147
The author retains all proprietary rights, (such as patent
rights) and the right to use in future works.
H.D. Thesis
II
Department of Medicine
Prince of Wales Hospital
Shatin, Hong Kong
July 1988
Dec larat ion
I
confirm
that
this
thesis
Myocardial Infarction in the Chinese
own work and that
institution
in
entitled
in Hong Kong"
it has not been submitted
application
for
admission
to
to
diploma, or other qualification.
Dr Woo Kam Sang
13th July 1988
"Acute
is
my
any other
a
degree,
Abstract of thesis entitled
"ACUTE MYOCARDIAL INFARCTION IN THE CHINESE
IN HONG KONG"
submitted by Dr Woo Kam Sang for the degree of M.D.
at the University of Hong Kong in July 1988
present
The
coronary
documents
thesis
disease
artery
myocardial infarction
and,
(AMI)
in
confirms
and
Chinese,
the
acute
particular
in
that
four
are
to
eight times less common than in Western subjects, but have
been increasing
the past
in
years.
20
delineate
To
the
clinical patterns of AMI in the Chinese, a 'cohort' of 666
AMI patients in Hong Kong (1971-1980) was studied.
median prehospital delay from onset
hours
and median delay from onset
of symptoms was
2.8
coronary care
unit
The sex ratio was
6.1 hours.
(cou) admission was
to
was
years,
63.6+10.2
being
higher
in
1.9:1,
The mean
and the male preponderance decreased with age.
age
Their
the
females
10 years higher than in
(68.3+11.9 years).
The means are
Western patients.
There were more admissions during the
cold
Cigarette
seasons.
hypertension
associatd
and
wth
smoking,
overweight
AMI
by
were
hypercholesterolaemia,
found
case-control
to
be
comparison.
closely
More
positive primary preventive measures are needed for their
control.
Prolonged
precordial
pain
was
the
presenting
symptom
80.9%
in
females,
bad
symptoms.
no
6.2%,
non-Q-wave
high
16%
of
pain
but
presented
oLder
mostly
nonspecific
with
A high level of alertness is required for their
prompt detection.
in
patients,
and
Anterior Q-wave
posterior
infarcts
incidence
of
hypotension
(13.5%);
arrhythmias
(45.1%)
supraventricular
infarcts
Q-wave
21.0%
in
of
patients.
failure
heart
tachycardia,
There
a
cardiac
sinus
or
fibrillation
or
of
striai,
was
including
(38.6%);
forms
the
in
and
31.4%
in
complications
clinical
present
infarcts vere
flutter, primary ventricular tachycardia and fibriLlation;
right bundle branch block
block
(11.3%);
and
an
ospita1 mortality within
(12.7%)
elevated
4
being higher in the females
recent Western figures.
weeks
atrioventricular
and
blood
was
urea
29.5%
(24.8%).
(195/666),
(36.7%) and higher than most
Twenty-two per cent of patients
died within 6 hours and 48% of deaths occurred within 24
hours after admission. Causes of death included heart
failure (29.2%), cardiogenic shock (18.5%), primary
arrhythmiaa
deaths of
(22.1%),
cardiac rupture
(5.1%)
and
sudden
POBt- mortem
uncertain causes (15.4%).
examination of 89 fatal AMI patients revealed the presence
of significant mechanical defecta potentially salvageable
by surgical correction in 14.6% including rupture of free
left ventricular wall (11.3%), interventricular septum and
of papillary tnuscle
preponderance
was
There
(3.3%).
in the left anterior descending arteries
lesions
of
(42.7%),
which is similar to findings in Western reports.
impact
The
evaluated
by
CCU
of
prospective
a
mortality
was
study
two
hospital
on
concurrent
of
comparable groups of AMI patients younger than 70 years of
age
and admitted at random into
the
general wards
a
The patients
patients).
(92
(iii patients) or
CCU
initially
treated in the COli had a lower mortality (15.3%) compared
with
those
in
wards
general
the
with
(29.3%)(p< 0.05),
Our data confirm the hypothesis that
fewer sudden deaths.
a CCII could salvage more patients in Hong Kong.
Seven
clinical
objective
simple.,
parameters
including
hypotension,
cardiomegaly,
arrhythmias,
elevated
the
urea
likely
congestion,
and
infarct, have been delineated
available
presence
ages,
pulmonary
blood
readily
and
to
characteristics
indicative of
be
has been devised from these factors and our AMI
can
stratified
be
increasing
verified
hospitals
(l976-l986)
method
into
mortality.
in
to
recommended.
another
in
assess
seven
The
886
AMI
Kong,
Hong
Ita
cardiac
A coronary prognostic index
fatal outcome.
wide
A1I
with
subgroups
CPI
has
from
Guangzhou
severity
as
in
six
and
a
the
of
a
(CPI)
cohort'
stepwise
successfully
been
patients
application
of
general
Shanghai
quantitative
Chinese
is
-2Content s
PAGE
L.
General Introduction
6 -
2.
Epidemiology_of Coronary Artery Disease
in the Chinese
9 - 12
2.1
Introduction
2.2
Materials and Methods
2.3
Results
2.3.1
Prevalence of Coronary Artery Disease
in Rang Kong
2.3.2
Prevalence of Coronary Artery Disease
in Taiwan and China
2.4
Discussion and Review of Literature
2.5
Summary
2.6
Tables and Figures
3.
23-63
The Clinical Patterns of Acute Myocardial
Infarction (AMI) in the Chinese in Rang Kong
3.1
Introduction
3.2
Materials and Methods
3.3
Results
3.3.1
General Featured of AMI
3.3.2
Coronary Risk Factors in the Hong Kong
Chinese
3.3.3
Symptotnatologies of AMI
3.3.4
Clinical Features of AMI
8
PAGE
3.3.5
Conduction ]efects of AMI
3.3.6
Hospital Mortality of AMI
3.4
Discussion
3.4.1
general Features of AMI
3.4.2
Coronary Risk Factors
3.4.3
Clinical Presentations of AMI
3.4.4
Conduction
3.4.5
Hospital Mortality of AMI
3.5
Summary
3.6
Tables and Figures
4.
Seasonal Variation in the Development
of AMI in Hong ion&
4.1
Introduction
4,2
Materials and Methods
4.3
Resulta
4.4
Discussion
4.5
Summary
4.6
Tables and Figures
efects in AMI
The Impact of Coronary Care Unit
on Mortality from AMI in Hong 1(on
5.1
Introduction
5.2
Materials and Methods
5.3
Results
64 - 74
75 - 84
-4PAGE
5.4
Discussion
5.5
Summary
5.6
Tables arid Figures
6.
Delay in Admissions to a Coronary Care
Unit in Hong Cong
6.1
Introduction
6.2
Materials and Methods
6.3
Results
6.4
Discussion
6.5
Summary
6.6
Tables and Figures
7.
Pathology o
7.1
Introduction
7.2
Materials and Methods
7.3
Results
7.4
Discussion
7.5
Summary
7.6
Tables and Figures
8.
A Coronary Prognostic Index
or the Chinese
8.1
Introduction
8.2
Materials and Methods
p
Fatal. AMI in the Chinese
85 - 97
98 - lii
112 - 123
-5-PAGE
8.4
Results
Discussion
8.5
Summary
8.6
Tables and Figures
9.
Validation of a Coi-onaryrognostic Index
for the Chinese - A Tale of Three Cities
9.1
9.3
Introduction
Materials and 1ethods
Results
9.4
Discussion
9.5
Summary
9.6
Tables and Figures
10.
General Summary and Conclusion
10.1
General Summary
10.2
Conc1uion and Recommendation
11.
References
12.
Appendix
13.
Acknowledgement
8.3
9.2
124 - 132
133 - 143
-6CHAPTER i
GENERAL INTRODUCTION
Acute myocardial infarction
manifestation of
top
the
i1.ler
coronary
years.1
The
features,
pathophysiology
been
co-untries
literature.2'21
and
in
complications
and
described
has
been
the past
20
clinical
AMI
of
have
Western
the
in
undoubtedly
information
This
dangerous
a
factors,
risk
epidemiology,
recognised
well
is
artery disease which
the western
i-n
(AMI)
has
contributed to and facilitated the advances in management
including
AMI,
of
units,2223
regimens
limitation
24,25
therapies
arteries.
and,
concept
the
of
infarct
recently,
more
coronary
of
various
by
size
care
thrombolytic
the
rapid reperfusion of the occluded coronary
for
26-30
The Chinese form a large ethnic group accounting
one-quarter
for
distributed
Singapore.
most
of
their
in
in
world
mainland
China,
them differ
socioeconomic
Taiwan,
now
Hong
mainly
Kong
from their western counterparts
background
and
bave,
however,
factors
the western patterns
the past
population,
and
Apart from many other ethnic dissimilarities,
modernisation,
towards
the
of
20 years.
the
been
level
in
of
changing
in many Chinese communities
To what extent
these could have
-7affected the occurrence and disease pattern of AMI
is
an
interesting and important issue to be addressed.
clinical
In
coronary
artery
practice
disease
it
is
generally
in particular,
and,
that
felt
AMI
in
Chinese are less common than in the western countries
their
occurrence appears
to
increasing.
be
the
but
The present
thesis will deal with the epidemiology of coronary artery
disease,
and1
Hong Kong.
more specifically, of AMI in the Chinese in
The epidemioJ.cgical literature
in Taiwan and
mainland China will be reviewed in detail.
The clinical,
pathological patterns and prognosis
patients
Hong
in
Kong
will
in
examined
be
of AMI
'cohort'
a
and
reported.
Attention will be focussed on various prognostic clinical
parameters in AMI, and an attempt will be made to devise a
simple but practical index for the objective assessment of
clinical severity and prediction of short-term prognosis.
The
prognostic
index
will
applied
be
to
and
verified
against different cohorts' of AMI patients in Hong Kong and
in other Chinese cities.
the
In
dedicated
Chinese
decade,
coronary
to
equipments have
moSt
past
been
cities,
number
a
care
(CcU)
established
based
on
in
the
of
with
a
special
units
sophisticated
few hospitals
hypothesis
that
in
the
prognosis of AMI could be improved and more patients could
be salvaged by special care in such units.
investment in
communities
hospital in most Chinese
forthcoming in expectation of an
in general
CCU
will
More and more
be
increasing AMI incidence, and the economic and clinical
implication will certain].y be great. This thesis wiLl
specifically test this hypothesis.
The impact of CCTJ on
mortality of AMI in a general hospital in Hong Kong will
be critically evaluated and, as a relevant side-issue, the
delay in admitting AMI patients to a CCTJ will be assessed.
it is hoped that this thesis will provide a nicre
comprehensive documentation of the clinical patterns and
characteristics of
AMI
recomamendations
its prevention
on
1990s can be based.
in the Chinese, on which useful
and
treatment in the
-9CHAPTER 2
EPIDEMIOLOGY OF CORONARY ARTERY DISEASE
IN THE CHINESE
INTRODIJCTION
2.1
was
As
coronary
artery
affluent
Western
introduced
disease
been
has
countries
the
many
for
chapter,
previous
the
in
killer
top
in
Extensive
years.
literature on the incidence of coronary artery disease is
available
nowadays
Western
in
countries.
2-9,30-43
However the corresponding information on the occurrence of
coronary
amount
artery
to
disease
communities
Chinese
in
twelve hundred million people
one-quarter
comparatively
total
the
of
scanty.
world
majority
The
and
years,
from
large
sections
underdeveloped
urbanised
areas
cities,
socioeconomic
status.
improved considerably.
tuberculosis,
fever
and
these
of
with
to
Chinese
are
of
Over the past
health
changed
and
advancement
in
people
has
of
the
Diseases such as plague, pulmonary
schistosomiasis,
cholera
have
industrialised
spectacular
The
for
is
regions
highly
account
population)
distributed in China, Taiwan and Hong Kong.
30
(which
have
satisfactorily controlled.
leprosy,
either
P.heumatic
been
malaria,
typhoid
eradicated
or
fever and rheumatic
heart disease, once highly prevalent in these areas, have
- Io -
been declining, while degenerative cardiovascular diseases
hypertensive
and
Malignant
diseases,
cerebrovascular
have
have
Lncreas]ng.
been
cardiovascular
diseases
killers in the
together
diseases
have
last decade.
superceded
become
44-46
diseases
the
and
leading
three
In fact the latter two added
malignant
diseases
causing
in
mortality among the Chinese in these regions.45
The
purpose
of
present report
the
to
is
review
specifically the occurrence of coronary artery disease in
these
be
Chinese communities.
important
in
the
The updated information will
planning
allocation of resources, and
of
health
services,
care
the planning of professional
training in these areas.
2.2
MATERIALS AND I'IETEODS
The occurrence of coronary artery disease in Hong
Kong, Taiwan and China has been assessed by a multifaceted
approach.
This has consisted of the evaluation and review
of the prevalence of coronary artery disease in hospitals
and among the general population, along with the incidence
of
acute
myocardial
infarction
and
coronary
deaths
in
these areas.
Extensive
medical
literature
reviews
between
1960-1985 were made to delineate these three facets of the
- 11 data
from
and Clina.4759
Taiwan
Few estimates
specific or sex specific rates were available,
were
number
a
of
reports
on
of
age
there
but
epidemiological
community
survey or on prospective Community cardiovascular control
programs
of coronary artery disease from the communes or
factories.
from the vital statistics
Apart
data basing
on either clinical or exercise parameters were included in
the present review.
For Rang Kong, the vital, statistics were reviewed
from
the
Department
sexes
reports
annual
for
of
Medical
the
total population data
1969-1985).
combined,
Data
(all
tapes
Health
and
and both
ages
from
the
Census
and Statistics Department were analysed for data speciic
for age and sex (1961-1984).
occurring
over
mortality aver that
way
to
make more
of
age
the
age.
use
Treating all the deaths as
and
of
gave
40
this
a
rough
estimate
of
seemed to be the only
the officially published vitaL
Statistics from the Medical and Health Department.
During
the period 1961-78 the eighth edition of the International
Classification of
iseases
and
during
1979-85
the
ninth
edition were used in the classification of deaths in Hong
Kong and all admissions in the eleven government hospitals
and
the
sixteen
government
assisted
hospitaLs,
accounted for 89Z of all boepital. beds in Hong Kong.
which
All
- 12 patients with ischaemic heart disease cl.assified under the
'410-414', including acute myocardial
infarction (410), other acute and sub-acute forms cf
ischaeic heart disease (41.1) chronic ischaeinic heart
disease (412) angina pectoris (413) and asymptomatic
ischaeic heart disease (414) were recruited in the
present survey. Case studies were also made in Hong Kong
code
numbers
in the Nedical Unit B of the Queen Elizabeth Hospital and
the Cardiac Unit of the Prince of Wales Hospital.
The
registers of all the cardiac patients were analysed.
Coronary artery disease in
Kong and Taiwan
were diagnosed by the presence of one or more of the
IIong
following: acute inyocardial infarction satisfying the WHO
criteria; typical angina pectoris; cardiac rhythm or
cardiac
failure
associated
with
ischaemic
electrocardiographic changes; the presence of pathological
evidence of coronary artery disease at post-mortem
examination.606"
In
mainland China,
coronary
arterial
disease vas diagnosed by similar guidelines based on the
criteria of
the 1974 National Symposium on Epidemiology
and Prevention of Coronary Artery Disease and Hypertension
positive electrocardiographic response after
A
double-step exercise test was defined as 0.5 mn or more
horizontal or sagging ST-segment depression for 2 or more
- 13 minutes, and this was revised to "i mm or more" after
1979. In Taiwan, 1 mm ST-segment depression was taken as
positive electrocardiographic response in all the reviewed
reports
2.3
RESULTS
2.3.1
The
incidence and prevalence of coronary artery
disease in Hong Kong
In the past 20 years the mortality from coronary
artery disease has increased markedly from 15.5 to 44.4
per 100,000 total population, and in those older than 40
years of age, from 99.1 to 148.7 per 100,000 (Table 1).
The
increase, however,
was
in the
1970s,
and
both
the
crude death rate and the death rate at ages over 40 have
changed Little in the past ten years. Moreover, the age
specific mortality rates bave not increased throughout
this period (Table 2 and 3 and Figure i). The rate were
higher in men than in women, being very low in the males
below 44 years of age, around 130 to 200 per 100,000 males
in the age group 55-64 years, and 900 to 1,400 per 100,000
males above 75 years of age.
The sex difference was not
as great as in Western countries.
For acute myocardial infarction the age specific
mortality rates ware twice as high in the males as in the
- 14
females at all ages.,
for both sexes the incidence was
arid
markedly higher in people above 55 years of age (Table 4
and Figure 2).
From the published vital statistics,
the
(total hospital admissions) of acute myocardial
incidence
infarction from 1979 to 1986 was in the range of 100.2 to
117.3
100,000
per
population
older
than
40
years,
with
total deaths from acute myocardial infarction in the range
of 59.0 to 87.8 per 100,000 population older than 40 years
per
year
(Table
The
5).
overall proportion of coronary
artery disease amongst hospital in-patients increased from
4.2
per
9.6
to
inmates,
1,000
and
1,000 medical admissions (Table 6).
the medical units of
Pririce
from
16
to
28.2
per
A survey conducted in
the Queen Elizabeth Hospital and the
of Wales Hospital also revealed the same increase
from 12.2% to 38.5Z of adult cardiac admissions (Table 7).
2.3.2
The
incidence and prevalence
of
coronary artery
disease in Taiwan and in mainland China
The
Taiwan ranged
mortality
from
from 5.7
coronary
100,000
per
artery
disease
in
total population per
year in 1971 to 30.0 per 100,000 total population per year
in 1978 (Table 8).
Among the general population, clinical
evidence of coronary artery disease
of
the
evidence
population
according
above
to
40
years
exercise
as identified in 2.7%
of
age
(1974),
and
electrocardiographic
- 15 criteria was found in from 3.0% to 17.6% of the population
ranging
from
30-59
years
of
age,
with
an
average
prevalence of 7% (1964-1967, Table 9). The proportion of
acute myocardial infarction was 2.08 per 1,000 medical
in-patients.
Beijing,
Shanghai, Guangzhou, Tianjin and Hopei confirmed a similar
occurrence of coronary artery disease iii the 1970s. The
annual mortality due to coronary artery disease was from
22.7 to 35 per 100,000 population (Table 8), and the
prevalence of coronary artery disease among the general
population was from 2.4% to 3.9% according to clinical
evidence and from 2% to 9.5% according to exercise
electorcardiographs (Table 9). The prevalence increased
with increasing age from 35 years onwards. The incidence
of acute myocardial infarction (hospital admissions) in
In
mainland
mainland
China
China,
ranged
from
information
19
to
99.5
from
per
100,000
population, with deaths in range of 9 to 41.9 per 100,000
population per year (Table
2.4
DISCUSSION AND REVIEW 0' LITERATURE
Coronary
associated
century.
io).
with
artery
Western
disease
has
modernisation
in
been
the
closely
twentieth
It has been highly prevalent among most affluent
- 16 -
countries sttch as Australia, New Zealand, tsrael, Finland,
Norway
State
Sweden,
America
of
United
Derutiark.
(Table
countries, roughly 200
Kingdom
and
Table
12).
and
li
the
In
United
these
350 per 100,000 population,
to
or
500 per 100,000 population above 40 years, die of coronary
artery disease each year.
the adult niales
which
(700 to 900 per 100,000) than the females
per
250
to
(80
The mortality is much higher in
Acute myocardial
100,000).
be more objectively identified,
infarction,
affects 400
to
870 per 100,000 adults per year, causing deaths in 79
to
cari
100,000 adult
2-9,30-43
adult females.
500
per
males,
In comparison,
the
28
or
to
incidence
of
100,000
per
185
coronary artery
disease among the Chinese is much lower than their Western
counterparts.
incidence,
the
0f
the
annual
one-sixth,
the
incidence
one-eighth
to
one-tenth,
various
facets
coronary
of
mortality
acute
and
the
myocardial
mortality
coronary
of
is
roughly
infarction
from
acute
myccardial infarction is roughly one-eighth of the Western
figures (Table 11 and Table 12).
coronary artery disease among the
not be easily identified.
The actual prevalence of
general population may
On the whole, its prevalence of
3% to 7% in the Chinese is roughly one-quarter of that in
their Caucasian counterparts.
- 17 -
Precautions should be taken in the application of
data from mortality statistics
the reported mortality
as
rate may rise merely because of an increased awareness or
level
ascertainment,
cf
iatrogenic
transfer
another.32'43'62
from
from
made
could
error
of
an
to
arise
International
the
to
of
category
disease
source
changes
possibility
the
one
Another
periodic
the
witb
Classification of Diseases used to code death certificate
data.
as
To counter these objections to using mortality data
indicator
an
disease,
made.
closer
a
categories
In
incidence
the
of
look
into which
diseases
and
increased
in
we have
"ischaemic
of
Other
found
order
in
that
artery
diagnostic
the
combined
hypertensive
disease,
heart
insufficiency'
inyocardial
same
the
several
the
at
coronary
of
these deaths may be coded must be
regard,
this
incidence
Hong
Kong.45
also
However,
the apparent six-folds increase in mortality from coronary
artery
disease
spurious,
in
and
is
Taiwan
over
8-years
an
probably
most
due
period
to
is
gross
under-diagnosis of coronary deaths in 1971.
There has been a 30.5
ischaemic
1975-1977
heart
and
a
disease
in
increase in mortality from
Hong
iong
further increase of 10.4%
which have not been well reflected
in
in
in
the
period
1977-1979,
the secular trend
- 18 -
figures expressed in logarithm scale.
increase
predominantly attributed
is
This apparent large
to
a
large
increase
in age specific mortality among the population older than
75
years
in both sexes,
and
aging of our population.
to
In addition, the influence of possible increase in levels
of awareness and ascertainment of ischaemjc heart disease,
particular
in
among
older
the
should
population,
be
realised.
A multifaceted approach has been adopted
present
Data
review.
from
field
surveys
in
the
coronary
of
artery disease and acute myocardial infarction registries,
as well
more
as
from
vital statistics were used to provide
comprehensive
Nevertheless,
picture
from
different
a
viewpoints.
a wide range of occurrance frequencies
for
coronary artery disease has been observed among different
communitiea in Taiwan and mainland China.
of
these
possible
structure
data has
variables,
and
be made with
to
such
selection
as
bias,
the
the
Interpretation
due respects
reference
minor
cf
the
population
difference
in
diagnostic criteria and level of ascertainment, as well as
the quality and completeness of information from different
centres in these areas.
The present review has not included any 'silent"
ischaemie cardiomyopathy which could escape from clinical
identification.6366
could
be
common
a
type
of
cardiomyopathy in Europe or North America, but it has been
shown
be
to
uncommon
in
likely that its omission,
Kong.67
Hong
ft
therefore
is
if any, would not have affected
the overall review.
In China, there is a decrease of prevalence from
north
to south.
Tianjin,
with
compared
Taiwan
and
The exact reason has yet to be identified
but
when
Guangzhou.
is higher in Beijing and
The prevalence
those
in
presumably it could be related to the difference in build
and habits.
those
prevalence
The
Beijing and
in
Hong
in
Cuangzhou.,
and
Kong
is
similar
in-between
to
that
in
More research work including the identification
Shanghai.
of any difference in coronary risk factors in these cities
is needed.
The lower incidence of coronary artery disease in
the Chinese is similar to that reported in Japan and many
other
1975
parts
revealed
infarction
Indians
factors,
in
and
a
the
68-69
lower
incidence
The
pathogenesis
importance
of
acute
with
Presumably
and
life
of
Singapore
acute
of
compared
Malaysiens.7°
diet
from
Reports
Chinese
including
contributory.
the
*
Asia.
of
coronary
myocardial
myocardial
that
some
habits1
in
in
the
ethnic
could
thrombosis
infarction
be
in
has
- 20 received considerab.e atttti.or recently.7177 In this
connection,
other thromboembol.íc diseases such as
pulmonary tlirombøembolLsm atd deep vein thrombosis, which
are very comuon among the Caucasians, are aJ.so
comparatively much
less frequently found in the
Chinese.78 79
More work on coagulation profiles, as
well as the various coronary risk factors among the
Chinese in comparison with those among the Caucasians,
will be required to elucidate the whole issue.
While there is a common tendency of a declining
incidence of coronary mortality in USA, Australia, Finland
and possibly aLso in the United 1(ingdom, no such trend has
been
witnessed
communt.es. 9,33-34,37-39,42
the
in
On
the
Chinese
contrary,
an
increasing incidence is identified by all practitioners in
Beijing, Tianjin, Shanghai, Taiwan and Hong gong. There
has been scarcely any report specifically examining the
impact of aging, as compared with other coronary risk
factors, on the increasing incidence in the Chinese. The
present paper is unique in that we are able to evaluate
this issue by comparing the age specific mortality rates
of coronary artery disease and acute myocardial infarction
in Hong Kong over the past twenty years.
be
These appear to
fairly constant, suggesting that the apparent increase
- 21 in incidence in Hong Kong is predominantly the resuLt of
aging of our population. On the other hand, the static
incidence within each age group would also imply
the
failure of coronary risk factor control on the community
Level in Hong Kong, and possibly also in other Chinese
communities.
epideiniological
The
implications
of
our
findings is great. llore work is required to evaluate, and
hopefully offset, the impact of industrialisation and
urbanisation in the three Chinese communities during their
process of modernisation. For example, at present in Rong
Kong men in the higher socioeconomic groups seem more at
risk of death from coronary artery disease than men in the
lower
socioeconomic
groups.80
This
issue
wilL
be
further discussed in the next chapter.
The size of the total Chinese population at risk
is
large.
communities,
With
now
the
continued
still
aging
predominantly
of
the
young,
Chinese
we
are
expecting a bigger problem from coronary artery disease in
the coming decades.
2.5
SC)IMAR.Y
The
occurrence
of
coronary artery disease,
particular acute myocardial infarction,
three Chinese communities, Hong Kong.
was
Taiwan1
in
reviewed in
and mainland
- 22 -
China, using a tnulti.faceted approach.
(from community surveys
the
incidence
Coronary
and hospital admission data)
(from deaths
artery
Both the prevalence
disease
hospital
and
of
adiissioris)
infarction
myocardial
acute
and
and
were much lower than those in most Western countries.
these three territories
In
the prevalence of coronary artery
the mortaLity from coronary artery disease,
disease,
incidence
myocardial
acute
of
from acute
mortality
infarction,
and
infarction were
myocardial
the
the
roughly
one-eighth to one-quarter of the average Western figures.
While
been declining
have
been
in most
increasing
communities wich
people.
In
completely
a
Bong
explains
affluent Western countries,
these
in
trends
in
three
of
Kong
aging
the
the
increase
a
large
they
Chinese
twelve hundred milLion
population
and aging is undoubtedly
rates,
such
prevalence and mortality figures have
the
the
population
total
population
of
in
contributing factor in
Taiwan and China.
However more work
is
required to delineate and assess the relative significance
of
the
changes
in
the
socioeconomic
and
coronary
risk
factora in the process of modernisation.
The
should
implications
certainly
deserve
planning in these regions.
of
more
these
changes
consideration
and
trends
in
future
TabLe i
ortaliy Frati Ischaeiiic Heart Disease in Bong Kong
Population in Bong Rorg
Year
Total
>40 years
(ei)
(p2)
(Z)
Total
I.H.D. Death
Per
100,000
1)
1969
3863900
1971
4045300
1136100
1973
4185800
1975
Per
100,000
(P2)
597
J.5.5
(28.1)
1126
27.8
99.1
1206200
(28.8)
1185
28.3
98.2
4337400
1269300
(29.3)
1278
29.5
100.7
1977
4512900
1343000
(29.8)
1738
38.5
129.4
1979
4878600
1435500
(29.4)
2071
42.5
144.3
1981
5154100
1538400
(29.8)
2103
40.8
136.7
1983
5313200
1587900
(29.9)
2361
44.4
148.7
1985
5422800
1636300
(30.2)
2387
44.0
145.9
-
-
TabLe 2
Year
25-34
1961
2.8
1962
Mortality Rates of Ischaemic Heart Diseases
in Hong Kong (1961-1984) Males (3 year moving
average rates per ioo,000 population)
35-44
45-54
55-64
65-74
75+
11.8
43.9
175.2
416.8
926.4
24.5
2.4
11.5
44.3
188.6
401.5
890.6
24.9
1963
2.5
12.8
47.0
201.3
415.7
972.7
27.3
1964
2.2
12.9
49.8
201.4
492.2
1125.5
30.6
1965
2.8
12.4
47.4
179.8
551.8
1344.3
32.7
1966
3.1
10.4
41.8
159.8
570.6
1423.3
33.0
1967
2.4
7.1
39.4
156.9
531.2
1410.2
32.3
1968
1.3
5.4
34.2
140.2
427.8
1144.3
27.6
1969
0.6
4.2
31.8
132.3
357.1
961.0
24.9
1970
0.6
5.0
31.0
121.9
337.8
821.9
24.].
1971
1.0
5.2
32.9
130.1
396.9
954.9
27.9
1972
1.5
5.6
36.].
122.9
387.2
975.5
29.0
1973
1.4
5.6
34.2
121.8
373.3
975.6
29.5
1974
0.9
5.4
35.3
118.8
360.3
895.5
29.8
1975
0.9
5.6
32.3
128.0
399.1
912.0
32.5
1976
1.5
7.1
34.8
135.5
425.1
938.6
36.0
1977
1.8
8.].
37.7
146.1
434.3
965.8
38.9
1978
1.8
9.2
39.9
153.7
432.3
1022.5
41.4
1979
1.6
9.4
38.3
147.6
440.4
1055.5
42.0
1980
1.7
8.8
37.2
142.4
440.2
1046.3
42.8
1981
1.3
7.8
35.7
1304
420.9
1022.5
42.8
1982
1.1
5.8
34.1
1.34.5
409.0
981.2
44.2
1983
0.9
5.8
31.5
130.6
403.2
963.6
44.8
1984
0.8
4.8
28.8
132.9
402.8
908.9
44.8
Total.
Table 3
Mortality Rates of lschaemic Heart Diseases
in Horg 1(ong (1961-1984) Females (3 year moving
average rates per 100,000 population)
Year
25-34
35-44
45-54
55-64
65-74
75+
Total
1961
1.4
2.9
14.3
70.2
196.6
639.3
20.1
1962
1.2
3.1
13.8
70.9
194.6
603.9
19.9
1963
1.0
1.7
15.3
65.3
204.6
644.8
21.0
1964
0.6
2.7
17.1
66.2
216.6
718.9
23.5
1965
0.3
3.0
19.8
65.6
232.6
853.6
27.0
1966
0.3
4.1
20.3
63.1
238.6
881.9
28.8
1967
0.8
3.4
18.6
63.4
226.8
866.1
28.8
1968
1.2
2.7
13.3
50.2
179.1
667.5
23.1
1969
0.8
2.4
10.2
50.6
155.1
578.5
21.2
1970
1.0
2.8
11.5
45.4
158.8
544.3
21.6
1971
1.1
3.1
14.5
55.2
185.6
657.3
26.6
3.972
1.4
3.1
16.0
55.2
1.84.9
657.0
27.8
1973
0.7
2.6
15.8
57.7
182.8
643.5
28.6
1974
0.6
2.4
146
56.3
187.1
594.1
28.6
1975
0.4
2.2
12.9
54.4
200.7
596.4
29.5
1976
0.7
2.8
11.2
55.8
202.5
655.5
31.8
1977
0.5
2.7
12.2
60.1
218.4
707.2
35.0
1.978
0.4
2.7
12.4
64.3
225.6
751.8
37.9
1979
0.3
2.5
13.2
65.3
238.4
711.0
38.5
1980
0.9
2.6
13.2
61.8
233.1
729.4
39.4
1981
1.1
2.2
14.0
62.1
227.1
726.2
39.9
1982
0.9
1.2
14.5
63.8
217.4
754.5
41.3
1983
0.5
0.8
13.2
62.7
216.4
723.7
41.2
1984
0.2
0.8
12.3
62.6
213.1
714.1
41.4
Table 4
HK Mortality from Acute Ilyocardial Infarction (1978-1986)
3 year
15-24
1978
1979
1980
198].
1982
1983
1984
1985
1986
0.3
0.2
0.2
moving averag
Mil (Male )
25-34
35-44
1.0
0.6
0.8
1.0
1.0
0.4
0.2
0.1
rates pr LC000O population
45-54
4
18
6
2].
6
15
4
23
26
23
22
29
26
5
3
5
4
7
55-64
78
72
67
69
69
95
82
88
91
65-74
162
225
204
179
225
253
228
236
238
75+
30].
445
407
42].
426
484
396
422
548
AMI (Female)
15-24
1978
1979
1980
1981
1982
1983
1984
1985
1986
0.2
0.2
25-34
0.3
1.2
0.5
0.2
0.6
0.7
45-54
55-64
65-74
75
1.0
6
1.0
0.9
0.9
1.0
1.0
1.1
1.1
0.6
4
35
25
31
36
37
89
94
110
102
100
117
104
128
146
205
236
2.34
269
283
343
283
279
267
35-44
6
9
10
11
5
lO
9
46
31
38
34
Table 5
Incidence of Acute )lyocardial Infarction (I) in
Hong Kong (1979-86)
Population in Hong Kong
rear
Total
(Pl)
4,878,600
1979
5,038,500
1980
5,154,100
1981
5,232,900
1982
5,313,200
1983
1984
5,364,000
5,422,800
1985
5,532,600
1986
<
)
> 40 years
AMI
(Z)
rotai
1,502,600
1,538,400
1,564,600
1,587,900
1,607,600
1,636,300
1,681,800
AMI mortalities
29.4
29.8
29.8
29.9
29.9
30.0
30.2
30.4
Per
100,000
(P1)
(P2)
1599
32.8
111.4
(847)
(17.4)
(59.0)
1365
27.1
(865)
(17.2)
1415
27.5
(976)
(18.9)
1497
26.6
(1096)
(20.9)
(70.0)
1806
44.0
117.3
(1325)
(24.9)
(83.4)
1720
32.1
107.0
(1202)
(22.4)
(74.8)
1640
30.2
100.2
(1321)
(24.4)
(80.7)
1723
31.1
102.4
(1476)
(36.7)
(87.8)
(P2)
1,435,500
Per
100,000
90.8
(57.6)
92.0
(63.4)
95.7
Table 6
Year
Prevalence of Ischaendc Heart Disease in
Hospitals in Hong Kong
Hospital
Medical
Patients
Pat len t s
(H.P.)
(M.?.)
lschaemic Heart Disease
Total
Per 1000
(H.?.)
Per 1000
(M.?.)
1969
257466
65236
1076
4.2
16
1971
284062
64111
1566
5.5
24
1.973
346320
118858
2025
5.8
1.7
1975
400182
133998
2630
6.6
20
1.977
453301
151621
3317
7.3
22
1979
631196
199471
5302
8.4
26.6
1981
692017
216290
5791
8.4
26.8
1983
793102
265588
7208
9.6
28.2
1985
786238
266982
7095
9.0
26.6
Table 7
Ischaemic Heart Disease in Q.E.H. (Medical Unit B) and PWH*
Total
Ned Pat.
Total
Year
1969
Isehaemie Heart Disease
Total
Card. Pat
-
% Med. Pat
i Card. Pat
596
73
-
12.2
1971
6828
802
121
1.8
15.0
1973
9171
910
149
1.6
16.4
1977
12357
1039
193
1.6
19.0
1979
13120
1286
218
1.7
15.7
1984_85*
10777
910
256
2.4
28.1
1986_87*
10747
1649
635
5.9
38.5
Q.E.H.
Queen Elizabeth Hospital
P.W.H.*
Prince of Wales Hospital
Med. Pat.
:
Medical Patient
Card. Pat.
:
Cardiac Patient
Table 8
Year
Coronary Mortaliyin the Chinese
Locations
Age Range
Mortality
per l00000
1977
Hong Kong
All age
38.5
1977
Hong Kong
> 40 yr
129.4
1985
Hong Rong
All age
44.0
1985
Hong Kong
40 yr
145.9
1971
*Taiwan49
All age
5.7
1978
Taiwan52
All age
30.0
1974
Beijing59
All age
22.7
1975-79
Beijing55
Adults( 15 yr)
35.0
1972-74
Cheng Ting57
40 yr
273.5
(Hope i)
1976
All age
29.6
Beijing59
All age
51.5
Tianjin59
All age
45.2
12 cities59
(China)
*
Vital statistics, in Taiwan
(939 coronary deaths out cf 16.6x106 population in 1971)
+
17 deaths out of 6216 farmers in cominuue
Table 9
Year
PrevaLence of Coronary Artery Disease in General Population
Location
Diagnostic Criteria
Age
Clinical
1964-67
Taiwan47'48
1974
Taiwan49
1971-74
Beijing5°
3044(Ma1e)*
3%
4059(Male)**
3.2-17.6%
(Average 7%)
> 40 yr
All ages
>4Oyr
1974
Beijing54
Exercise ECG
2.7
0.9
2.4
2-9.5%
30-4O'
(Average 3-5%)
1972-73
Jee-Lin58
Adult
6.3%
1971-79
Tianjin58
Adult
7.6%
1977
Beijing51
1975-79
Beijing ++
1979
40 yr
3.9
33-44
2-3
45-54
3-5
> 55 yr
6-10
Beijing54
)40 yr
3.93
Beijing58
Adult
4.1%
Beijing58
Adult
5.4%
Guangzbou58
Adult
7.9%
* Male tricyle-cab driver
** Upper social class
+
Survey of l0O0O farmers, fisheruLen factory workers and
non-manual workers
++ Wu Y.K. personal couiunication 1979
Table 10
Year
Incidence of Acute Mvocardial Infarction (AMI)
in the Chinese
Location
Age Range
A}1I/l00,000
Beijing50
1971-74
AMI Mortality!
l000O0
(Tears)
Mean 32.3
19
9
36.5
50
10
1975
Cheng Ting53
>35 yr
53.1
41.9
1976
Harbin53
>40 yr
40.6
20.7
1975
Guangzhou53
>40 yr
39.7
35.0
1974-78
4 cities59
Adults
28.3-64
13.3-41.9
1974-76
Beijing56
Adult
65.1
1977-80
Beijing56
Adult
99.5
1977-79
Shijing Shari55
>15 yr
52-64
23.4-26.8
1979-86
Hong Kong
All age
1-44.0
17.2-36.7
>40 yr
90.8-117.3
57.6-87.8
(M)
:
Males
(M)
55-64 yr
67-95
(F)
55-64 yr
25-46
(M)
65-74 yr
179-253
(F)
65-74 yr
94-146
(F)
:
Females
Table II
Countries
Comparison of Coronary Deaths
in Different Countries (1970-So)
Age
China/Hong Kong
All age
)40 yr
(M)
(F)
(M)
(F)
Japan6869
Deaths/100,000
Per Year
Incidence
Ratio
40
1
145
1
35-64
35-64
45-74
45-74
6-140
2-64
35-420
14-220
All age
50
120
1
>40 yr
1
Australia6'8i36
All age
210-600
4
Fin1and4042
All age
35-74 yr
70-450
747.1
2-lO
All age
All age
288
191.7
5
New Zealand81
1972 Male
Female
Male
Female
1976 White
Maori
>40 yr
40 yr
All age
All age
277-4141.5
84.7-2744.7
161-531
325-667
Norway35
All age
96-405
2-IO
Israel4
All age
180.9-256.4
4-6
U.KJ'3336
All age
35-74 yr
45-64 yr
45-64 yr
185-470
671.7
260-900(470)
41-320(185)
All age
35-74 yr
200-500
5-LO
6695
5
All age
113.0
3
40-80 yr
40-80 yr
96.6-1737.5
17.5-1390.7
5-8
(M)
(F)
U.S.A)'3437
Rochester3437
USSR82
(M)
(F)
(M)
Males
TY
:
Females
7
5
4
4-6
5-10
5
6
3-5
4-6
Table 12
Comparison of Incidence of Acute Nyocardial Infarction
in different countries (1970-80)
Age
AN3/100,000
ANI deathsl
100,000
Incidence
Ratio
>40 yr
45-74
45-74
40-99.5
23-80
23-225
10_110
1
30-69
220-741
3-1570
7-10
Israel4'7
All ages
870
10
Japan5
(Hiroshima)
Adult
280
2
40-69
40-69
405
96
4-10
40-46
60-600
(Average 220)
2-6
40-64
40-64
217-1549
6-533
40-69
500-1500
10-15
110-450
3-5
30 yr
258
3-6
35 yr
430-490
110-140
4-10
Countries
China/Hong Kong
(ii)
(F)
Australia18
1
I
(Perth)
Norway35
(M)
(F)
Sweden9
(Malmo)
Goteborg5
(M)
(F)
1-2
79-504
28-185
8-15
5
U.K.
Edinburgh2
<70
Oxford3
U.S.A.
Rochester37
Frai:ninghatn31
(M)
(F)
All age
Teeside6
(M)
>35 yr
Males
(P)
489
Females
2
10
disease mortaLity in aong
Death rates are expressed
in logarithm nonversion scale to embrace the
wide ranges in different age groups.
Ischaemic heart
Kong 1961-4984.
Figure L
M25-3q
Men aged 25-34, F35-4L
Warnen aged 33-44, etc.
10000
................
1000
-.--..- F75*
........
Deaths
M65-7;
perye
per
100 000
populatIon
..
.
100
"-'-.
(log scale)
.
- ............
F3-54
......................
....... .'
L
_-:------::
i
1961
r
r
i
r
1966
i
i
i
r
r
r
1971
years
r
i
i
i
1976
r
i
r
r
r
1981
r
r
Acute
Hong
'igure 2
myocardial
infarction
oug
1978-1986.
The
iorta1ity
in
mortaLity
is
?r5Sed in logarithm conversion scale to
embrace the wide ranges in different age
groups.
The incidence in fema1s aged 3544
years
is
app-oximateLy
per
100,000
1
throughout.
Men aged 25-34, F35-44 = Women aged 35-44, etc.
M25-3'I
1000
.-
-.
F7S4..
..
-F5-71l
100
Deaths
per year
per
100,000
population
Uog scale)
4h54
....
lo
* ......
1
1
1978
r
1979
M34
......
r
r
1980
1981
1982
years
r
1983
T
I
I
1984
1985
1986
- 23 -
CHAPTER 3
ThE CLINICAL PATTERNS 0F ACUTE NYOCARDIAL
INFARCTION IN THE CHINESE IN HONG K01C
INTRODt7CTION
3.1.
has
been
disease
Hong
shown
was
It
increasing
an
and incidence
Kong
the previous chapter that there
in
well
as
prevalence
of
as
acute myocardial infarction
in
communities
in
other
in
Chinese
Taiwan and mainland China, which account
of
artery
coronary
of
the worldTs population.
Although
for one-quarter
of
figures
the
the
incidence and mortality of acute myocardial infarction in
these
communities
Chinese
one-sixth
of
those
found
is
only roughly one-eighth
in
the Western countries,
to
the
actual size of this problem is quite voluminous since the
For a long time,
denominator population at risk is large.
acute myocardial
infarction has
countries
Western
10-13,22,83-84
morbLdtty.
the
available
nowadays
coronary
features,
prognosis
countries.
of
on
for
its
the
risk
literature
natural
history,
acute myocardial infarction
on
the
Chinese
in
and
is
and
Western
corresponding
the
population
the
in
clinical
complications
factors,
However
recognised
mortality
high
Extensive
14-21,23,85-89
information
been well
is
comparatively
- 24 -
sparse.
information
The
paper attempts
This
various
on
aspects
updated knowledge will
provide
to
important
this
of
more detailed
a
certainly be
useful
understanding and clinical management of this
issue.
for
the
disease
in
the Chinese.
MATERIALS AND METHODS
3.2
hundred
Six
patients
one
of
Queen
with
myocardial
acute
Elizabeth
(Medical
between
Hospital
consecutive
Chinese
infarction admitted
three medical units
the
reviewed.
sixty-six
and
B
and
1971
of
Unit)
1980
The demographic characteristics were
into
the
were
outlined
Fifty-six patients whose records were either
in Figure 3.
including 21 patients who died on
missing or incomplete,
arrival and 31 patients with grossly incomplete
data were excluded from the study.
clinica].
Two hundred and twenty
four patients were admitted between the period of 1971-76,
compared with 442 patients
The hospital records
of
the
for
patients
1976 were studied retrospectively.
four years 1977-1980.
admitted
in
before
or
A standard data entry
form was used, since 1977, fr the recordings of clinical
features,
complications
(Appendix i).
were
progress
of
all
patients
These forms were entered prospectively and
later analysed
myocardial
and
L1
infarction
details.
was
made
The diagnosis
either
by
of acute
pathological
- 25 -
confirmation
post-mortem examination
at
clinical
by
or
identification with the WHO criteria, when at least two of
the following three abnormalities were present60
Characteristic
1..
presentation
clinical
of
precordial. pain for more than half an hour.
Pathological Q wave,
2.
inversion
e1ectrocardiograms
the
in
ST elevation or
T wave
subsequent
with
evolutionary changes.
3.
An
unequivocal
rise
aspartate
the
in
aminotransferase (SCOT) level to over 45 lU/mi on one of
three successive days, with the highest level being at
least twice that of the lowest one in those with
borderline elevation.
A Q-wave infarction was diagnosed when new, or
presumably new, Q waves of at least 0.03 second duration
and 0.2 mV in depth were detected in either (a) leads lI,
III
and AVF,
(b)
leads
I
and
AVL
or
Cc)
two
or
more
precordial leads. Non-Q-wave infarction was diagnosed
when enzymatic and precordial pain criteria were met with
the presence of ST or T changes, but with no development
of Q waves. An infarct was categorized as anterior when
electrocardiographic changes occurred in
or
two
or more precordial
leads,
and
as
Leads
I
and AVL
posterior when
changes occurred in leads II, III and AVFI with or without
- 26 a
dominant
wave
R
intraventricular
according
criteria
defect
of
type
presence and
Tb
conduction
the
to
in V1.
ai.9091 The specific types
definitions are as follows
of
determined
was
and
Rosenbaum
of
blocks
Recht
and
et
their
Right bundle branch block (REBE) required a QRS
duration
0.12 sec. with an rSR or qtt configuration of
the QRS complex in lead V1 and a deep S wave in lead I.
Left bundle branch block (LBBB) required a QRS
0.12 sec. with a wide notched R wave of RsR'
duration
configuration of QRS complex in lead I and V4 to V5.
REBE
plus left anterior hemiblock (LARE) was
defined as REBE with left axis deviation of 450 or
greater, associated with rS complexes in lead Il and III,
and the axis abnormality not a result of pathological
Q
wave.
RBBB
plus
left posterior
bemiblock
was
(LPRB)
defined as RBBB with a rightward QRS axis between +120°
and +1800 in
the
absence of lateral wall infarct, right
ventricular hypertrophy or history of symptomatic chronic
lung disease or cor pulmonale.
First
degree
atrioventricular
required a PR interval 0.20 sec.
was
claesified
as
Nobitz
Type
(A-V)
block
Second degree AV block
i
and
2
according
to
- 27 -
standard
criteria.9'
Type
I
block was characterized by
the presence of variable PR intervals of conducted beats
arid
Type
2
block
was
Characterized
constant PR
intervals.92 Third
by
intervals despite variations in RR
degree A-V block involved complete A-V dissociation with
the ventricular rate less than 60 beats/tnin. and
nonconducted P waves occurring outside the ventricular
refractory period.
All patients, who presented at the accident and
emergency department of the hospital with symptomatologies
and clinical features cf AMI, were admitted into hospital,
irrespective of their ages, presence or absence of . any
There has been no changes in this
complications.
admission policy throughout the whole study period. Four
hundred
and
eighty-seven
patients
admitted
were
into
general wards and 179 patients into the coronary care unit
which
started to function in August 1977.
(COtE)
Admissions to COU were dependent upon the availability of
vacancies, whether the patients were under 70 years, and
the presence of certain complications in those above 70
years, such as malignant dysrhytbmias
defects. Patients admitted 48 hours or
of
symptoms
ere
intenaive
coronary
care
onset
not
normally
except
in
or
conduction
more
after the
considered
the
presence
for
of
- 28 -
All patients managed in the general wards
complications.
initially had
their ECG moiiitored
least 48 hours
at
for
and those in the CCII were motiitored throughout their stay
in
the
for
CCTJ
average period of
an
hours
72
(Appendix
Their electrocardiographic rhythm strip were analysed
2).
posteroanterior
Standard
manually.
upright
X-ray
chest
films were obtained on admission or during the first day.
the
For
very
semirecumbent
radiography
tube
patients,
films
were
performed
was
distance
film
to
sick
portable
anteroposterior
Portable
taken.
by
of
standard
with
Cardiornegaly
cm.
122
technique
chest
a
was
evaluated on the basis of increased (> 55) cardiothoracic
ratio,
which
vas
defined
as
the
relation
between
the
widest transverse diameter of the heart and the internal
diameter of
level
the
of
chest,
the
highest
the latter being measured
on
point
left
the
at
the
hemidiaphragm.
Pulmonary congestion was diagnosed according to the method
ßattler
of
blood
et
al.93
interstitial
flow,
redistribution
when
pulmonary
of
edema,
pulmonary
localised
alveolar edema or diffuse alveolar edema was present.
Patients were usually kept in hospital for three
to
four weeks.
four
weeks
among
The hospital deaths that occurred within
t}e
644
record were analysed and
patients
the
with
fully
clinical parameters
complete
in
the
- 29 -
initial
three
days
after
admission
association with
in
mortality were determined.
Arrhythmias
along
standard
inserted
were
transvenous
lines
and
into
patients
(excluding Mobitz Type
1)
pacemakers
cardiac
developing
treated
were
failure
cardiac
and
second
degree
or complete AV block (Appendix
Pacemakers were not routinely used prophylactically
3).
in patients with bundle branch block or
fascicular
left
b lock -
order
In
to
disease,
52$
patients
'cohortt
were
factors
including
the
studied
control
the
prevalence
overweight
and
artery
the
frani
smoking,
cigarette
hypercholesterolaemia,
a
and
coronary
of
selected
randomly
factors
risk
the
development
predisposing
were assessed.
evaluate
to
AMI
certain
of
hypertension,
diabetes
mellitus
Their occurrence was compared with that of
group
matched
with
ages
recruited
from
381
referrals for preemployment examinations (42%) and routine
health check-up (58%)
centre
in a comprehensive medical screening
(Sing Tao Medical Centre) in 1975-79.
none of the
later group was found to bave any organic heart disease.
The control group with matched ages was randomly selected
from a retrospective review of the clinical records of the
referrals
attending
the
Sing
Tao
Medical
Centre
in
the
period
1975
to
-
30
Hypertension
1979.
definite
included
(l60/95 mmHg) as well as borderline (150/90-160/95 mmHg
hypertension
or
Those who had stopped smoking for 10 years
.
were
more
regarded
non-smokers.
as
Overweight
was
present if the body weight was 20% or more above the ideal
body weight
set down by
scheme.
Diabetes
the Metropolitan Life
included
mellitus
Insurance
overt
the
diabetics requiring medication as well as the subclinical
cases
was
biochemically.9596
diagnosed
assessed
groups
both
in
cholesterol
Blood
by
modified
the
Liebermaun-Burchard reaction Chi-square
The
used
assess
ta
respective
with
YatesT
coronary
of
correction was
significance
statistical
the
prevalence
test
of
the
and
the
437 were males
and
risk
factors
mortality rates of clinical subgroups.98
3.3
RESULTS
3.3.1
General Features of AMI
Among
the
666 AMI patients,
229 were females, with
Their
ages
ranged
being
63.6
+
over 60 years.
their mean
a male
from
28-89
10.2 years,
to
famale ratio of 1.9:1.
years
with
the
mean
and the majority (67.0%)
age
being
The females were older than the males and
ages were
68.3
+
11.9
years
and
61.0
9.9
- 31 -
years
respectivel.y
(Table
The disease was
13).
both men and women below 50 years (Figure 4).
men predominantly
in
age groups
the
the age of 70 years
over
51
to
rare
in
ft affected
years
69
and
it affected both sexes equaLly.
tnformatin on socioeconomic status was available in 471
The majority of patients came from the
patients (70.7%).
socioeconomic
lower
involved
class)
atid
non-professional
in
most
works
of chest pain
wards
Fifty-nine
3.2
hours.
to
retired
or
14).
Their
arrival
in the
(Table
median delay from onset
was
were
percent
of
patients
arrived at the hospital within three hours of the onset of
infarction.
There
were
more
admissions
for
acute
myocardial infarction during the cold months from October
to
arch,
compared with
the
hot
seasons
from April
to
These will be dealt with separately in greater
September.
details ir' the following chapter.
A detailed history could be taken in 632 patients
(94.9%).
One hundred and fifty-four patients (24.4%) had
history of systemic hypertension, 89 patients (14.1%) had
diabetic history)
accidents and
57 patients
26 patients
(9.0%)
had cerebrovaseular
(4.0%) had chronic obstructive
airway disease.
3.3..2
Coronary Risk Factors in the Hong Kong Chinese
The
prevalence
of
risk
factors
among
the
32
-
referrals
ages
those
or comprehensive nedical screening with matched
shown
is
-
found
Table
in
AHI
the
in
and
15
When compared with
16.
patients,
distinctly associated with inyocardial
male
and
female
infarction
in
Hypertension
(p< 0.05).
patients
smoking
cigarette
was
both
and
overweight were more frequently found in the male patients
than
the
in
male
controls
hypercholesterolaemia was more obvious
impact
The
(p <. 0.05).
of
in
female patients
compared with female controls, as well as
in all patients
The mean serum cholesterol level
younger than 60 years.
of
young
the
males
of
was
and
239.962.3 mg/lOO
mg/LOO
245.2+122.9
and
respectively
those
patients
were
these
ml
higher
(p< 0.05)
The significance of diabetes mellitus as
in
the
females
the
in
significantly
the young control groups
al
than
(Table
17).
an aetiological
factor for IHD in both young and old patients has not been
witnessed in the present study (Table 15 and 16).
Symptomatologies of AMI
3.3.3
Thirty-nine
patients
had
a
and
previous
four-tenth
history
of
percent
of
the
angina,
9.5Z
had
previous episodes of infarction and 51.1Z of the patients
were compLetely asyinptontatic and myocardial infarction was
their
first
disease.
c1inical
Precordial
manifestation
pain
was
the
of
coronary
commonest
artery
presenting
33 -
-
symptom (80.9%), preceded by unstable angina in 5.8%.
102 patients
In
there was no warning pain anywhere
(15.3%),
Acute dyspnoea occurred in 32.5%, palpitation in
at all.
15.3%, profuse perspiration in L2.0%, nausea and vomiting
it,.
8.9%
of
included syncope
symptoms
weakness
of
dizziness,
or
and
pyrexia
limbs,
Other presenting
respectively.
patients
the
sudden collapse,
constitutional
other
symptoms (table is).
Clinical Features of AI
3.3.4
0f
1973-1980,
636
the
132
admitted
AMI patients
the years
in
(20.8%) had non-Q-wave infarcts,
patients
294 patients (46.2%) had anterior Q-wave infarcts and 200
patients
19).
(31.4%)
Twenty
patients
posterior Q-waves
had
(3.1%)
sites
were undetermined.
LBEB
or
Most
normal
(Table
anterior
patients,
and
infarct
the
them were related
of
ECG.
infarcts
combined
In 30
infarcts.
apparently
Q-wave
posterior
had
Their
to
clinical
vital
features included hypotension (systolic blood pressure
(
90
mml{g)
congestion
other
or
cardiomegaly
(13.6%),
oedema
(38.6%),
cardiac arrhythmias
tachycardia
(rate
tachycardie,4
atrial
ventricular
ectopi.cs
)
sinus
(45.1%)
in
(45.1%),
bradycardia
the
(within
forms
(3.2%),
of
sinus
supraventricular
100/min.),
fibrillation
pulmonary
or
initial
flutter,
72
early
hours),
- 34 -
vertricu1ar
fibrillation.,
( > 10
tachycardia
or
pericarditis
(3.3%),
mmot/L)
and
(24.8%)
ventricular
primary
elevated serum urea
disorders
conduction
(23.4%)
(Tables 19, 20 & 21).
3.3.5
Conduction Defects in AMI
The
12.7%,
30%
3.1%
and
common
posterior
11.3% with hospital mortality of 50.6%,
and
respectively
34.7%
anterior
in
of RBB, LBBB and A-V block were
incidence
(20.1%)
infarets
Q waves
(Table
(Figure
(8.0%)
Its occurrence was transient in
Il
was
more
compared
with
RBBB
21).
5)
19).
(p.( 0.05)
(Table
patients
(13.4%).
0f
the 82 RBBB patients, 36 patients (43.9%) had definite new
RBB and
43
22).
anottier
In
patients
possibly
(52.4%)
nine
patients,
preterminal agonal rhythm.
the
new
RBBB
(Table
occurred
RBEB
as
A combination of RBBB and LAUB
was seen in 18 patients (22.0%) and of RBBB and LPHB in 4
patients (4.92).
Of the
20 LBBB, six patients
transient, LBBB were definitely new
and possibly new in another
6
(30%) were
in 12 patients
patients
(30%).
(60%)
Of the
72
patients with A-V block, first degree A-V block was found
in
25
patt$uts
patients
block,
(50%),
(34.7%),
second
degree
A-V block
of whom the majority (91.7%) were Type
and third degree L-V block in 24 patients
respectively
in.
(ab1e
23).
A-V block
was
more
36
1
(33.3%)
commonly
- 35 -
associated
wth
posterior
anterior inarCts
with
second
(Table
degree A-V blocic,
Mobitz
Type
degree
A-V block
occurred in
(5.4%)
infarcts
A-V
2
in
than
(25.5%)
19).
O
36 patients
th
three patients
b1ock
with
progression
two
patients
(66.7Z),
(33.3%) (p>O.1).
had
(8.3Z)
third
into
whereas
out of 33 patients with Type
11
with
i
this
A-V block
Third degree A-V block was preceded by
second degree A-V block in 13 patients (54.2%), by RBBB in
8 patients (33.3%) and by bilateral bundle branch block in
3
patients
(12.5%)
respectively
(Table
23).
It
was
present in 8 out of 60 isolated RBBB patients (13.3%) and
three out of the 22 patients (13.6%) with bilateral bundle
branch block, compared with 13 out of 554 patients (2.3%)
without
these
Isolated
left
types
axis
of
branch
bundle
deviation
or
LAHR
block
were
(p.( 0.05).
found
in
5
patients (0.8%).
Hospital Mortality of AMI
3.3.6
Out of the 666 AMI patients, 195 patients (29.3%)
died within 4 weeks.
Of the 170 patients admitted in the
years 1971-75, 46 patients (27.1%) died compared with 149
(30.0%)
in
the
period
significantly higher with
the males
Q-wave
1976-80.
the
females
Mortality
(36.7%)
was
than with
(25.4%) (p( 0.05) (Table 13), and with anterior
infarcts
(39.7%)
compared
with
posterior
Q-wave
- 36 -
infarets
(28.5%)
non-Q-wave
and
respectiveLy (p< 0.01)
(Table
infarcts
(10.6%)
Advanced ages,
19).
( > 70
years), hypotension., cardiomegaly, pulmonary congestion or
oedema, elevated serum urea
form
the
sinus
of
tachycardia,
atrial
ventricular
ectopic,
ventricular
cardiac arrhythmias in
leveL1
fibrillation
ventricular
fibrillation,
supraventricular
tachycardia.,
particularly associated with
tachycardia
or
primary
Q-wave
infarct
ominous
factors
anterior
and
RBBB,
early
flutter,
or
were
0f the 59
with significantly higher mortality (Table 19).
RBBB complicating áuterior infarcti.on, 35 patients (59.3%)
died compared with 81 out of 235 patients (34.5%) without
RBBB
four
and
out
of
16
patients
(25%)
complicating posterior infarction (p< 0.001).
19 (32.2%) had hypotension, 33
patients,
failure,
had
with
RBBB
0± these 59
(55.9%) bad heart
24 (40.7%) had elevated blood urea and 39 (66.1%)
some
types
cardiac
of
dysrhythmias.
0f
the
22
patients with bilateral bundle branch block (B.BB.+LAHB or
LPRB),
13 patients
(59.7%) died whereas
six out of eight patients (75%) with
this occurred in
a combination of RBBB
and third degree A-V block, and in 28 out of 60 patients
(46.7%) with
9.1%
when
isolated
RBBB
was
RBßB (p. 0.1).
transient
and
The mortality vas
56.3%
when
it
vas
persistant, but isolated LAIB did not adversely affect the
- 37 -
short-triu outame (Table 22)
with
LBBB
(3o) was
Tbe mortality of patieiits
significantly
higher
than
that
of
non-Q wave infarcts (1O.5), but the presence of LBBB in
Q-wave infarcts had no significant adverse effect on the
short-term mortality.
The mortality for third degree A-V block (45.8%)
was
significantly higher
block (30.4%)
of
than
patients
with
or
grade
lower
of
A-V
on the whole, the survival
but
(Table 23),
that
A-V
without
block
were
not
significantly different (Table 19).
factors
Other
significantly
history
related
angina
of
analysed
and
found
mortality
to
be
not
previous
included
infarction,
or
to
pericarditis,
hypertension and peak levels of SGOT (Table 20).
Causes
death included heart
of
failure
(29.2%),
primary arrhythmias (22.1%), cardiogenic shock (18.5%) and
cardiac rupture
(5.1%)
with rupture of the
free wall,
were above 70 years of age.
of
infarction,
previous
hypertension,
40%
24).
(Table
had
heart
Of
the
ten patients
60% were females and 50%
Only one patient had history
50%
had
failure,
post-infarction
50%
had
cardiac
dysrhythmias and 80% died of cardiac rupture within 3 days
after their admission in hospital (Table 25).
and
eight-tenth
percent
of
deaths
occurred
Twenty-two
within
the
- 38 -
six hours
initial
and 48.2% within 24
after admissions,
hours (Table 26).
3.4
DISCUSSION
3.4.1
Cenerai Features of AMI
clinical
The
infarction
pictures
classical
the
to
the Western countries with respect
in
clinical
complications
features1
prognosis.
myocardial
acute
of
conforms
Chinese
the
in
pattern
10-21,23,83-89
short-term
and
general,
In
their
to
Chinese
the
patients with acute myocardial infarction were ten or more
older
years
As
those
the
Zealand21
USA,99
years
(18-22)Z
contains
50
years
years (30%).
a
Lane
the
older
than
70
were
in
as
of
New
Atlanta
of
younger
years.
Western
such
Auckland
Hospital
patients
the
in
i:Iospital
Piedmont
of
(15-20)Z
series
than
Green
the
and
and
in
reported by most Western series,
countries.
from
counterparts
their
than
Our
than
50
present
smaller proportion of patients younger
but more patients
(.( 10%),
older than
70
The male preponderance in the Western series
(6:1) was less impressive in our present series and there
was
Kong.
male
a
greater number
The
overall
preponderance
of
iia1e
older
to
declined
female
female
with
patients
ratio was
age
until
in
1.9:1;
the
Hong
the
seventh
- 39 -
decade wien the sex ratio became reversed to O.8:L
number
The
AMI
of
doubled that
1977-BO has
adniissions
the years
in.
period
the
in
Tbis
1971-76.
is
attributed to a more reliable record entrance and keeping
system in the medical unit, and to an increasing incidence
of
AMI
an aging population
in
which has
Hong Kong,
in
Apart from these,the more popularity of
increased by 33%.
Western medicine, as compared with the traditional Chinese
medicine even among the older generation in Hong Xong, has
called
for
This is probably the case, as evidenced by a
AMI attack.
140%
for hospital care during an
greater demand
a
increase
the
in
240% increase
overall hospital
admissions
in Hong
in medical admissions
iCong
and
a
in the
same period.
the majority of patients
In the present report,
came from a lower socioeconomic class.
with
workers
caution
the
and with
Singapore,
should
It
reflect
the
socioeconomic
be
locality1
from
taken
is
the
and
section
the
for
proportion
China.
the
in
probable
lower
General
National
the high
reports
in
phenomenon.
simply
from
findings
that
in accord
This is
Hospital
of
aowever,
interpretation
this
socioeconomic
selective
admission
this
of
observation
may
cross-section
of
bias
to
collar
blue
70,100-101
in
of
public
lower
general
- 40 -
Lam et
bospitai.s.
al
in Hong Kong by analysing the age
specific mortality rate
standardized
ischaemic heart
of
mortality-ratio
disease,
districts
for
the
and
the
proportional mortality ratio for occupations in Hong Kong
have
l981
in
demonstrated
socioeconomic
status
incidence
ischaemic
of
higher
that
associated
was
heart
with
disease
of
Level
higher
a
men.8°
in
Our
findings have, nevertheless, highlighted the fact that the
susceptibility
to
infarction is not,
as
classes.
myocardial
acute
of
commonly believed,
or executive
professional
social
development
the
confined
fact,
In
a
the
to
changing
class distribution of ishaemic heart disease has
been observed and reported in the UK, USA and Scandinavian
ccuntries)0207
prevalence
increasing
smoking
class.
the
risk
It
and
mostly
is
of
coronary
hypertension
risk
factors
with
an
such
as
socioeconomic
lower
the
in
Further specific studies
factors
associated
are recuired to
in different population groups
address
in
Hong
Kong.
3.4.2
Coronary Risk Factors
The
control
group
special selected group who
medical screening centre
for
in
present
the
turned up
in
a
study
is
comprehensive
routine health check-ups
preemployment medical examinations.
a
or
They were found to be
- 41 from
free
any
cardiac
diseases.
principle,
In
generalisation basing on data from the referral-volunteers
has
cautious,
be
to
they
as
tend
either
be
to
hypochondriacs or aggressively healthy, and therefore the
study
subjected
is
Nevertheless,
fairly
to
reflection
of
bias.
may provide
group
profile
the
selection
of
specific control
this
true
risk
a
coronary
of
factors among the general population in Hong Kong.
a
risk
This
is probably the case, as a separate survey of hypertension
in
Hong
specifically
which
1982,
people
and
doubt,
infarction as
the
Western
impact
better
about
smoking
habits
of
also
revealed
similar
least
10
years older
With
reports.
of
of
acute
myocardial
a manifestation of coronary artery disease
certain
underestimated.
acute
in
development
is definitely related to aging.
at
Census
109
No
are
Kong
Hong
the
asked
community,
our
in
findings.
1981,108
in
,Kong
myocardial
risk
such
On the whole our patients
than
most
advanced
factors
may
of
those
in
the
age
groups,
the
be
diluted
and
Information from a younger subgroup with
infarction
could
probably
provide
idea of the risk factors concerned.84'1016
a
Of
the risk factors evaluated, cigarette smoking turns out to
be the most consistent risk factors for both sexes and all
42
age groups.
This
Framiugham
of
Hong
USA
117-123
.
Countries.
Kong
in agreement with tbose reported in
is
.
óthr
many
in
.
been
had
Smoking
the
in
and
past.124
period
the
tn
problem
big
a
Western
Lfl
1.959-61
roughly three-quarters of male adults and one-quarter of
female
adults
smoked.
decreasing
progressively
witnessed.109
male
adults
It
in
dropped
subsequent
In
number
to
23.3%
probably
1984,
years
smokers
of
due
relentless
the
to
was
and 18.7% of
1982
in
a
anti-smoking campaign by WHO and its successful launching
in Hong Kong in recent years.
Hypertension
has
myocardial infarction
or
disease.84'11011417
been
other
associated
closely
forms
with
coronary artery
of
921123,125'26
Hypertension has some conflicting relations in the setting
of
acute myocardial
mmUg
(5-10)
acute
drop
myocardial
infarction,
in
the
in
blood
systolic
infarction
pressure
hand;127
one
on
there may be
that
and
a
after
the
possible occurrence of acute hypertension during the acute
stage due to the acute stress of the cardiac insult on the
other
hand.28
patients
160/95
whose
mmHg
In
blood
before
the
present
pressure
the
was
episode
oniy
those
persistently
above
study,
of
acute
myocardial
infarction, and those whose blood pressure was at or above
43
ven
levels
this
before
regarded
were
discharge,
as
hypertensive.
The
obvious
in
changes
younger
the
of
random on day one
cholesterol
patients.
cholesterol
serum
infarct.127'12913°
of
of hyperchalesterolaemia
importance
are
level
in
routineLy
have
We
We
has
been
preexisting
or
significant
difference
cholesterol
levels.
found
months'
3
level.
between
the
relation
to
blood
at
similar
Also
The
the
to
there
fasting
the
131-133
of
The day-i level
be
to
aware
taken
for cholesterol level.
more
is
no
is
random
and
impact
of
hypercholesterolaemia has been extensively studied by many
Western
group.
by
the
84,110-ill ,11.4,117-118,120-123
them,
the
appears
ml,
pioneered
workers
to
risk
Start
especially
present.
117-118
of
developing
from
a
when
However
As
coronary
cholesterol
other
.n
level
risk
Frainingl-iain
observed
artery
of
factors
Hong Kong
the
cut
by
disease
180 mg/lOO
are
also
off
level
for hypercholesterolaemia has been arbitrarily set at 260
mg/lOO mi. for the females and 280 mg/lOO ml for the maLes
for
practical reasons,
since more
intensive intervention
will
generally be advocated by most
Hong
Kong
with
cholesterol
levels
clinical workers
above
these
in
ranges.
This level has also been used in the nine countries survey
- 44 -
of risk factors for myocardial infarction in young mer'
in
1975.
concentration
The
cholesterol
of
the
of
control population in the comprehensive medical
centre in 1975-80
1959-61
1(ong,24
Hong
in
and
tribal population in Mongolia,
executive officials
reported
that
to
as well as
Foozhou of
in
China,
the
Ting
Cheng
commune
134-137
but
(Table
levels are significantly lower than most
reported
Western
the
in
significance
high
of
higher
Jiangshoo
These
27).
figures
138-142
cholesterol
density
is
'normal'
countries.
the
on
that of the
to
than those of the people from Taipei, Szechuan
and
screening
to those found by Barnes in
similar
is
normal
The
as
(}IDL)
a
protective factor against coronary artery disease has been
well
recognised.14344
A
series
small
with normal total cholesterol level
in
China
matched
had
lower
control.145
work
the
in
A)I patients
army hospital
compared
HDL-cholesterol
More
of
is
with
the
in
the
demonstrate
any
required
significance of IIDL-chclesterol in the Chinese.
We
have
not
able
been
to
significant effect of diabetes mellitus on the development
of acute myocardial infarction.
The pick up rate may be
affected by the various diagnostic criteria on biochemical
ground.
We have
followed
a
relatively
strict criterion
-
recommended
by
NationaL
the
Diabetes
Group.9596
Data
The WHO Work Group have demonstrated that 3.5
to 5.0% of
diabetes mellitus in Hortg Kong have some forms of coronary
artery disorders, compared with roughly 20% in the western
cities
such
London
as
Geneva
Berlin.146
and
Workers
Beijing have reported a prevalence of 3.92 to 7.5% of
fror
in their patients with acute myocardial
diabetes mellitus
infarction.10L
A survey carried Out
failed to document
also
mellitus
infarction.100
of
the other hand,
On
Shanghai in
1981
significant effect of diabetes
development
the
on
a
fl
acute
myocardial
in clinical practice,
it has been commonly recognised that diabetes taellitus
with
associated
closely
hypertension
is
and
hypercholesterolaemia, and that many patients may present
cardiomyopathy
ischaemic
'silent'
with
symptomatic acute coronary events.
rather
than
65,147-150
Overweight has been significant as an associating
factor
risk
associated
in
the males
smoking,
with
hypercholesterolaeinia.
not
a
only.
151-153
Iti
Many
of
them
are
hypertension
general,
common problem in the Chinese as
overweight
also
and
is
compared with the
Caucasian especially when a Western standard of weight is
used as
as
reference.
a risk factor
Perhaps obesity may be more relevant
for coronary artery disease.
154-156
In
.
body
regard,
this
useful
reflect
to
excessive
affected by height.
as
indicator
ari
.
index
mass
84157-162
adiposity
may
and
it
be
more
is
less
More researcb using body mass index
needed
is
delineate
further
to
the
significance of obesity in the Chinese.
Many of
individual.
In
the
above
order
to
factors
coexisting
are
in
more objectively delineate
an
the
independent significance of each factor in relation to one
another,
it will be more useful to analyse these factors
by multiple discriminative regression, and more work along
117-118,163-164
this line will be needed.
association
strong
The
hypertension
with
with
infarction
agrees
myocardial
infarction
a
..n
acute
of
occurrence
smoking
of
Shanghai.
myocardial
study
case-control.
100
It
and
on
acute
revealed
also
that hypertension and smoking in particular are important
risk factors affecting the Chinese.
This message would be
useful as a reference in the planning of preventive health
programmes for the Chinese coutmunities
While controversy
over the use of cholesterol-lowering agents in the primary
prevention
of
settled.,165
would
appear
coronary
anti-smoking
to
be
a
artery
disease
campaign
simple,
on
has
a
economic
harmless measure for primary prevention.166
yet
national
and
to
be
basis
definitely
- 47 3.4.3
Clinical Presentations of AMI
adopted
We
simple
a
classification
localisation of infarct positions
which
included
also
of
the
into anterior infarct,
anterolateral
anteroseptal,
and
anteroapical infarcts, as well as posterior infarct, which
embraced both
inferior
posterior
strictly
and
infarcts.
This was more practical since the localization of infarct
positions
by
specific.167
mortem
electrocardiographic
criteria
Similarly,
correlation with
the
findings
poor
not
non-specificity
and
criteria
electrocardiographic
is
very
post-
of
differentiating
for
have
non-transmural
lesions
been well
12,168-169
Accordingly in the present study,
recognised.
transmural
the
and
were
infarcts
classified
into
Q-wave
or
non-Q-wave
infarctions and no differentiation has been made between
transmural or non-transmural infaretions.
Only 80Z of the patients presented with typical
prolonged precordial pain at the onset of infarction, and
around
well
l5
with
of
infarction was
the
other
marty
groups.99'17073
patients
dyspnoea,
Instead,
presented
with
palpitation,
gastrointestinal
series
upset,
a
This agrees
painless.
involving
proportion
certain
nonspecific
elderly
complaints
dizziness
cerebrovascular
age
of
like
syncope,
or
accident
or
pyrexia.
diagnosis
The
Symptoms
could
associated
clinical
could
ntissed
b
wrongly attributed
be
medical
conditions,
alertness
unless
maintained
is
to
a
and
their
ages
high
level
of
with
the
delineate
any
dealing
in
these
arid
elderly groups of patients.174
Similarly,
clearcut
from
pattern
small
a
certain
prodomata
of
*
unstable
before
17$-176
angina
complication,
unstable
and
with
and
with
of
the
as
a
mortality
was
20%
infarction
reported
those
many
in
nature
serious
The
association
close
its
that
a
of
experience
hospital
overall
the
for
onset
actual
myocardial
concurs
angina
apart
patients,
our
Kong revealed
Countries.'78182
Caucasian
to
previous
Hong
in
This
l0%.'
from
the
Our
developed
patients
able
(6.2%) having unstable angina
group
period
infarction.
not
were
we
of
acute
with
myocardial infarction should deserve more recognition, and
this
potentialLy
salvageable
form
coronary
acute
of
syndrome should be treated more positively.
The
complications
reports
years1
Western
10-20
many
clinical patterns,
appear
to
years
ago.
reports
countries
conform
in
more
particular,
to
most
10-12, L4-lS 23,84-89
from
appear
and
coronary
to
care
demonstrate
In
units
that
their
Western
recent
in
the
younger
are being affected
patients
and
there
tbat
a
is
lower
incidence of complications including cardiogenic shock or
resistant
groups.
heart
failure
13,21,83,183-185
among
Reports
and
Tianjin
revealed
also
San FraQcisco,
in
clinicaL pattern, with comparatively older ages,
proportion of
female patients,
higher
recent
in
changing trend towards
increasing
incidence
a higher
to
More
demonstrate
a
current Western pattern, with
the
of
of pump
stage.00'18687
appear
Beijing
from
reports
acute
the
a higher
incidence
failure and conduction defects, associated with
hospital mortality
classic
similar
a
age
myocarda1
acute
on
infarction in other Chinese communities
Shanghai
younger
the
acute
myocardial
infarction,
a
higher proportion of patients below 50 years of age, lower
incidence
of
mortality.
inyocardial
pump
101,188
failure
With
infarction
and
a
increasing
other
in
decreasing
incidence
Chinese
hospital
of
acute
communities,
similar changes in their clinical pattern will probably be
expected in the years to come.
Cardiac arrbythinias have been reported
to
occur
in 40% to 100% of AMI patients, depending on the mode and
timing cf ECG monitoring after onset of symptoms, age of
patients
and
extend
of
infarcts.
21,189-203
Our
incidence of bradyarrhythmias in the forms of sinus or
- 50 junctional
bradycardia
high
grade
and
(4-6%)
atrioventricular block (7.4%) is much lower than those
reported by Rtmari 195 , Norrs 198 and Pantr,dge 197
.
.
could be an underestjmatjou since the CCU care was
available only in the later period of the present study
and oniy 57.0% of patients have been continuously
monitored during the acute stage of AM3. In patients who
came under CCIJ within one hour, Pantridge reported the
This
occurrence of bradyarrhythmias in 6L% of patients, and 40%
within
after onset of AMI symptoms.
4
hours
Bradyarrhythmias may be associated with higher incidence
of ventricular dysrhythmias, but they are usually well
related to increased
parasympathetic activities, particularly in posterior
myocardial infarction and usually respond to vagolytic
tolerated.
Bradyarrhythmias
medication.
With
system,
are
the computerization of ECG monitoring
it has been found that ventricular ectopic is very
common and occurs in about 100% of AMI patients, but the
classical preceding warning
arrhythmias for ventricular tachycardia and the benefit of
ventricular
have
been
ectopics
such
suppressing
prognostic
value
of
questioned. 191,194,199
the
On
the
other
hand,
the
promptness of development of ventricular dysrbytbmia has
been found to
be related to the extent of infarct size
51
is the main determinant for prognosis in both short
wbich
and long terms, and this will be separately dealt with in
the
tachyarrhythmias
supraventricular
tachycardia,
atrial
flutter
or
impending
heart
incidence
is
the
similar
functional
naturally
fibrillation,
failure
Most
to
of
or
including
them
should
reported
tachycardia
shock.
Their
the
Western
in
transient
are
of
sinus
are also associated with
cardiogenic
those
disturbance
treatment
.
Similarly,
supraventricular
paroxysmal
series.200203
89-19O,192
chapter
later
extensive
be
and hallmark
infarcts,
and
towards
the
directed
limitation of infarct size and correcting the haemodynamic
Occasionally atrial tachyarrhythmias could
be related to transient atrial ischaemia or atrial
infarct,20203 when administration of vasodilator or
specific antiarrhythmic agents may be helpful.
The incidence of pericarditis in our patients
derrangement.
reported in
the
In clinical practice,
Western countries.204208
onset of pericarditis as halimarked by the onset of
persistent precordial pain and the identification of
(3.3%)
is
much
lower
pericardial rub, may be
than those
(6.8-20%)
indistinguishable from the initial
symptom of chest pain and therefore there may be problem
in
their recognition.209210
In autopsy series)
80%
of
patients
myocardial
.ïitt-i
involvement.211
inadequate
infarction
discrepancy
The
documentation
had
attributed
is
to
retrospective
clinical
in
pericardia).
studies, the flitting nature of the diagnostic pericardial
friction rub and the lack of predictive factors that alert
the coronary care staff to
developing
workers
pericarditis.
experience
the
the patients
209-212
share
We
the
that
at high risk of
late
with
onset
other
type
of
pericarditis syndrome previously described in the 1950e by
Dressier
very
is
nowadays.213215
uncommon
This
disappearing
perhaps
and
decrease has
been related
to
the
decreased use of oral anticoagulant and to more aggressive
treatment
early
of
infarction
post-tnyocardial
Although pericarditis developing during the
pericarditis.
acute phase of myocardial infarction has not been shown to
substantially
increase
rate,204209
important,,
recognition
in
possibilities.,
order
hospital
the
of
to
complication
this
avoid
including extension of
extensive myocardial
precordial pain and
mortality
other
remains
diagnostic
the
infarction
on
the
persistence
the elevation of
the
'ST'
damage based
and
of
segments,
and Other therapeutic errors.209
3.4.4
Conduction Defects in AMI
The
incidence and natural history of A-V block,
- 53 -
RBBB and bifascicular block complicating acute myocardial
infarction in
the present series, conform to
described
patterns
in
the general
iiterattire.l7_20B9
Western
-v
block complicating posterior infarction are mostly Mobitz
Type
and happen on the initial 12 to 72 hours.
i
bigh grade A-V block could persist
occasions
days without any haemodynatnic
no
intervention
and
is
bundle
the
branches
block
Atrio-ventricular
anteroseptalinfarction
parallel
Norris
to
of
complicated
l7-19,892L8-2l9
Bundle
few
narrow
is
216-217
spared.
common,
and
their
with
this
including
findings,
5%
a
association
less
reported
infarction
anterior
block..
who
complex
are
in
are
many previous
al
et
The QRS
for
and accordingly
impairment
required.
On most
that
from
patients
with
heart
complete
by
involvement
branch
is
are
more often found &nd precede the occurrence of high grade
A-V block, and the site of disturbance is in the proximal
portion
itself.
cf
the
220-221
infarets
with
right
The
A-V
bundle
without A-V block (38.l%)
the
mortality
hospital
block
within
or
(62.5%)
is
although
anterior
for
higher
bundle
His
than
the difference
that
fails
to achieve a statistically significant level due to small
numbers.
This
is
parallel
to
many
previous
reports
highlighting the ominous nature of their combination due
- 54
both to the conduct10
effects
Nearly
of
infarction have
.
infarct
itself.
and
attacks
Stokes-Adatns
these
lethal
are
due
unless
ventricular
to
pacemaker
a
This has been the routine practice in
used.
found
like many
Nevertheless,
series.
that
even
disturbance,
high,
.
.
the
patients with high grade block from anterior
all
asystole
disturbance and to the baemodynamíc
222,228-230
massive
the
if
patients
the
from
survive
hospital mortality
fibril lation.
cardiac
failure,
the present
other workers, we have
rate
because of massive anteroseptal
death
is
shock
the
is
conduction
very
still
infarction causing
ventricular
late
or
19,222,225,230
Similarly, right bundle branch block complicating
anteroseptal
infarction
is
hospital mortality rate.
dangerous
very
Our
.BBB
59.3%
with
incidence
(12.7%)
is
higher than the overall average incidence (7.6%) reviewed
by
Roas
et
anteroseptal
typical
'QR'
al.19
lt
is
infarction
pattern
Similar pattern found
more
(20.1%)
in
in
right
often
and
associated
presents
precordial
with
with
EGG
the
leads.
the pre-terininal stages had not
been included.
This typical 'QR
pattern occurs as new events in
96.3% of our patients, associated with higher incidence of
haemodynamic
impairment
and
cardiac
dysrhytbmias,
reflecting
a
inyocardial
infarction
patients.
In
more
in
present
the
previous
the
pattern
clinical
strious
Chinese
of
group
62.9Z
reports,
acute
of
RBBB
of
are
combined with either left anterior or posterior henilbiock
and
of
37.17e
patients
have
1BBB.19
isolated
We
more isolated RBBB (73.2%) in the present series.
isolated
or
combination
in
anteroseptal
complicating
infarction
infarction
massive
prognosis.
18-20,220-226,228-241
Whether
RBBB
hemiblock,
with
is
marker
a
of
poor
with
prognosis
poor
The
have
is
due not so much to the conduction disturbance itself as to
the
myocardial
massive
sustain
damage
which
This probably could explain
it.
necessary
is
failure
the
to
of
cardiac pacing to decrease the high mortality rate since
the patients will eventually die of pump failure or late
ventricular fibrillation.
In
patients
infarction,
proximal
who
die with
occlusion
RBBB
of
the
and anteroseptal.
left
anterior
descenting artery is always found at autopsy and the size
221-222,242-243
is
massive.
of necrotic myocardium
The
association of RBBB with massive infarction, together with
the high early but not immediate mortality suggests that
something specific could and should be done about it.
methods
were
available
for
the
control
of
If
infarct
- 56 -
size)2425
many
patients
and RBBE would have
the moSt
complications
later
fibrillation
and
with
to
pump
failure
since many of
gain,
A-V
like
infarction
anteroseptal
ventricular
block,
might
be
the
and
avoided
hopefully the chances of survival in the acute phase could
be improved.
along
We have recently treated a few such patients
anterior descending
which
was
Occlusion
lines.
these
artery was
infusion
plasminogen-activator
or
the
present
reopened
successfully
intracoronary
of
in
by
patients,
all
use
the
recombinant
of
urokinase,
left
proximal
of
tissue
associated
with
the
disappearance of RBB.
No
will
doubt,
stimulate more
this
encouraging
and more
interest
preliminary
research
result
work
on
such intensive approach to patients with RBBB complicating
anterior infarction.
RBBB complicating posterior infarction is benign
and often time
left
the
RBEB could be
anterior hemiblock
increase
in
disturbances
mortality
or
is
rate
a
or
preexisting.
benign
arrbythmias.19'244245
showing
lesion
incidence
The
Isolated
of
no
conduction
incidence
of
left anterior bemiblock varies between 4.2% and 12.6% with
an average of 7% and our incidence (3.6%) is comparatively
lower.
Our incidence of left posterior hemiblock is even
-
lower
but
(o.5%)
reports
this
19,246-247
-
parallel
i8
Its
mortality
high
coiabined with RBBB agrees with the
reviewed by
Rocs
al19
et
most
other
(75%)
when
to
average figure (71.57o)
posterior heuib1ock
Left
an ominous sign with high incidence of deaths
is
from pump
failure caused by extensive anterior and inferior necrosis.
Our incidence of LBBB
(3.1%)
is
similar
the
to
4.3% incidence found by Norris, but is slightly lower than
average figure
the
(5.2b).
19221
The hospital mortality
'
rate of LEEB was reported to be 16-72%, with an average of
mortality
44.7%.
Our
lower.
LEBE
ventricular
pump
poorly
lesione
and
221,243,248
delineated
and
LEBE
(30%)
comparatively
is
associated
with
therefore
higher
The
often
onset
of
presents
it
diffuse
left
incidence
LBBB
as
is
a
of
often
chronic
The sites of infarction are often indetermined in
presence
the
often
is
fibrosis
failure.
of
of
present series.
LEBE,
as
in
most
of
the
cases
in
the
Only a few LEEB could be clearly related
to the presence of Q-wave anterior infarction, but we fail
to
demonstrate any detrimental effect on
their mortality
when LEBE were present in these small numbers of patients.
3.4.5
Rospital Mortality of AMI
Our hospital mortality at
higher
than
those
reported
in
four weeks
most
(29.3%)
other
is
Western
-
13,21,83,183.-L85
Sris,
*
in
Shanghai1
Series
but
Tianjin,
-
sLmilar
].S
Taiwan
and
to
of our patients, especially of the
an
the Chinese
Zealand
from
and
few reports
A
the
those reported
Chinese
smaller
a
The
females,
important factor contributing to
among
co
Francisco.l8687249
San
in
8
ol.der
ages
certainly
is
the higher mortality
from Auckland
Scandinavian
region
New
of
have
also
highlighted the detrimental effect of advanced ages,
their
mortalities
are
series
a
present
regional
is
hospital
similar
ours.99'17173
to
nonselective
which
is
from
one
The
general
a
proximity
close
in
and
all
to
people within the drainage area.
All patients with acute
myocardial
admitted
infarction
could
be
into
hospital
promptly, and over 50% of the patients arrived at hospital
within
Chapter
2.8
6).
hours
after
Since
onset
the
nearly
all
of
patients
symptom
(see
admitted
were
counted1 irrespective of whether they were attended to
in
the general wards or coronary care unit, the inclusion of
a
certain proportion
of
patients
in
the
early unstable
period could probably also account for a higher mortality
in hospital.
In the present series over 22% of the deaths
occurred within
the
initial
six
hours
after
hence lending support to the above suspicion.
admission,
The impact
of a coronary care unit on AMI mortality in Hong Kong will
- 59 -
be elucidated and discussed in Chapter 5.
Forty-seven and seven-tenth percent of deaths are
due
pump failure presenting with cardiogenic shock or
to
heart
failure.
Shanghai
and
This
similar
is
BeijingJ0001
findings
the
to
Norris
et
in
reported
al
a
higher incidence of deaths due to arrbythmias (52%) and a
similar incidence of death
their
patients
in
to pump
due
l966-69,
failure
these
but
changea
and 62% respectively in patients managed
care
unit
greater
in
1977_19.21
availability
It
expected
is
monitoring
of
in
to
in
12%
the coronary
that
and
(41%)
with
the
resuscitating
facilities of the coronary care units, more patients will
benefit,
less
will
die
proportion of deaths
of
due
cardiac
pump
to
dysrhythmias
failure wilL
and
be
the
even
higher in the years to come.
Our incidence (5.1%) of free wall cardiac rupture
as the documented cause of death is
incidence
average
reported
figure
by
Norris
et
lower than the 10-17%
al,
and
(8%) reviewed by Bates.25°
the
overall
However there
may be underestimation of the actual occurrence of cardiac
rupture,
since among
group with
the
sudden deaths1
who
account for 15.1% of the total deaths, there could be more
patients
documented
with
by
cardiac
rupture
postmortem
that
have
examinations.
yet
The
to
be
clinical
- 60 -
patterns
of
conform to
patient
died
the classic
wall
free
of
rupture
cardiac
findings1 with high proportion of
older ages and females sex, scarcity of previous infarct,
higher
incidence
post-infarction
of
equal
hypertension,
distribution of infarct sites and occurrence mostly within
the
initial
this entity as
myocardial
must
is
needed,
improved means
and
developed.250253
be
these
of
Recognition
admission.
after
of
a relatively common complication cf acute
infarction
diagnosis
findings
days
four
fatal
AMI
pathological
The
will
cases
of
reviewed
be
separately in Chapter 7.
Apart from advanced ages, the majority of hospital deaths
were associated with hypotension, heart
dysrhytbmias
conduction
and
failure,
defects.
All
cardiac
these
are
markers of extensive infarcts and our findings concur with
the
were
pictures. 19-211189-190,192,254
classic
coexisting
influence
deserve
on
with
the
further
one
evaluation,
outcome
this
and
factors
independent
Their
another.
short-term
Many
certainly
should
will
be
further
elaborated and discussed in Chapter 8.
3.5
Summary
In
acute
order
myocardial
to
delineate
infarction
the
(AMI)
clinical
in
the
pattern
Chinese1
of
666
- 61 -
Chinese patients with AMI admitted into one
medical units
period
o
1971-1980
were
63.6+10.2 years)
years),
and
in Hong Kong
reviewed.
being higher
years
10
counterparts.
general hospital
a
Their
greater
than
those
The overall male to
of
from
casia
highlighting
their
the
AMI.
was
(68.3±11.9
the
Western
Most of our
socioeconomic
lower
susceptibility,
professional and executive class,
the
ema1e ratio was 1.9:1,
but the male preponderance declined with age.
patients
itt
age
iiean
females
the
in
the three
of
apart
the
to
class,
from
the
development
of
Cigirette sTaoking was the most consistent associated
coronary risk factor
for
ages; hypercholesterolaemia
all
for the younger patients, hypertension and overweight were
documented
Thirty-nine
associatiig
percents
of
AMI
with
patients
had
the
males.
previous
angina
in
and 9.5% had history of inyocardial
pectoris
Apart
be
to
from
patients1
Prolonged
the
there
presence
was
precordial
presenting symptom.
no
of
unstable
pattern
definite
pain
angina
was
in
5.S%
of
prodromata.
dominant
the
Fifteen percent
of
infarction.
(80.9%)
of patients, mostly
older females, had no pain but presented with nonspecific
gastrointestinal
upset, and a high level of alertness is required for their
symptoms
prompt
of
syncope,
detection.
palpitation,
Twenty-one
and
percent
bad
non-Q-wave
infarctions, ¿6.2% anterior Q-wave and 31.4% had posterior
inEartions.
Q-wave
incidence
Higher
complications were present
clinical
of
including hypotension (13.6%),
heart failure (38.6%), cardiac arrhythinias (45.1%), in the
forms
of
fititter,
sinus
tachycardia,
early
ventricular
atrial
fibrillation
ectopics,
of
ventricular
tachycardie and primary ventricular fibrillation, elevated
high
blood
urea
pericarditis
(24.8%),
conduction defects such as RBB
and LBBB (3.3%).
and
(3.3%)
(12.7%). A-V block (11.3%)
RBBB (whether isolated or combined with
left fascicu].ar block) and A-V block complicating anterior
Q-wave
infarctions were ominous, with high
incidence
of
punp failure, cardiogenic shock and cardiac dysrhythmis,
whereas
complicating
those
posterior
LBBB appeared to be
were benign.
a
Q-wave
infarctions
more chronic lesion
with moderate mortality.
Out of the 666 »ii patients, 195 (29.5%) died in
hospital within four weeks.
in
the females
(36.7%).
The mortality rate was higher
These were higher than those in
mostly with younger age and
most current Western reports
higher
male
Causes
preponderance.
of
deaths
included
heart failure (29.2%), cardiogenic shock (18.5%), prinary
cardiac
arrhythmias
Forty-eight percent
(22.1%)
of
and
deaths
cardiac
rupture
occurred within
(5.1%).
24
hours
-.
after
admission.
Apart
63 from
advanced
ages,
Q-wave
infarctions, hypotension, pulmonary congestion, high blood
urea.,
cardiac arrhythmias
Q-wave
infarction
are
and REBE complicating anterior
marlers
of
extensive
infarcts
associated with high hospital nortalities.
The
conform
to
clinical
the
patterns
classic
picture
of
but
AMt
in
the
overwhelmed
Chinese
by
the
higher ages of patients and possibly more serious spectrum
of clinical seventies.
These findings will 'oc usefui. for
the understanding and management of AMI in the Chinese.
Table 13
WfOCARDIAL INFARCTION IN MEDICAL UNIT B
QUEEN ELIZABETH HOSPITAL
MALE
YEAR
TOTAL
FEMALE
MORTALITY(%)
NOR.TALITY(%)
TOTAL
1971-72
21
61.2
7
(3.3)
9
66.9
4 (19.0)
1973
38
60.1
11
(28.9)
17
65.7
4 (23.6)
1974
18
56.9
3 (16.7)
21
68.4
lo (47.6)
1975
25
58.4
3
(12.0)
21
67.4
4 (19.0)
1976
42
58.2
7
(16.7)
12
68.6
3 (25.0)
1977
42
58.5
5
(11.9)
22
70.3
11 (50.0)
1978
73
61.7
20 (27.4)
40
72.0
14 (35.0)
1979
117
61.0
39 (33.3)
51
69.6
20 (40.0)
61
61.4
16
(26.2)
36
68.4
14 (38.9)
437
61.0
111 (25.4)
229
68.3
84 (36.7)
1980*
1971-80
Male to female ratio
437/229 (1.9:1)
Overall mortality
195/666 (29.3%)
* Up to June 1980
Table 14
SOCIOECONOMIC FACTORS IN 471 PATIENTS WITH
ACUTE MYOCARDAL INFAB.CT ION
471 (ioO)%
TOTAL PATIENIS
RESIDENCE
(404 pts)
Rural
Urban Hut
(394 pus)
g
( 2.2)
L/C Estate
160 (39.6)
Fi at/House
189 (46.8)
D1uxe Quartr
OCCUPATION
40 (9.9)
Manual WorI
Clerical/ßtisiness
Professional
6 C i.z)
153 (38.8)
59 (15.0)
9
( 2.3)
House work
77 (19.5)
Retíred*
96 (24.4)
L/C Estate: Low cost estates
* Retired or unemployed for 10 years or mora
Table 15
CORONARy RISK FACTORS FOR MOCARDjAL INFARCTION
OCCURRENCE RATE
FACTORS
MEAN AGE
SMOKING
HYPERTENSION
HYPERCHOLES-
P VALUE
M.I.
C.M.S.
(M)
60 yr.
59.5 yr.
(F)
69.4 yr.
65.7 yr.
(M)
193/263 (74.9%)
110/294 (37.4%) < 0.001*
(F)
41/102 (40.2%)
(M)*
112/347 (32.3%)
17/86
;>
(19.8%)
71/295 (24.0%)
0.5
< 0.01
(
0.05*
(F)
72/178 (40.4%)
33/86
(38.4%) > 0.5
(M)
19f217
(
17/300
(
5.7%)
(F)
24/97
(24.7%)
4/86
(
4.7%) < 0.001*
(M)*
87/282 (30.9%)
50/296 (16.9%) < 0.001*
(F)
24/141 (17.0%)
22/86
(M)
41/341 (12.0%)
48/295 (16.3%) > 0.1
(F)
27/176 (15.3%)
8.8%)
.
o.i.
TE ROLAEM IA
OVERWEIGHT
DIABETES
LI.
Myocardial Infarction.
C.M.S.
Comprehensive Medical Screening.
M.
Male
ema1e
F.
Rypertensiot: B.P.
150/90 wmHg
Hyperch o le s ter o laemia
Seruut cholesterol 260 mg per 100 nEl in female
or 280 mg per 100 ml in male
*Significant difference between LI. and C.M.S.
8/86
(25.6%)
(
.>
9.3%) >
0.1
0.1
Table 16
CORONARY RISK FACTORS IN
ÌYOtJNGr MYOCARIDAL
INFARCTION PATIENTS
OCCIJRRENCE RATE
FACTORS
MEAN AGE
SMOKING
HYPERTENSION
P VALtJ
M.I.
C.M.S.
('i)+
437
44.4 yr.
(F)
50.8 yr.
50.7 yr.
(M)*
27/32 (73.02)
92/226 (40.72)
< 0.01*
(y)*
7/24 (29.22)
26/237 (11.0%)
<
(M)*
8/54 (17.8%)
(F)
HYPERCHOLESTEROLAEMIA
OVERWEIGHT
DIABETES
+
:
:
C
0.05*
7.0%) < o.o5
26/238 (15.1%)
7'
0.05
0.001*
(M)*
4/30 (13.3%)
4/227
(
1.8%)
(F)*
7/23 (30.4%)
15/235
C
6.42) < 0.001*
(H)*
18/36 (502)
0.001*
31/225 (13.82)
<
> 0.5
(r)
6/26 (23.1%)
56/235 (23.8%)
(M)
4/44 ( 9.1%)
13/228
(
5.72) > 0.5
(r)
6/34 (17.62)
16/243
(
6.6%)
49) years.
- 59) years.
Significant difference between M.I. and CM.S.
Male M.I. (32 -
Female M.I. (28
*
10/34 (29.4%)
16/228
> 0.5
)
0.05
Table 17
COMPARISON OF BLOOD CHOLESTEROL IN PATIENTS
WITH MYOCARDIAL INFARCTIONS AND IN CONTROLS
FEMALE
MALE
TOTAL
MEAN
1O.
AGE
(YR)
MEAN
CHOLESTEROL
(Mc/loo ML)
TOTAL
MEAN
NO.
AGE
(YR)
MEAN
CHOLESTEROL
(MG/lOO ML)
OLDER
INFARCT
221
60.2-4-9.2
215.2+49.8
106
66.4+12.3
230.3±80.2
CONTROL*
150
60.1+7.2
212.2+42.3
83
55.7+ 5.3
213.6+43.2
35
44.6+4.0
239.9+62.3
32
50.5+ 6.3
245.2+122.9
111
44.8±2.3
208.5+36.7
118
49.9+ 6.2
206.5± 26.0
YOUNGER
INFARCT
CONTROL*
* Referrals for comprehensive medical screening
Table 18
SYMPTOMATOLOGY OF 666 PATIENTS WITH ACUTE
MYOCARDLAL INFARCTION (1971 - 1980)
SYMPTOMS
UNSTABLE ANGINA
NO. PRESENT
Z
41
6.2
PAIN - PRECORDIAL
539
80.9
- EPIGASTRIC
24
3.6
1
0.2
DYSPNOEA
212
31.8
PALPITATION
102
15.3
PROFUSE SWEATING
80
12.0
NAUSEA/VOMITING
59
8.9
DIZZINESS
58
8.7
SUDDEN COLLAPSE (+ LOC)
32
4.8
OTHERS (PYREXIA, COUCH OR
WEAHNESS)
18
2.7
- NECK
LOC
Loss of consciousness
Table 19
CLINICAL FEATURES IN ACUTE MYOCARDIAL INFARCTION (1973-80)
FACTORS
Age <. 50 yr
50-59 yr
OCCURRENCE
10.5
WREN 'RESEN'
WRTALITY
(%)
SENT
(%)
MORTALLTY
WHEN
F-VALUE
-
-- ______
29.4
32.2
27.8
13/67
30/187
53/205
84/177
(19.2)
(18.2)
(25.9)
(47.5)
BP on admission
Normal
160/95
Z. 90/shock*
66.9
19.5
13.6
99/408
32/119
49/83
(24.3)
(26.8)
(59.0)
X-Ray
CTR>55%*
45.1
78/235
(33.2)
61.4
51/340
24.5
53/136
14.1
26/78
(15.0)
(39.0)
(33.3)
8.5
11.5
25.8
1.6
27/54
31/73
59/164
1/10
(50.0)
(42.5)
(36.0)
(10.0)
157/582
153/563
125/472
31/474
(27.0)
(27.2)
(26.3)
32/44
7/10
(72.7)
(70.0)
152/592
25/474
(25.7)
( 5.3)
<
Urea (> 60 mmol/1)* 24.8
66/148
(44.6)
67/448
(15.0)
<
0.001
Posjtjø of Infarct
20.8
Non Q-iaves
Anterior
46.2
+RJBB*
20.1
14/132
116/294
35/59
(10.6)
(39.7)
(59.3)
(42.9)
(62.5)
(28.5)
(35.8)
(25.0)
(26.6)
c
0.001
81/235
113/289
106/278
(24.5)
(39.4)
(38.1)
< 0.001
> 0.5
60-69 yr*
.70 yr*
Lung Field
Normal
Congested*
Puim. Qedema*
.> 0.5
< 0.05
(
>
0.001
0.3
( 0.001
44/286
(15.4) <
0.001
< 0.001
<. 0.001
Arrhythmia
ST or PAT*
VEB (Early)*
(Late)
VT/VP (t°)
(Early)*
(Late)*
6.9
2.1
-fA-V Block
2.7
5.4
Posterior
+A-V Block
31.4
25.5
+RBB
8.0
Undetermined (LBBB) 4.7
*
Significant adverse factors
Puim. Oedema : Pulmonary pedem.a
3/7
10/16
57/200
18/51
4/16
8/30
( 6.5)
'.
0.01
Z 0.02
< 0.02
?O.1
0.001
<0.01
'0.05
<0.01
39/149
53/184
(26.2)
(25.8)
'0.l
>0.1
CTR 55Z : Cardiothoracic ratio > 55%
kF
Atrial Fibrillation
Sinus tachycardia or paroxysmal atrial tachycardia
ST or PAT
VEB
Ventricular ectopic beats
VT/VF(I°)
: Primary ventricular tachycardia or fibrillation
Non-Q-wave : Ncn-Q-wave myocardial infarct
LBBB
Left bundle branch block
:
Right bundle branch block
Atrioventricular block
A-V Block
RBBB
:
Table 20
OTHER CLINICAL FEATuRES IN ACUTE MYOCARDIAL INFARCTION
FACTORS
OCCURRENCE
Angina*
39.8
64/256
(25.0)
107/388
(27.5)
'O.5
Previous infarct
10.1
17/65
(26.2)
154/579
(26.6)
0.5
HypertensiOn
24.4
38/157
(24.2)
79/392
(20.2)
> 0.5
Pericarditis
3.4
5/22
(22.7)
166/622
(26.7)
) 0.5
A-V block, Anterior
5.4
10/16
(62.5)
106/278
(38.1)
0.05
25.5
18j51
(35.8)
39/149
(26.2)
0.1
19.8
62.3
28.0
14/63
87/401
70/180
(20.6)
(21.7)
(38.9)
k-V block, Posterior
WHEN PRESENT
MORTALITY
(%)
WHEN ABSENT
(Z)
MORTALITY
P-VALUE
SGOT
45 unit
45-300 unit
. 300 unit
* Angina
angina pectoris on effort.
+ Previous infarct = EGG Q waves with no evolutionary ST or T changes.
BP>160/95 inmHg.
++ Hypertension
7
,
0.5
0.05
Table 21
CONDtJCTION DEFECTS COMPLICATING ACUTE MYOCARIDAL INFARCTION
(1973-1980)
TOTAL INFARCT
YEAR
NO. MORTALITY
RBBB
NO.
Z
(X)
MORTALITY
A-V BLOCK
LBBB
No.
I
MORTALITY
(Z)
1973
55
(27.3)
8
14.5
4 (50.0)
3
5.5
1
(33.3)
1974
39
(33.3)
6
15.4
6 (10.0)
2
5.1
0
(
1975
46
(15.2)
8
17.4
3 (37.5)
4
8.7
0
C
1976
54
(18.5)
5
9.3
2 (40)
1
1.9
1977
64
(25.0)
13
20.3
2 (15.4)
1
1978
113
(30.1)
15
13.3
9 (60.0)
1979
168
(34.5)
14
8.3
1980
97
(30.9)
636
(28.9)
X
MORTALITY
(X)
5
9.1
o)
7
17.9
3 (42.9)
0)
5
10.9
1 (20)
1
(loo)
5
9.3
1 (20)
1.6
0
C
0)
11
17.2
4 (36.4)
4
3.5
2
C 50)
13
11.5
4 (30.8)
5 (35.7)
2
1.2
2
(loo)
16
9.5
6 (37.5)
13
12.4 10 (83.7)
3
1.0
0
C
o)
lo
9.3
4 (40.0)
82
12.741 (50.0)
20
3.1
6
C
30)
72
Right Bundle Branch Block.
RBBB
LBBB
Left Bundle Branch Block.
A-V BLOCK : Atrio-ventricular Block.
:
NO.
(X)
2 (40)
11.3 25 (34.7)
Table 22 RBBB C0M?LICATIG ACUTE M!OCARDIAL INPARCTION
RBB
Onset of RBB
Total
RBPB
Possible
New
1973
8(4)
4
1974
6(6)
1975
Year
Probably
New
Definite
New
+
RBBB
+
Transient
RBBB
LAHß
LPHB
3
2(0)
i(I)
i(o)
4
2
2(2)
8(3)
5
3
i(o)
i(o)
1(0)
1976
5(2)
3
2
i(o)
1977
13(2)
4
9
2(0)
1978
15(9)
7
7
4(4)
1979
14(5)
5
4(3)
1980
13(10)
7
1
5
2(1)
i(i)
L(0)
Total
82(41)
43
3
36
18(10)
4(3)
ii(i)
(
)
Hospital Deaths
1
1
3(0)
i(i)
3(0)
2(1)
Table 23
Year
HIGH-GRADE ATRIOVENTRICULAR BLOCI( IN ACUTE MYOCARDIAL INFARCTION
110 A-V BLock
Type I Type 2 Subtotal
1(1)
1973
1(1)
1110 A-V
110
Type i
Type 2
2(1)
2(1)
1975
3(0)
3(0)
1976
2(0)
2(0)
1977
3(2)
3(2)
2(1)
1978
5(1)
5(1)
4(1)
1979
4(1)
4(1)
1980
3(1)
II°/tII°
BBBB
(
)
i(I)
REBE
EBBS
I(o)
1974
22(6)
Total
Block preceded by
11°
2(1)
1(0)
1(L)
4(2)
i(o)
4(0)
3(1)
1(1)
i(i)
i(o)
7(4)
2(1)
12(4)
2(1)
3(2)
9(4)
3(1)
2(1)
1(1)
6(3)
23(7)
11(4)
1(1)
2(l)
Second/Third degree Atrioventricular Block.
Bilateral Bundle Branch Block.
Hospital Deaths
8(6)
3(1)
47(19)
Table 24 MODE OF DEATHS IN ACUTE MYOCARDIAL INFARCTION (197 l-1980)
TOTAL DEATHS
195
100 Z
POSTMORTEM DONE
89
45.6%
HEART FAILURE
57
29.2%
CARDIOGENIC SHOC1C
36
18.5%
PRIMARY ARRHYTHMIA
43
22.1%
CARDIAC RUPTURE
10
5.1%
SUDDEN DEATH (7 CAUSE)
32
16.4%
OTHERS
17
8.7%
TA1LE 25
Patients
Age
Sex
CLINICAL FEATURES OF lo PATIENTS WITH FREE-WALL CARDIAC RUPTURE
P0611100
of Infarct
Postinfarction
Hypertension
Ilypo tens ion
Heart
Failure
Cardiac
Dysrhythuiias
Timing*
of Death
1
72
H
Anterior
-
-
-
+
5 Hr
2
72
F
Anterior
-
+
-
-
1/2 Hr
3
62
F
Anterior
-
+
-
-
i Hr
4
81
F
Anterior
+
-
+
1 Day
5
75
H
Posterior
+
-
-
-
20 Hrs
6
57
M
Anterior
-
-
+
-i-
5 urs
7
65
M
Anterior
+
+
+
2 Wks
3
64
F
Posterior
1-
-
+
+
4 Days
9
59
F
Posterior
-
-
-
-
1 Hr
10
86
F
Posterior
+
-
+
-
3 Days
+ ; Present
Absent
* : Duration after admission
:
TabLe 26
TIMING OF
TOTAL DEATHS
EATH5 IN ANI (1971-80)
195
(100%)
io
C 5.i)
6 flours
33
(16.9%)
7 - 12 Hours
17
( 8.7%)
13 - 24 Hours
34
(17.4%)
25 - 148 Hours
23
(11.8%)
days
44
(22.6%)
8 - 14 days
21
(10.8%)
14 days
13
( 6.7%)
DIED ON ARRIVAL*
lIFTER lIDMISSION
3 -
*
7
21 Deaths on Arrival) but clinical record incomplete vere
not included.
Table 27
Year
BLOOD CHOLESTEROL LEVEL AMONG THE 'NORMAL' CHINESE
City
Age Croup
Cholesterol+1.S.D.
Remarks
mg! 100 ml.
1964-66
Hong Kong124
50.8
206.9+58.4
207.1+42.8
Inpatient (M)
(F)
1975-80
1960
1974
Hong Kong
44.8
49.9
Tianjin1-34
Inner135
30-69
Norm1 (M)
208.6+36.7
Normal (F)
206. 52 6 .0
Adult Farmers
172.0+25.5
Tribe People (M)
Mongo lia
(F)
204.6
207.5
1973
Foozbou135
35-50
Military Officers
206.8+42 3
1973
Wanxiang135
(Szechuan)
35-60
Farmers
165.9+30.2
1973
Yanzhing135
Farmers
15 1.
Adult Farmers
165.0+27.8
Pedicabmen
Executives/Military
179.0+30.0
198.0±35.0
1. 3
(J lang sh oc)
1974
Cheng Ting135
1968
Taipei136
40-59
40-59
o ff i c ers
1982
Taipei137
(M): Males
(F): Females
50-59
60-69
Healthy (Males)
Healthy (Females)
184.1±30.9
188.8+32.0
igure 3
Demographic
acute
cf
characteristic
myocardial
(1.971-1980).
infarction
cohort
the
indicates
The
number
in
parenthesis
chapter
AMI
to
specified
referring
the
patients.
G(MC): General wards in Medical Unit Ct
Queen Elizabeth Hospital
in Medical Unit 'B'
GW(MB): General vard
Queen Elizabeth Hospital
Coronary Care unit, Medical Driit 'B'
CC.3:
Queen Elizabeth Iospital
1971-198OJns
[22 AMIJ
[55
compSt 1Mormtlw
(21 Dsd ot Arrivil)
4W1 GW
1971-1976: 224
ISS (3)
i
CCU (A
77- Jun. 50)
1977-1980:442
1973-1980: 63eco.
19-1W19:
I 195HøipdiiDsthI
51?
[AMI7
I
174
ccuj
j
385
(MC)
JilpDu8O
AMJ
o 141GW -__ ________
+45
AMI
380W
(MB)
Au 17-
21(5}
325 AMI
Aliv*>Shr.
Od lB - BuG 89 Tt
cculj
L,xciuds: 9 Eaily Dt*IU (Cl hr) o1
pl2e (5)j
ccu
*fftDIOr&d
9 Tr.nsf.rrd from MC
2 Trnsforr.d ta MC
fl.gure 4
Age and sex distribution o
the patients.
AGE AND SEX DiSTRIBUTiON
(TOTAL 666. MALE 431 FEMALE 229)
150
100
50
<50
50-59
60-69
AGE (YEARS)
>70
igure 5
ELeCtrocardiogram of 54 years old mari with
extensive
acute
anteroseptal
infarction
Complicated by right bundle branch block.
The wide 'S' wave in lead I, QR pattern in
:
'S'
wave
in
V6
tachycardia are demonstrated.
_ I]T' ____ TifT.
i:
1.
.....
!.t.L ....
f
RHYTf*1
_
;
RIPi 111
L...:
.......... _.L..,
.....
i
.
.
-
..... ...J,
.L..i.. .. ............
: ......... L..
..........
... .
sinu.s
........
.
].:r
and
.
I
-
rr
-
i ..........
41._jIi:
Fi
I:I.
i
h
1
I
1 ....
Ò5-40112
02005
-
- 64 -
CHAPTER 4
SEASONAL VARIATION IN THE
DEVELOPMENT OP ACUTE MYOCARDIAL INFARCTION
HONG KONG
I
INTRODUCTION
4.1
For
long
a
health was found to be closely
tiaie
related with weather and climate.
ancient
literature
traditional Chinese medicine written as
thousand
two
the
In
years
there
ago,
many
are
on
early as
descriptions
concerning the correlation between natural phenomena and
ailments,
including
activities,
aspects
the
physiological
treatment255257.
and their
diseases
human
on
In
the
Western literature, speculation on the effects of climate
upon health
HAir,
Waters
back
goes
at
least
Places"258.
and
Hippocrates
to
Heberden
in
and
his
1772 reported
that patients suffering from ischaemic heart disease had
an
increased number of attacks of angina pectoris during
the winter
months259.
Justin
and
Hungtington
in
their
early studies in the United States of America related the
daily
mortality
to
18821888260261.
been
directed
the
weather
More recently
to
myocardial infarctioL
the
in
a
seasonal
(AMt).
In
New
lot
York
in
of attention bas
variation
the
City
of
temperate
zones including the United States of America,
acute
and cold
the United
- 65 -
Kingdom, Netherland, Finland, China, Japan and Austra1ia.
a fw exeptions
with
be
higher
winter
iu
true
also
the
on
than
in
day-to-day
a
of AMI was found to
incideric
summer262283.
mis
was
On
the
basis273274281.
other hand, a few reports fron ti'e subtropical regions in
the
United States
increase
in
of America and Egypt have reveaLed an
number
the
of
hospital
admissions
AMI
of
during the hot summer months when compared with the cooler
winter
months 284-286
stress
i.e.
.
latitudes
extreme
arid
latitudes
cold
heat
experience
harmful
is
also
is
been
has
bimodal
A
.
in
damaging
suggested
of
high
the
in
thermal
cold
hot
low
the
278-279,284-286
However
.
subsequent study in another low latitude subtropical area
did
support
not
Therefore
the
such
a
latitude-temperature
relationship
exact
between
environmental
particularly in the
temperature and myocardial infarctiorz
subtropical and tropical zones remains unclear.
all
previous
temperature
meteorological
works
have
only
while
factors
on
emphasised
the
the
Moreover,
significance
influence
the
model267.
of
other
of
seasonal variation of AMI
has not been systematically delineated.
Hong
lS'N.
Kong
is
located
at
the
latitude
of
22°
It is a subtrcpical city and is bioclimatologically
classified
as
comfortable hyperthermal
according
to
the
- 66 -
cLassification287.
GreogOrCZUk
Since
it
shown
was
in
the previous chapter that there were more AMI admissions
in Hong 1ong during the
study
Hong
in greater detail
to
ICong,
logical
to
the seasonal pattern of AMI
in
cold
whether
see
seasons,
it
it
conforms
is
to
bimodal
the
thermal stress, and in the meantime explore on
pattern o
the influence of other meteoroLogical factors.
MATERIALS A1D METHODS
4.2
All
patienta
with
acute
infarction
myocardial
admitted into Medical Unit B of Queen Elizabeth HospitaL
between
Ist
January
the
months
infarction
confirmation
diagnosed
was
at
their
of
December
31st
1979
were
classified according
They were
studied retrospectively.
to
and
1973
either
myocardial
Acute
admission.
pathological
by
post-mortem examination
or
by
clinical
identification according to the WHO criteria as described
in the previous chapter.
Information on meteorological data for the period
between 1973 to 1979 was obt&ined from the annual reports
of the Royal Hong Kong Observatory.
The average values of
these meteorological factors for each month in these seven
years were calculated.
The
of
AMI
relatiohsbip between the
admissions
and
the
seasonal
seasonal variation
changes
of
these
meteorological
factors
was
assessed
corresponding regression coeEfjcjent
method
standard
inter-relationship
of
of
caLcu1ating
by
Cr value), using the
least
square288.
Individual
the
factor
The
similarly
was
evaluated.
4.3
RESULTS
4.3.1
Time Distribution of AMI
0f
the
patients
517
with
AMI,
313
(60.5%) were admitted in the 6-months period from
to March compared with 204 patients
6-months
the
period
admission rate was
April
frani
higher
(39.5%)
in
October
admitted
September.
to
October,
patients
November,
in
The
January
and March (Figure 6).
Meteoro1o_gica1 Observation in Houg Kp
4.3.2
September,
especially
summer,
In
Rong Kong was under
July,
in
the
August
influence
and
of several
tropical depressions and typhoons developed in the South
China
to
Sea..
31°C
28°C,
with
while
The average monthly maximum temperature rose
the mean monthly temperature being around
the
mean
monthly
atmospheric
pressure
dropped to the level of 1004.4 mb, the mean wind speed was
in
the
range of 6.4
-
6.9
Knots
and
the mean relative
humidity stayed around 80-84Z (Table 28).
In late autumn
beginning in November and in early winter, owing to
the
- 68 -
readjustment
masar
alteration
and
atmospheric
of
circulation, the East Asian frontal system started forming
the
along
achieved
China
intensified
coast,
progressively
the eld air
peak activity in January when
its
and
movement became more frequent and the frontal system moved
The average monthly minimum temperature dropped
inland.
to
the mean
13.6°C.,
temperature dropped
atmospheric pressure rose to 1020 mb,
was
range
the
in
of 7.4-8.8 Knots
to
the
15.80C,
the mean wind speed
and
the mean monthly
relative humidity dropped to around 70%.
closely
followed
the
seasonal
mean
pressure,
atmospheric
humidity
the
general,
In
wind
pattern
the
correlation
of
coefficient
fluctuation
and
speed
relative
changes
temperature
-0.96,
being
the
of
-0.57
and 0.58 respectively (Table 28).
Correlation of AMI_incidence and Meteorological
4.3.3
Fac tors
The variation of AMI admissions followed closely
the
changing
(r-o.79)
except
i).
and
pattern
the
of
mean
the
mean
atmospheric
in February and December
in
monthly
teemperature
pressure
this
period
(r0.90),
(Figure
The o'eral1 correlation factor for the whole period
was -0.58 and 0.67 respectiVely, while that of the mean
wind speed and mean relative humidity was 0.73 and -0.61
respectivley (Table 29).
DISCUSSION
4.4
Although long-period biological phenomena related
to
seasonal or other changes in weather and climate are
fairly
well
known
human
in
influence of weather changes
biometeorology,
daily
the
on human patbophysiology is
extremely difficult to demonstrate in a way which complies
modern scientific
with
every
person
in
standards289.
large
a
group
to
One
cannot
respond
to
expect
given
a
meteorological change at the same moment and to the same
On most occasions only a statistical correlation
degree.
could
expected,
be
physiological
where
mechanism
conditions
difficulties
controlling
not
truly
be
a
be
climatic
non-climatic
observations made at
may
in
phenomena,
biological
could
could
factors
the
cases
in
reproduced
under
chambers.
These
necessity
the
to
deeper
the
elucidated
be
attributed
are
other
rarely
involved
meteorotropism
the
controlled
the
only
and
which may
possibility
that
of
affect
weather
central meteorological observatory
representative
of
the
atmospheric
environment which the individual members are exposed to,
the
time-lag
possible
phenomenon
and
non-uniformity
of
some
their
between
a
clinical
diagnostic
triggering
events,
criteria.
weather
and
Some
the
of
- 70 these
problems
could be circunvented,
as
in
present
th
study, by involving a large population in a localised area
over a long time, and using a simple and clearly defined
criterion for diagnosing the clinia1 events.
In the present study,
seasonal
eteoro1ogical
a relationship between the
changes
and
number
the
of
AMI
patients admitted into one medical unit of a big general
hospital, was sought.
The majority of the patients came
from lower socioeconomic classes
protected
daily
from
activities,
could
changes
of weather
stress
the
and
be
and would
therefore
assessed.
the
not
changes
be
Those
who
their
in
influence
such
of
died
well
before
Their exclusion
admission were not included in analysis.
would not affect our analysis since the overall mortality
of
coronary
remained
attacks
unchanged
at
different
climatic condition and therefore any changes in the number
of admissions were not the result of changes in mortality
pattern
269,273-274
meteorological
Since
changes
to
the present study related the
the AI admissions,
would
it
have been influenced by the social factors that may affect
the patients' readiness to seek hospital care.
have
happened
during
the
Christmas
This may
festival
and
the
Chinese New Year and may account for the relatively lower
admission
in
December
and
February.
A
large
scale,
- 71 prospactive
community-based survey would be required for
the critical evaluation of the influence of such social
factors
Hong l(ong is biocliînatologically comfortable in
February and December) between comfortable and cold in
January, between comfortable and warm in Tlarcb, and
uncomfortable and warm in the period from April to October
.
.
290-291 .
(Brazol classification)
are similar to those found
.
Dallas 284-286 .
However1
we
These
in
have
seasonal
New
changes
Orleans
encountered
a
and
higher
incidence of AMI during the cool, and dry winter months, a
finding deviating from the bimodal pattern of thermal
is
In a similar study in Bombay which
stress.
"permanently hyperthermic" and in Lisbon which is
"comfortable-hypothermic', admission of AMt were also
inversely and linearly related to air temperature over the
range of 11 -30 oC282-283,292
The relationship of AMI with other meteorological
elements depends on their interrelation with temperature.
correlates inversely with the
Atmospheric pressure
temperature changes in these three cities. Xt is likely
that in seasons with high pressure, the meteorological
development of
AMI
influence of low temperature.
On
impact
on
the
is dominated
by
the other band,
the
with
- 72 -
higher
temperature
Bombay
in
and
atmospheric pressure was associated with
in
the number
of AMi admissions.
drop
the
Lisboi,
in
a secondary rise
Relative humidity and
rainfall bear no consistent independent relationship with
the seasonal variation of
correlations
A11,,
depended
maitily
since their corresponding
on
environmental texuperature (Table 30).
in
agreement with
Beijing281.
factors
and
1977
1978
were
These findings are
the work conducted
of
study,
latter
the
In
in
results
the
relationship with
their
in
meteorological
nine
evaluated
stepwise
by
regression analysis atid the regression equation (Y4.276 0.0058 z Air temperature 4- 0.0056 z Mean daily temperature
difference - 0.0088 x Mean wind speed) so obtained clearly
highlighted the significance of air temperature and wind
speed in the oc
temperature
situation,
stress
of
harmful
direct
The
objectively
rrence of AMI.
cardiovascular
the
on
and
evaluated
providing
a
similarly confirmed,
hyperbaric oxygen
isohaemia
has
in
been
system
reproduced under
Although
atmospheric
of
environmental
of
scientific basis
hypothesis29300.
reduction
effect
the
pressure
a
for
been
has
controlled
the
thermal
effect
adverse
has
not
been
the beneficial therapeutic effect of
the
management of acute myocardial
recognised
both
in
theory
and
in
pract.Ce
301-304
In
.
addition,
mechanisms may contribute
in cold weather.
to
other
some
indirect
the higher incidence of A}I
These may include the higher incidence
of respiratory tract infection with its associated stress,
circulating
higher
catecholamine
level,
the
increased
socio-psychological stress related to the festivals in the
cold seasons and changes
in activities and dietary habits
in these periods.
data,
Our
together
with
the
others
discussed
earlier, have confirmed that the seasonal variation of AMI
is dominated by the influence of environmental temperature
with an invetse linear relationship over the range of il
-
in atmospheric pressure may exert
a
31°C1
while
a
drop
secondary adverse effect.
Nowadays, with
the
efficiency
and convenience of air-flights, people can travel within a
short
time
to
a
distant place with contrasting climate.
In view of the conclusion of the present review, patients
with iscbaemic heart disease should be warned against the
possible risk of exacerbation.
advice,,
order
a piece of practical
they should travel in certain "ideal" seasons
to minimise
the places,
ranges
As
the meteorological differences between
should avoid exposure
and strong wind,
and
to extreme temperature
it would be beneficial
them to limit their activities while adapting to
environment.
in
for
their new
- 74 -
SUMMARY
4.5
seasonal
The
acute myocardial
Kong
were
fluctuations
infarction
studied
of
(AMI)
the
incidence
1973-1979
in
retrospectively.
in
Sixty-five
of
Hong
percent
(313/517) of AMI patients were admitted to ho8pital in th
cool season from October to March
November and January,,
and
cold
air
with peak months being
when the East-Asian frontal
movement were
active.
The
AMI
system
admission
correlated with the mean monthly atmospheric pressure arid
wind speed (r0.7) and inversely with the mean monthly air
temperature,
relative
Previous
literature
elements
was
humidity
on
reviewed
the
and
and
rain
influence
the
present
of
fall
(r-O.6).
meteorological
findings
in
Hong
Kong were discussed in the light cf similar collaborative
studies in Lisbon and Bombay.
the
development
predominantly
of
AMI
the
on
was
The seasonal variation in
found
fluctuation
dependent
to
be
of
environmental
temperature, with an inverse linear relationship over the
range of 11-30°C,
and secondarily on tbe occurrence of
sudden drop in atmospheric pressure.
a
This conclusion will
induce patients suffering from ischaemic heart disease to
be
cautious
when
contrasting climate.
travelling
to
other
places
with
Table 28
Summary of Monthly Meteorological Observations Made
at the Hong Kong Rya1 Observatory (1973-1979)
Mean
Mouths
Air Temlerature
Mean Max.
Mean Min.
OC
Mean
Pressure
°C
nib
Mean
Relative Humidity
Mean
Wind speed
Z
Knots
January
15.8
18.7
13.6
1019.7
74
7.7
February
16.8
19.8
14.5
1018.6
76
7.4
March
18.9
21.7
16.9
1016.2
82
8.1
April
22.7
25.7
20.6
1012.5
84
6.7
May
26.2
29.0
24.2
1009.0
85
6.4
June
27.7
30.4
25.8
1006.1
84
6.3
July
285
31.4
26.5
1005.6
81
6.7
August
28.1
31.2
26.0
1004.4
83
6.6
September
27.5
30.4
25.3
1009.4
80
6.9
October
24.9
27.9
22.8
1013.2
73
8.8
November
20.4
23.5
18.1
1018.3
66
7.5
December
17.5
20.7
15.2
1020.3
69
7.8
-0.96
0.58
-0.57
Correlation Coefficient*
* With Air Temperature
Table 29
Correlation of AMI Admission and Meteorological Factors
in Hong Kong (1973-1979)
AMI
Admissions
Months
Mean Air
Temperature
Mean
Pressure
mb
Mean
Relative Humidity
Mean
Wind Speed
Knots
Z
January
62
15.8
1019.7
74
7.7
February
41
16.8
1018.6
76
7.4
March
52
18.9
1016.2
82
8.1
April
40
22.7
10125
84
6.7
May
39
26.2
1009.0
85
6.4
June
30
27.7
1006.1
84
6.3
July
32
28.5
1005.6
81
6.7
August
31
28.1
1004.4
83
6.6
September
32
27.5
1009.4
80
6.9
October
59
24.9
1013.2
73
8.8
November
63
20.4
1018.3
66
7.5
1ecember
36
17.5
1020.3
69
7.8
-0.61
0.73
Correlation Coefficient*
* With AMT Admissions.
-0.58
0.67
Table 30
Correlation of AMI Admissions and Meteorological Pactors and
t:heir Interrelationship in Hong Kong Bombay and Lisbon
Air
Temperature
Atmospheric
Pressure
Relative
Humidity
0.67
-0.61
0.73
-0.63
-0.96
0.58
-0.57
0.95
0.49
-0.46
-0.53
-0.62
0.26
0.21
0.45
0.79
-0.30
0.78
-0.61
-0.92
0.52
-0.91
Wind
Speed
Rainfalls
Correlation with
(I)
(z)
(3)
r
(1)
(2)
(3)
;
:
:
AMI
r
Temperature
r
AMI
r
Temperature
r
AMI
r
Temperature
r
-0.58
-0.52
-0.81
Correlation Coefficient
Hong Kong
Bombay
Lisbon
Figure 6:
Time-distributjn
myocardial
acute
B
Queen
Unit
The
1973-1979.
patients
the nunber of
of
infarctions
in
Medical
Elizabeth
Ilospital
in
ordinate represents
with infarction8.
YAt]
30
20
7
JULY
8 91011121 23 4 56
JUNE
Dc
MONTHS
Figure 7:
Time-distribution curves of acute myacardial
infarctions
arLd
mean
the
ontb1y
temperature
pressure
and
atmospheric
1973-1979
scale
in
1ong.
Rang
The
temperature increases dovwards ana
UTU
1
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UNHONG-KNG
EUZAT HØ?*.
1
in
- 75 CHAPTER 5
THE flPACT OF CORONARY CARE UNIT ON
MORTALITY FRON HYOCARDIAL INFARCTION
IN HONG KONI
iNTRODUCTION
5.1
The use of coronary care units
yocardia1
infarction has
increased
at
for
(cou)
acute
extraordinary
an
rate in most countries over the past decade.
Despite the
tremendous costs involved in providing this type of care,
relatively little attention has been paid to the critical.
question of whether patients treated in such units derive
benefit.
any
fact,
In
their effectiveness
are
methodology
and
Critic t sm.
the
limited
their
and
evaluation
of
data
present
demonstrating
study
open
often
are
designs
to
305
Since
August
1977,
a
3-bedded
has
CCU
been
established in Queen Elizabeth Hospital, providing service
on
a limited basis.
the
prevalence
incidence
past
20
of
As reviewed in the previous chapter,
coronary
artery
disease
and
AÌ1I
in Bong Kong have increased markedly over the
years.
With
increasing prevalence
the
pressure
coming
from
in Bong Kong on one hand,
this
and the
problem of limited resources for our medical care on the
other,
it would be most important to review the impact of
the ccU on the mortality of acute myocardial infarction in
our locality.
MATERIALS AN
5.2
Patients
METHODS
were
those
with
acute
inyocardial.
infarction admitted into two of the tbree medical units of
Queen Elizabeth Hospital (Q.E.H.) between October 1978 and
December
turned
1980
up
(Figure
Depending
casualty
the
in
3).
on
department
the
of
they
day
Q.E.R.,
156
patients were allocated at random into Medical Unit
and
patients
141
(Figure
into
TCI
Unit
of
general wards
(OW)
respectively
Q.E.H.
The latter group of patients
8).
ßt
stayed
in
the
throughout the whole period when they
were ir'. hospital while the former group received treatment
in
the
CCtJ
in
the
initial period
(4-7)
Patients
days.
included in the present study were either below 70 years
of age or had complications of dysrhythmias or conduction
Thirty-three patients with ages above
defects.
70
years
and uncomplicated acute myocardial infarction vere treated
in the general wards of both units, and therefore were not
Twenty patients (9 COU and
included in the present study.
li.
cW)
who
died within
hour
one
admission,
of
or
who
developed cardiac arrest before or soon after arrival to
hospital
and
never
regained
fuLl
consciousness
were
excluded.
Acute
myocardial
infarction
was
diagnosed
- 77 accoraing to the WHO criteria de8cribecl in the previous
chapters. All patients had their cardiac rhythm monitored
in the initial 48 hours. In tbe 3-bedded CC1J tlere were
two fully-committed nurses in constant attendance under
the Supervision of a
with training and
experience in CCU nursing, including the recognition of
cardiologists
warning
dysrhythmias ,
cardiopuLmonary
resuscitation,
In the general
defibrillation and advanced life supports.
wards, the patients stayed in the noncommitted beds
near-by the open nurse station. The nurse to patients
ratio was 1:8, and cardiac rhythm was monitored by
bed-side EC
machine with audio visual alarms for
bradytacbyarrhythmias. A common protocol of management
with allowance for individual modification was adopted
during their stay in hospital (Appendix 2 and 3). Norris'
coronary prognostic indices were used to compare the
clinical severity of various subgroups of patients.15
Patients who died suddenly without any definite
complicating causes being detected in the post-mortem
examinations were classified as having died of primary
arrhythmia; while those wh did not have post-mortem
examination were çlassified as having died of sudden death
of an uncertain cause.
The Chi-square test with Yates' correction and
-
-
78
the Studentts t-test were used
assess
to
the statistical
significance of the data.98'3
RESULTS
5.3
In the period from October 1978 to December 1980,
patients
129
with
admitted into
same
the
acute
the CCU,
period,
loo
myocardial
95 were males and 34 females.
patients
admitted
were
general wards,
73 were males and 27 females
Among the men,
15
out of
out of 95
into
In
the
(Table 31).
CCU patients and 25
(15.8%)
(34.2%) GW patients died
73
were
infarction
Among the
(p<. 0.01).
women, 10 out of 34 (29.4%) in CCU and 6 out of 27 (22.2%)
).
in GW died (p>0.5
The overall mórtality was 19.4% and
31% respectively (p> 0.05)(Table 31).
females was
years
65.7
those
of
in
The mean age of CCU
11.4 years compared with
+
Coronary prognostic
GW.
60.3
8.3
indices were
higher in both males (p< 0.05) and females (p>0.5) in CCtJ
compared with those in GW.
After
these
two
their
coronary
(Figure 9)(Table 32).
and
4
overall
(21/69)
older
than
in
respect
prognostic
indices
years,
70
their
of
(p > 0.1)
Thirteen out of the 88 men (14.8%)
Out of the 23 women (17.4)
with 30.4%
The
patients
groups became comparable
and
ages
excluding
and 26.1%
mortality was
in CCU died1
(6/23) respectively
1.5.32
and
compared
in
GW.
29.32 respectively
- 79 (p
0.02)
deaths
(Table
in
32).
Seventy-six
precent
CCtJ and 77.4% (24/31) of deaths in
within
seven
output
accounted
days
occurred
in
cardiac
rupture
for
45%
hospital.
in
72%
GW
in
or
Heart
o
deaths
(Table
33).
sudden
in
CCTJ
of
of
GW occurred
failure
Primary
death
(L9!2)
or
while
low
these
arrhythmia,
uncertain
cause
accounted for 44% of deaths in CCtJ patients compared with
54.8% in GW (p> 0.5).
5.4
DISCIJSSION
Since its introduction 20 years ago, the CCU has
been
proof
advocated
of
with
benefit
its
much
is
enthusiasm
still
although
lacking
305-309
workers have cast doubt on the superiority of the
care
given
Critical
in
general
evaluation
of
wards
this
or
at
issue
definite
few
CCLI over
305,310313
home
has
A
unmasked
the
prb1ems of study design, the changing natural history of
acute
myocardial
infarction,
the
improvement
in
the
standard of care in general wards over the years, and the
problem of referral bias on the age or clinical severity
of patients305.
available,
strict
In the present time,
randomization
of
if CCU facility is
patients
with
acute
tayocardial infarction for CCU or general ward admission is
generally regarded as
unethical1
if not impossible.
The
selection of patients in the present study is not strictLy
- 80 but
raudomized,
this
study
has
designed
been
to
specifically ninimise the effect of any passible selection
bias.
has
It
been
concurrent
treatment
compared.
The
conduted
groups
majority
prospectively
the
in
of
patients
and
two
were
hospital
saine
were
admitted
at
random into different medical units and there±ore into two
different groups
(cciJ or GW)1 according to the days they
turned up in the casualty department and no cross-over was
allowed.
period
The saine policy of admission was adopted in this
and
patients
the
were
protocol in the saine hospital.
treated
with
common
a
The vide range cf clinical
severity of the patients was evaluated and expressed
in
numerical values by using the Norris' Coronary Prognostic
Index15
so
compared.
that
the
two
patients
Seven
could be more
groups
bad
who
complication
from other hospitals
selectively referred
properly
for
were
intensive
coronary care and intervention,, and four younger patients
scheduled for CCU admissions have to stay in the general
beds of medical unit
study,
because
time.
Their
of
'B'
and therefore excluded from the
unavailability
numbers
were
small
of
and
CCU
if
beds
at
that
anything,
they
could have only adversely affected the outcome of the CCU
group.
On
the
whole
the
CCU
patients,
especially
the
females, were older and clinically more serious than those
randomized
the general wards.
in
the admission into the
due
to
70
years
who
had
two
most probably
is
CCTJ of patients older than
complications
conduction defects.
the
This
of
dysrliythmias
or
After excluding these oldar patients,
groups became more comparable and well matched.
There were 129 CCU patients from Medical Unit
B' and 100
Gw patients from Medical Unit lCTincluded in the present
Nine other patients in Medical Unit
study.
patients
Unit
in
TEl and eleven
were excluded because
'C
they either
died within one hour after adtaission or developed cardiac
arrest before or soon after arrival to hospital and never
regained
admitted
CCU was
into
morning
next
consciousness.
full
transferred back
admission
after
patients
Two
vice
and
patients originally admitted into Unit
holding
cards
follow-up
the
They were not
included
in
present
the
Unit
versa
TCT
the
1C'
nine
for
they were
as
corresponding units.
the
of
to
originally
0f these
study.
nine patients, two (22.2%) died after their transference.
Their
outcome
remaining
number
of
in
these
the
two
significantly
differ
-
in
these
two
different number
units
fulfilling
frani
The difference
general wards.
the
patients
explained by
into
not
did
groups
may
of patients
the
other
those
in
also
the
be
admitted
criteria
of
inclusion, as well as by the daily fluctuation of patients
- 82 -
turning up in the casualty department over a period of 28
months.
In our
in
CCU had
infarction
a
the patients initially treated
experiences
hgher chance
compared
with
from myacardial
survival
of
those
general
in
The
wards.
overall mortality was 15.3% and 29.3% respectively and the
difference was statistically significant.
The benefit for
the female patients was not so obvious, presumably due to
the number of females in both groups being small and the
coronary
prognostic
index
in
the
females
CCU
being
higher.
As
expected,
sudden deaths were more frequently
recorded
in
patients
staying
in
general
initially
in
the
with
those
staying
smalL number of such
wards
CCU,
deaths did not make
compared
although
the
the difference
statistically significant.
The beneficial
effect
of
OCtY,
however3
has not
been accompanied by a significant decrease in the observed
case
fatality rates
in
the medical
'B'
Unit
in 1971-76
(25%) and 1977-80 (3l.4%),i.e. before and after the period
when
CCU was
introduced.
This
apparent
discrepancy
in
outcome is probably attributed to admissions of older and
clinically more serious patients in the latter period.
As
has been commented on in Chapter 2, with more popularity
of Western medicine in Hong Kong, more old patients were
- $3 -
more willing to seek hospital admissions, wbile previously
a
significant proportion of them would stay at home and
outside hospital.
die
importance
and
relevance
again reiterates
issue
This
concurrent
of
studies
the
when
outcome of different treatment modalities is compared.
While argument for home care against CCTJ care for
myocardial infarction is
most people
in Hong Xong malces
initial
the
issue irrelevant
this
to
Our data strongly support the use of the
our community.
in
in some advanced
the noisy and overcrowded home environment of
countries,
CCtJ
still going on
period
myocardial infarction.
by
However,
patients
the evidence has
far
so
from
suffering
only been applicable to those younger than 70 years of age.
SUMMARY
5.5
groups
A
prospective
of
patients
study
concurrent
suffering
made
was
2
myocardial
acute
from
on
infarction admitted at random into the coronary care unit
or
general wards.
their
than
older
those
70
the two groups were well matched in respect
years of age,
of
After excluding
ages
and
clinical
severity.
Those
initially
treated in the CCU had a higher chance of survival from
inyocardial infarction compared with those
wards.
The
overall
mortality
29.3Z(27/92) respectively
was
(pL. 0.05).
l5.3Z
in
the
general
(17/111)
and
Sudden deaths were
- 84 more
frequently
general wards.
encountered
in
those
treated
in
the
Our findiugs strongly support the use of
the CCIJ by patients below 70 years of age.
Table 31.
MORTALITY FROM MYOCARDIAL INFARCTION
IN CORONARY CAR! UNIT AND GENERAL WARDS
Male
GW
CCI]
Total No.
95
CCI]
GW
CCI]
GW
73
34
27
129
100
65.7+11.4
60.3+ 8.3
61.3+12.4
59.3+7.7
7.3+ 3.0
7.0+ 2.5
6.5+3.2
Mean Age
59.8+12.4
58.9+7.2
Mean CPI
6.7+ 2.2
5.9±2.3
(Z)
7.7
3.1
15
28
10
(15.8)
(34.2)
(29.4)
Deaths
P Value*
Overall
Female
0.001
6
(22.2)
>
:
General Wards
* For their mortality rates
P valve for CPI difference in Males
0.05
:
Females :>O.5
Overall
31
(19.4)
(31.0)
>
0.5
CCU : Coronary Care Unit
Norris Coronary Prognostic Index
CPI
GW
25
:
0.05
MORTALITY FROM MYOCARDIAL INFARCTION IN PATIENTS BELOW 70 YEARS
Table 32
Male
CCCI
GW
OCU
GW
CCU
GW
88
69
23
23
111
92
58.6+7.3
Total No.
Mean Age
58.9+11.4
58.6+7.1
60.2+8.0
Mean CPI
6.5+ 2.8
6.0+2.8
7.1+4.0
13
21
(14.8)
(30.4)
Deaths
(Z)
OCh
:
CPI
:
GW
6.9+ 2.9
6
11.
(17.4)
< 0.001
P Value*
*
Overall
Fenale
(26.1)
? 0.1
For their mortality rates.
:
0.1
Females :C.5
Overall
6.64 3.1
:
0.3
58.7
6.3+2.8
17
27
(15.3)
(29.3)
<
Coronary Care Unit
Norris Coronary Prognostic Index
General Wards
p value for CPI difference in Males
59.1±11.3
0.02
Table 33
CAUSES OF DEAT1 IN NYOCRDIAL INFARCTION
GW
lieart Failure
Low Output
Primary Arrhythmia
COU
5/31
(16.1%)
11/25
(44.0%
9/31
(29.0%)
7/25
(28.0%)
5/31*
6/25*
(16.1%)
(20.0%)
Cardiac Rupture
0*
3/25*
(12.02)
Sudden Death**
12/31*
2/25*
(38.7%)
Others
3/31
(9.72)
*
COU
GW
:
General Wards
Value
0.05
> 05
0 5*
(8.0%)
1/25
(4.02)
Primary Arrhythmia, Cardiac Rupture
and Sudden Death grouped together
Sudden Death of Uncertain Cause
Coronary Care Utit
**
p
05
Figure 8
:
Allocation and demographic characteristics c.
kMI patients in the coronary cara (CCtI) and
general ward (GW) groups.
7 referrals from
[Emergency
othr hospitafaj
A&E Dept
MB
MC
141
156 A
AMT]
h.'
12 OLD
GW
4YOUNG AMI
21 OLD
GW
(NOCCUBED)
14OCCUJ
[120GW]
I
9 Arrest or
Early
2 Transfer
9 Tranfer
11 Arrest or
to MC
to MB
Early deaths
[29 ccv
[o0GW
I
Figure 9
:
Coronary prognostic index (CPI) of patients
with
myocardia].
into
admitted
infarction
coronary care uUit of medical unit ,B
(
ccu) and general wards of medical unit 'C'
ALI
(MC GW)
of Queen Elizabeth
ospital.
The dotted line
were below 70 years of age.
indicates the mean CPI of each subgroup.
M: Male; F: Female.
14O
O
o
co
o
-
z
8
o
o
lo-
I
cp
8
o
08z
UI
o
e
o
-
-OI
-
-
6
>.
o
o
O
I
-
<4z
O
o
000
too
8
080
8
8
02
M
F
M
F
o
MB CCU
MC GW
- 85 -
CEAPTER 6
DELAY IN ADMISSION TO A CORONARY CARE UNIT
IN HONG KONG
INTRODUCtION
6.1
Coronary
associated
century.
artery
with
western
disease
been
has
modernisation
twentieth
the
in
closely
It has been shown in the previous chapter that
Hong Kong, like most affluent Western countries,
is
facing
the problems associated with coronary artery disease the
prevalence of which is expected to increase with aging of
our population.
(cou)
with
in decreasing the hospital mortality when compared
that
the general wards has
in
prospective
It
controlled
been
also
bas
complications,
salvageable
early
The importance of the coronary care unit
study
been confirmed by
described
demonstrated
itt
last
that
including various ominous but
cardiac
stage after
arrhytbtuias,
the
the
a
chapter.
major
potentially
usually develop
in
the
onset of acute coronary symptoms,
and 75% of deaths occur in the first two hours before any
life-saving
instituted
2,196-197,314-319
coronary care
cauld
treatment
.
To be able
in the acute stage,,
be
to benefit from
patients with AMI must
be admitted as soon as possible into such a unit.
However
- 86 even in the more affluent countries, 50% of the patients
fail to get into the coronary beds within four hours after
the onset of symptoms, and such a delay in admission has
been the great concern of most interested workers in the
past decade 2, 70, 171,188, 196 317,320-332
Another reason calling for the early admission of
patients with AMI is based on the concept of myocardiuxn
salvaging which has been recognised to be most important
for their prognosis in both short and long-terms.
Measures
to
preserve
salvageable myocardium,
including
revascularisation by throabolytic therapy, have come into
practice with promising results in recent years, provided
that they could be applied within four hours from the
onset of symptoms 26-28 ,333-334
The purpose of the present study is to determine
the amount of time taken up by different stages before a
patient is finally admitted to a CCU of a general hospital
information could prove useful in
developing recommendations to shorten the delay with a
in Hong Kong.
This
view to prevent more patients from dying of AMI.
6.2
MATERIALS AND METHODS
A coronary care unit with 3 beds was established
inside a general medical ward of Medical Unit B in Queen
- 87 -
ElIzabeth Hospital
December
1980,
August 1977.
it
298
patients
From August
with
219 were admitted into
depending
patients
certain
on
(younger
complications
including
defects.
onset
than
some
of
intensive
were
complications.
Included
these,
of
the
presence
of
than
years,
70
and
conduction
48 hours
more
after
normally
in
ages
tlie
dysrbythmias
care unless
coronary
and
older
those
in
admitted
symptoms
of vacancy,
years)
70
malignant
Patients
Of
B.
coronary care unit (Figure 3),
th
availability
the
myocardial
acute
infarction were aduiitted into Iiedical Unit
to
11977
the
in
or
not
the
present
considered
presence
of
study were
the
for
some
141
patients admitted in the general wards of Medical C Unit
of the same hospital and recruited as the control group of
a prospective study to evaluate the benefit of CCU on the
mortality of AMt in Hong Kong described in last chapter.
Of these 398 patients,
hours after arrival.
72 patients
(18.2%) died within
6
Of the remaining 326 patients, 271
patients (83.1%) were interviewed by the medical officers
and around 80% of them were able to give an account of the
various stages from the onset of their symptoms right up
to hospitalisation.
Information from their relatives or
other witnesses given at
recorded
in
the
the
assessment
time of admission was
sheets
within
24.
hours
also
of
- 88 -
admission.
Apart
from the
the interviews
history,
connection
with
premonitory
signs
the
patientsì
focussed on
acute
and
the
social
medì.cal
the circumstances
conditions,
time
and
including
in
any
they were noticed.
The
first
the
periods
between
the
patients'
illness
and the
time
they reached
awareness
the
of
CCU were divided
into four stages as follows.
Hospital arrival time: The total time between the
onset of acute symptoms which precipitated the seeking of
admission
to arrival
at
emergency department of
the
the
hospital.
Emergency
room
delay:
The
time
spent
in
the
emergency room from entry to referral to admission office.
Transfer
time:
The
time
spent
on
admission
procedures and transference to the general wards.
General ward delay: The time spent in the general
wards till transference to CCtJ.
Total delay: Total time from onset of symptoms to
actual admission to coronary care bed.
Acute
according to
myocardial
infarction
the WHO criteria described
was
in
diagnosed
the previous
chapters.
The
standard
error
of differences
between mean
delay times was calculated and the differences between the
- 89 -
means
t-test
were
assessed
statistically
by
student's
the
335
6.3
RESULTS
63.l
Hospital Arrival Delaj
Fífty-níne percent of the patients arrived at the
emergency department of the hospital within 3 hours after
onset of their symptoms, with a median delay of 2.8 hours
(Table
34 and 38).
Twenty percent of
the patients took
more than 12 hours and some as long as 72 hours to turn up
at the emergency department (Table 38).
6.3.2
Delay in Hospital Procedure
Most patients vere attended
to
promptly
in
the
emergency department, with a median delay of 4.8 minutes,
although
some
patients without much
distress
apparently
waited for 2 hours in the emergency unit (Table 35 and 38).
Fi,fty-two
percent
of
the
patients
were
transferred to the general medical wards within another 20
minutes but with one-quarter of the patients, transference
was delayed for more than 30 minutes, and with
as long as three hours (Table 36 and 38).
a
few for
This was often
caused by the patients' indecision regarding admission and
time was wasted on lay-consultation with their relatives.
Delay in General Wards
6.3.3
Fifty-two
percent
were
patients
the
of
transferred to CCU within three hours but others intended
CCU admission had
for
wait
to
for
as
long
before they were transferred into CCtJ (Table 37
median
The
intrahospital
delay
in
respect
hours
48
as
and 38).
the
of
166
patients who were intended for CCU care was 2.9 hours.
Those
who
died
hospital
in
shorter
had
transference delay but there was no significant difference
in
the delay time in any other stages between those who
survived and those who died in hospital (Table 37).
DISCUSSION
6.4
The
advantage
after
hospitalisation
early
of
onset of symptoms has been well accepted and emphasised by
many workers, but information from most hospital series
have
failed
demonstrate
322-323326
any
-
This
not
is
correlation
significant
mortality
hospital
between
time.
to
and
deLay
the
unexpected
since
the
effect of delayed treatment of acute myocardial infarction
could
only
be
reflected
by
the
change
in
community
mortality of iscbaemic heart disease, which could only be
assessed accurately by a controlled prospective community
survey2'325.
Since
most
of
the
deaths
related
to
AMI
- 91
occurred in
the
first
few hours after onset
symptom,
of
those patients admitted early in their deveLopment of AMI
would be a high risk group vulnerable to
of
cardiac
dysrhythmias
and
ibriL1ation,,
the development
ventricular
including
death2 196-197 314-319
sudden
Although early treatment of such patients would save inny
lives who would otherwise die outside hospital,
prognosis
overall
such
in
hospital
patients
high-risk
mortality
figure
patients with short delay time.
benefit
of
myocardium
reversible
may
therefore
and
affect
patients
which
limit
both
the
up
of
series
those
for
the
measures
such
push
On the other hand, their
delayed admission may deprive
the
may
the poor
the
may
salvage
infarct
short
the
concerned of
same
and
size,
long-term
and
prognosis.
Twenty percent of our patients failed to
severe precordial pain
elderly patients without
a
The majority of them
detailed account of their illness.
were
give
to
mark exactly the onset of their infarction38474.
delayed
This
Those
patients
for
shorter
a
who
died
time by
in
hospital
had
been
the hospital procedures.
can be easily accounted for as
they presumably were
in greater distress at the time they first appeared in the
emergency department
and therefore were
sent
up
to
the
- 92 -
wards earlier.
There is nc significant difference in the
delay time in any other stages between the deaths and the
and
survivors
.
findings.
this
322-323,326
agreement
in
is
We
have
with
excluded
other
the
patients
those
(18.1% of total A11l admissions) who died within 6 hours of
They
admission.
were
usually
their admission histories were
patients'
usually
relatives
avail.
no
to
often incomplete by
instability.
their
on
death
deaths
early
and
that
earlier,
Outcome
the
but
were
it
was
usually
or serious electrical
infarct size
discussed
As
elements
two
after
These
associated with large
these
distress
Attempts have been made to obtain information from
time.
the
greater
in
differently by the delay time factor.
influence
the
would
of
affected
be
It is believed that
the exclusion of these early deaths would not create any
major distortion to the true picture.
we
Initially
prehospital
after
phase
stages20'21'27.
However
patients
up
turned
at
pLanned
onset
we
the
of
found
symptoms
that
emergency
down
break
to
into
the
severaL
the majority of
department
of
the
hospital directly for treatment and only a minority gave
the
history
before going
of
to
having
consulted
the hospital.
their
family
Presumably this
doctors
could be
attributed to the proximity of the hospital which serves a
- 93 -
small but densely populated region ±!L Hong Kong.
ít
moi-e
practical
therefore
use
to
We found
tte arrival
time
at
hospital as ¿ yardstick to measure the time being delayed
th
the prehospital Phase.
hours
comparable
is
i(ingdom.
to
Otr median arrival time of 2.8
that
reported
in
the
United
Scandinavian countries3 United State of America,
Australia and New Zealand, but shorter than that reported
in Beijing and Singapore (Table 39).
from
ideal
20%
as
of
patients
bad
considerably
delayed unnecessarily.
centres
has
revealed
seeking
help
at
the
that
onset
However this is
arrival
their
Experience
in
far
time
other
the
patients'
hesitation
of
symptoms,
the
in
patients'
denial after AMI, the lay consultation and the indecision
of
family doctors
important
all
delay.
on recommending hospital treatment are
factors
leading
320,322,324-325,329,332
prebospital
to
approach
direct
The
to
the emergency department by our patients turned Out to be
a simple but useful way to shorten the prehospital phase
of AMI in Eong Kong.
In
many
countries
several
other
measures
have
been tried successfully to shorten the delay in securing
medical
care
establishment
paramedical
for
patients
of Mobile Coronary
flying
squads1
AMI,
with
Care
telephone
including
Units
the
(M.C.C.U.),
information centres
launching
the
arid
prograitlines
the
336-344
of
down-town
nature
geographical
MCCU may
The
.
urban
large-scale
areas
of
not
Hong
of
city
the
education
pub1i
applicable
be
Kong
and
because
cf
the
congestion
the
traffic, but couLd be useful in the New Territories.
in
of
It
has been tried out in Singapore (which is similar to Eong
Kong
many
in
cost-effective
respects)
345
but
not
launching
The
.
was
found
any
of
to
large-scale
public education programmes must be balanced against
possibility
of
arousing
who might
public
service
of
subsequently
the hospital.
anxiety
unnecessary
the
of
the
the
emergency
care
developing country
like
abuse
In
be
the
Hong Kong or China where many areas of the public national
such large-scale
services are still awaiting improvement,
health education programmes may not be cost-effective and
However a lot
therefore do not deserve a first priority.
of work
could
including
all
vuLnerable
diabetes
be
general
and
by
the
those
hypertension
their
primary
practitioners,
(e.g.
patients
mellitus,,
factors)
done
close
and
aid
treatment
hospital treatment.
and
the
stable
with
other
relatives
workers,
briefing
in
presentation of acute coronary syndrome,
first
health
on
their
angina,
coronary risk
the
clinical
its recognition,
indication
for
seeking
It would be useful to issue a booklet
- 95 -
containing
such
information
would be most helpful
these
to
if the Elong
patieuts
and
it
Kong Heart foundation
would be willing to take up this responsibility.
The patients
ccTJ
directly
delay
caused
ranged
from
median
delay
in most other centres were sent
front the emergency departments.
dealing
by
minutes
with
13
time
to
of
24
minutes
75
*inutes
The median
procedures
hospital
the
(Table
would
to
be
Our
39).
relatively
satisfactory, even though a small group bad been delayed
for
more
than
hours
four
seeking hospital
care
or
due
to
the
to
indecision
their
failure
making
in
on
the
correct diagnosis.
Our longest delay otcurred in the general wards.
For
some
of
their
them,
electrocardiograms
(ECG)
were
monitored and some basic therapeutic measures were started
during their stay
in
the wards.
But
in
the majority of
cases there was delay before the patients were attended to
by
the
medical
staff
and
delay
in
making
the
correct
diagnoses and therefore delay in applying ECG monitoring
and
therapeutic measures.
shorten this
delay time
Every effort must be made
Ideally patients
to
suspected of
suffering from acute coronary syndrome should be admitted
directly into
the CCU from the emergency department but
this will entail the creation of more coronary beds and
staffing
the
of
the
emergency
experienced personnel.
coronary
more
the
fasten
beds1
more
While waiting for the creation of
some
turnover
measures
CCU
cf
better utilize the beds.
of
by
departments
could
patients
adopted
to
therefore
to
be
and
These include adequate staffing
the CCU by experienced and interested physicians, the
use of isoenzyme CPK-MB and radio-isotope imaging of the
heart for more reliable screening, and the identification
certain subgroups
of
from
with
CCU346354.
the
low risk
junior medical staff in
early discharge
immediate
an
As
for
the
measure,,
the emergency department
and
in
the general wards should be more alert and better prepared
for diagnosing and treating this potentially fatal disease.
SUI(MARY
6.5
In a survey to improve AMI survival., it was found
that
median
the
admission into
hours,
time
from
Onset
of
symptoms
to
a coronary care unit in Hong Kong was six
median
a
delay
delay
of
2.8
hours
in
the
prebospital
phase mostly due to the patientsT hesitation to seek help,
24
minutes
in handling
the hospital procedures
hours in the general wards.
shorten
the
delay
in
and
2.9
Recommendations were made to
securing
coronary
care
and
these
would include public health
by
primary
health
coronary disease
to
education and office teaching
workers,
the
issuing
of
booklets
on
soue vuLnerable patients, appointing
more experienced medical staff in the emergency department
of
the
staff
general
in
the
hospitals,
general
better
wards
and
preparation
the
coronary beds in the community hospitals.
creation
junior
of
of
more
Table 34
Time
(Hours)
TINE DELAY IN PREHOSPLTA1 PHASE
OF AMI AFTER ONSET OF SThPTOM
Percentage of Patients
Cumulative Z
Alive(186) Deatb(43) Overall(229)
o -
1
30.1
20.9
28.4
28.4
2 -
3
29.0
37.2
30.6
59.0
4 -
5
12.9
9.3
12.2
71.2
6 - li
8.6
11.6
9.2
80.4
12 - 17
2.7
4.7
3.1
83.5
18 - 23
4.3
2.3
3.9
87.4
12.7
100.0
>
24
12.4
14.0
Tab Le 35
Tine
(Nm.)
<
TINE DELAY Th EMERGENCY DEPARTMENT OF HOSPITAL
Percentage of Patients
Survivors
Deaths
Overall
171
45
216
72,5
73.3
72.7
11 - 20
12.9(85.4)
11.1(84.4)
12.5(85.2)
21 - 30
7.6(93.0)
11.1(95.5)
8.3(93.5)
31 - 40
1.2(94.2)
2.2(97.7)
1.4(94.9)
41 - 50
1.8(96.0)
0
1.4(96.3)
51 - 60
1.8(97.8)
2.2(100)
1.9(98.2)
2.3(100)
0
1.9(100)
)
(
lO
60
) Cumulative percentage
(97.7)
Table 36
TIME DELAY IN ADMISSION PR.00EDURE
MID TRANSFERRENCE TO WARD
Percentage of Patients
Time
Survivors
Deaths
Overall
(Min.)
182
46
228
17.0
17.4
17.1
il - 20
34.6(51.6)
34.8(52.2)
34.6(51.7)
21-30
20.3(71.9)
37.0(89.2)
23.7(75.4)
31 - 40
13.7(85.6)
6.5(95.7)
12.3(87.7)
41 - 50
6.6(92.2)
2.2(97.9)
5.7(93.4)
51 - 60
2.2(94.4)
2.2(100)
2.2(95.6)
5.5(100)
0
4.4(100)
<lo
>60
(
) Cumulative percents
Table 37 TD DELAY IN ROSIAL PROCEDJRE - FROM GENERAL
WARD TO CORONARY CARE 1NIT BED
Percentage of Pat:ients
Time
(Hours)
Alive(136)
Death(30)
Cumulative %
OveralL(166)
O -
1
22.1
33.3
24.1
2 -
3
28.7
26.7
283
52.4
4 -
6
11.0
13.3
11.4
63.8
7 -
9
10.3
8.4
72.2
10 - 12
5.1
10.0
6.0
78.2
13 - 24
16.2
10.0
15.1
93.3
) 24
6.7
6.7
6.6
100.0
0
Table 38
TIME DELAY IN ADMISSION TO A CORONARY CARE UNIT
Hospital
Arrival
Time
Information
Available
Time Delay
Survivors
Deaths
Uni t
229/271
(84.5)
216/271
(79.7%)
228/271
(84.1%)
166/182
(91.2%)
* 0.2-72 lIra
**2.8 lIra
+ 10.3±17.9 llrs
0-120 Mina
4.7 Mina
11.6±17.3 Mina
3-180 Mina
19.2 Mina
27.8±23.8 Mina
0-48 Hrs
3 Urs.
* 0.3-48 Urs
**2.7 Urs
O-40 Mina
4.9 Mina
9.9+11.7 Mina
5-55 Mina
19 Mina
21.7+11.1 Mina
0-46 Urs
2.5 Hra
0-120 Mina
4.8 Mina
11.3+16.3 Mina
3-180 Mina
19.2 Mins
26.5±22.0 Mins
O-48 Hrs
2.9 Urs
8.2+11.7 Hrs
* 0.2-7.2 Hrs
**2.8 firs
+ 10.5±18.1 Urs
P Value ++
c.c.Us
Transfer to
Ward
+ 11.6+18.6 firs
Overall
Hospital Procedure
> 0.5
Emergency
0.5
** Median
+ Mean + S.D..
* Range
++ Comparing tl-ie mean figuresof the deaths and the survivors
Z. 0.05
8.4+11.8 lIra
7.2+11.1 lIra
> 0.5
Table 39
COMPARATIVE REVIEW OF PRE-CORONAHY CARE DELAY TIME
Hospital
Prehospital Phases(Hours)
Procedures(Mius)
To tal
Authors
Consult-
Decision
Period
Travel
Period
ation
Period
Adgey 1968
Moss 1970
Gambier 1970
Haghfelt 1971
Smyllie 1972
Armstrong 1972
Goldstein 1972
Simon 1972
Norris 1973
Hospital
Arrival
Emergency
Room
Transfer
Time
GW*/
Delay
CCU** (Hours)
Time
2
1.2
1.6
1.8
1.7
0.5
0.7
3.5
4.0
-
29**
45
13**
29**
3.5
4.1
2-10
2.2
1.5
0.3
0.2
1.5
0.5
1.2
1.1
2.3
0.5
09
0.3
0.3
2
3.2
3.6
2.5
2.8
3.8
60*
3.8
4.0
6.0
1O**
Henning 1975
Oh 1975
Kitchin 1977
4
4-
Konu 1977
1
Dellipiani 1977
Schroeder 1978
Fraser 1978
Rawlins 1981
0.6
1.5
1
1.5
0.2
2.5
1
4
Woo 1983
2.8
*
**
Median delay time in minutes or in hours
Delay in General Ward
Up to Coronary Care Unit
_60**
2.5
Tao 1982
+
3.0
4.8
75**
3.5
3.0
4.8
19.2
174*
6.1
- 98 -
CHAPTER 7
THOLOG'Z O' FMAL ACUTZ WDCARD1AL iNFARCTION
IN TEE CHINESE
INTRODUCTION
7.1
Acute
yocardial
infarction
is
potentially
a
fatal manifestation of coronary artery disease.
of
commoneSt
the
countries.
causes
10-11,83,330
As
death
of
was
in
.
reviewed
in
It is one
the
Western
the
previous
chapter, deaths from acute myocardial infarction have been.
found to beinreasing among the Chinese in Hong Kong and
From the
mainland China.
community point of view,
over
the deaths from acute myocardial infarction occur
50% of
in the first one to two hours after the Onset of symptoms,
often
before
hospitals.2
the
The
from
duration
admissions
gain
could
patients
onset
of
symptoms
into
to
death is so short that many problems have been encountered
in identifying the disease and establishing the diagnosis,
as
the
pathological
changes
could
minimal.355
be
While more useful and accurate methods of
are yet
to be designed,
there is
identification
a voluminous amount of
the literature describing the pathological findings of the
fatal
cases
in
the
hospitals
countries.71_721251_252J357364
Most
of
of
the
Western
patients
in
- 99 such
fatal Cases survived for a certain period,
pump
by
complicated
failure,
dysrhythnias
cardiac
focussed
the extent
on
incidence
before
coronary
of
conduction
disorders
Attention
death.
arid were
been
has
coronary atherosclerosis,
of
thrombosis
their
and
role
or
the
the
in
pathogetLesis of acute myocardiaL infarction, the incidence
of cardiac ruptures and their various patterns of cLinical
presentations.
available
such
Hcwever,
details
in
pathological
information
such
from the
reports
yet
most
could
Chinese
the
not
The scarcity of
Chinese.
from
is
probably be related to the traditional reluctance of the
to
give
examinations.
While
Chinese
authorization
post-mortem
for
of conducting post-morteui
the rates
examinations for many fatal disea5es were over 50% in many
Western countries, and those in the Scandinavian countries
could be as high
have
a
as
80%,
rate higher than 20%
Nevertheless,
this
understanding
of
in
the
information
is
new
infarction)
measures
including
to
is
deal
Chinese communities.
important
and
pathogenesis
complic&tions, and in fact
many
it would be rather unusual to
with
thrombolytic
possible
the
crucial to
the
for
the planning of
myocardial
acute
therapy,
which
could
significantly affect its prognosis and natural history.
We have encountered a relatively large
number of
- loo from
deaths
'cohort'
a
the previous
of
chapters,
infarct patients described
and have been able
highest post-mortem rate reported by any
The
todate.
which
we
present
hope
will
review will
be
useful
attain the
to
Chinese
report
our
series
findings,
presenting
in
in
a
true
pathological picture of myocardial infarct in the Chinese.
MATERIALS AND METHODS
7.2
We reviewed 666 consecutive patients with
myocardial
medical
infarction
unite
Hospital
in
admitted
(Medical
Hong
Unit)
B
Kong
into
between
of
of
arre
Queen
the
and
1971.
the
acute
three
ELizabeth
1981.
Their
particulars have been described in detail in the previous
Out of these,
chapters.
in hospital
failure
(Figure
(29.2%),
cardiac death
requested
to
Failing this,
3).
Causes
cardiogenic
(43.6%).
give
(29.3%) died within 28 days
195
of death
shock
included heart
(18.5%)
and
sudden
The families of the deceased were
consent
to
post-mortem
examinations.
an application for post-mortem examinations
as coroner cases was made when the causes or circumstances
of death were unexpected, or when death occurred within 24
hours after admission.
A total of 89 (45.4%) patients bad
post-mortem examinations carried out
period
of
16.6+8 hours
after
death.
on
them,
Their
at
a mean
bodies were
- 101 stared
temperature
at
examinations.
was
4°C
the
post-iortem
according
infarction
the
to
WHO
355-356
.
t L
before
Diagnosis of acute uyocardia1
pathologically
made
rC omtaeflda
of
fl :
1facroscopic changes in colour and rigidity of
(i)
cardiac tissue.
(ii)
Nitro-blue tetraclin staining, and
(iii)
Histological changes with routine haematoxylin
and eosin staining.
The heart specimens were routinely sectioned into
five small horizontal slices of approximately one cm
cm short of the mitral
valves, and the sites of infarcts were identified. Apart
thickness from apex to base,
from
consistency,
myocardium,
the
pallor
following
one
and
aedema
findings
of
the
looked
for
changes
were
routinely - fibrosis, pericarditis, epicardial fibrosis,
subepicardial. haemorrhage, aneurysm of ventricles and
Nitro-blue
rupture, as well as haemopericardium.
tetrazolin stain was applied routinely to one side of the
slice and a histological sampling section was taken and
stained with haematoxylin and eosin. The integrity and
patencies of the coronary arteries were inspected both in
the myocardial slices and in the remaining basal portion.
The proximal coronary arteries were probed and the patency
- 102 -
of the aortic ostia and coronary arteries were assessed.
Additional serial sectioning of the Coronary artery at 3-5
patients. Each section was inspected
and the degree of luminal narrowing was determined by the
percentage of external diameter. The coronary arteries in
each slice were opened up longitudinally and inspected for
the presence of fresh coronary thrombosis.
m was made on
75
A patient was diagnosed as having cardiac rupture
if there was a tear through the entire free wall or
interventricular septum, and if blood had been found in
the pericardial space upon gross inspection of the heart
('igure 10). In the absence of these, patients who died
suddenly were classified as having died of primary
arrhythuiias, whereas those without any pathological and
electrocardiographic documentation vere classified as
sudden cardiac deaths.
7.3
RESULTS
The
clinical characteristics of the
89
with post-mortem examinations were identical to
deaths
the
106
deaths without post-mortem findings except that in the
group without any post-mortem examinations, there were
more patients with preexisting hypertension, who also
survived for
a
slightly longer time before death (Table
-
Gross
40).
localized
incLuded
pallor
macroscopic
appearance
softening
respectively.
(68.5%)
suddenly3
rupture
patients
changes
patients
33
or
other
tie
(38.8%)
obvious
in
(Figura
0±
of
19
11)
had
in
died
who
cardiac
complication.
Ten
(ll..8Z) had cardiac rupture in the free wall and
cardiac tamponade.
In
the remaining 42 patients on whom
the causes of
post-morteut examinations was performed,
no
(2i.3Z)
patients
61
definite
no
structural
(49.4)
patients
patients
85
inarcts
the
patients
44
in
or yellowish disco1oratjot
haemorrhagic
and
1.03 -
sudden death remained uncertain.
Of the 89 post-mortem cases., acute infarcts were
identified in 83 patients
(94.3%),
and old infarct scars
Of the
were present in nine patients (l0.2Z)(Table 41).
13
cardiac ruptures, ten occurred in
inferoposterior
patient with
and
six
inferior
muscle)
and
rupture
in
patients
(14.6%)
two
their
had
anterolateral
infarct
patients
the
with
had
anteroseptal
of
(four
infarcts),
rupture
interventricular
evidence
free wall
of
one
papillary
infarcts had
septum.
Thirteen
extensive pre-existing
myopathic changes - 12 patients (13.6%) had diffuse patchy
fibrosis
another
and
one
there
patient.
was
left
Evidence
ventricular
of
aneurysm
significant
in
coronary
atherosclerosis was identified in 94.7% of patients (Table
42).
- 104 -
Coronary
(18.7%).
(l-v),
thrombosis
was
present
in
patients
14
Fourteen patients (18.7%) had one-vessel disease
33.3%
had
two-vessel
three-vessel disease
disease
with critical lesions
(3-V),
42.7%
and
(2-v)
in
tbe
left main stems (LMS) in 8%, in the proximal parts of left
anterior
descending arteries
arteries
(circum)
in
(LAD)
circumflex
45.3%,
in
and of right coronary arteries
8%,
(RCA) in 17.3% respectively (Table 42).
7.4
_ISCt1SSI0N
discussed
As
clinical
pattern of
Chinese
conforms
countries
the
to
infarction
in
clinical
their
to
chapter,
picture
classic
short-term
and
previous
the
acute myocardial
respect
with
complications
in
prognosis.
in
the
the
Western
features,
In
general,
Chinese patients with acute myocardial infarction are ten
years older than their Western counterparts and this could
account for the higher hospital mortality
series,
Shanghai.
as
well
188,369
as
the
in
There
.
is
reports
no
.
in.
from
the present
Beijing
.
significant difference
and
in
their clinical profiles between the groups with or vithout
post-mortem examinations
in
the
present
series,
and the
pathological pictures outlined therefore could be taken as
truly representative of fatal acute myocardial. infarction
- 105 -
in the Chinese.
With
the
development of coronary
units
care
in
the 1960s, patients vith acute myocardial infarction were
monitored
sudden
closely
arrhythmias
treated.
307-309
favourable
in
detected
be
cari
concept
This
where
environment,
has
any
promptly
and
been adopted more
or
less all over the world, associated with a decrease in the
number of deaths due to primary arrhythmias in the acute
and a higher proportion of deaths related to pump
stage,
mechanical
or
rupture
failure
estimated
is
to
and
cardiac
occur
in
2%
Cardiac
rupture.
to
8%
of
patients
after myocardial infarction1 and as the cause of deaths in
4%
to
With
13% of fatal cases of acute myocardial infarction.
successful
the
prevention
and
control
of
cardiac
arrhythmias, and with improvement in the treatment of pump
failure,
the significance of cardiac rupture
complication
may
become
incidence of cardiac rupture
different series.
obvious.368
more
in
as
The
a
fatal
exact
fatal cases varies with
Presumably it is quite dependent on the
post-mortem selection and post-mortem rate.
Our incidence
(14.6%) agrees well with the average figure1 but is much
lower
than
those reported
autopsy series
of 40
in
China.
188,369
fatal acute myocardial.
Two smaller
infarcts
in
Beijing and Shanghai respectively reported 22.5% incidence
- 3.06 -
of cardiac
and two other collaborative series in
these two cities reported 35.1% and 10.7% respectively of
fatal cases baying cardiac rupture on both autopsy and
cLiniCal grounds. The great difference could be due to
selection bias against post-mortem examinations in China,
in that the autopsy series mostly included all those who
died unexpectedly. Rupture in the free wall of the heart
usually causes death as a result of cardiac tamponade.
ruptures
gowever
course.,
in
some
rare
case5
it
may
follow
a
subacute
with an episode of bleeding into the pericardial
infarction,
accompanied by chest pain, and dominant features of severe
right sided heart failure.370 On even rarer occasions,
patients could survive the acute or subacute cardiac
ruptures because the bleeding had been confined by the
development of dense adhesions between the pericardial
layers, with the formation of a false ventricular
aneurysm.371372 This bas not been encountered so far
in our series, but a high level of alertness for this
potentially salvageable complication is warranted.
Rupture of papillary muscle, which is predominantly
related to posteroinferior infarct, and rupture in the
interventriculer septum, usually present more subacutely
with features of cardiogenic shock and left ventricular
space
over
a
few
days
following
the
- 107 -
failure. 205,253,364-367
.
ruptures may account
for some patients having these two modes of death . In
Card.ac
fact, they were documented to be present in three patients
in the present series. A large group (16%) of patients in
the present series, who died suddenly but of uncertain
causes since no post-mortem examination was performed,, may
contain some more cases of cardiac rupture.
Our pathological criteria for diagnosing acute
myocardial infarction followed those recommended by WHO in
The conclusion by WHO's panel of experts that
197O.
no completely reliable staining method was available for
demonstrating early ischaemic injury to the myocardium is
still upheld, and so far the demonstration of an infarct
less than two hours old, seems likely remain a difficult
problem.356
identified
examination,
Anyhow,
in
and
94.3%
for
evidence
of
the
infarcts
of
p]atients
remainder
at
in
were
post-mortem
the group,
the
diagnosis was based on clinical criteria only. In the
present series, clinical information was available on the
majority of patients, except for a small proportion (5.1%)
who were dead on admision. Old infarcts and patchy left
ventricular fibrosis were found in 23.8%. These go along
with the clinical history showing previous infarction in
lO.lZ of patients and the prevalence (24.4%) of
- 108 -
hypertension or hypertensive heart disease in the present
series.
Coronary atherosclerosis
fatal
of
cases
and
the
coronary
identified
remaining
relatively normal arteries.
incidence o.E
were
This
52
95
cases
of
similar
is
in
had
the
to
7%
aal infarction having normal arteries or no
atherosclerosis
reported
by
Eliot.373
This
lends support to the hypothesis that coronary spasm could
cause
significant
myocardial
ischaemia
have
spasms
coronary
been
obstruction
vivo.
in
documented
fatal
and
coronary
Such
be
mechanism
in
In patients having died of cardiogenic shock
or
to
the
unstable angina and Prinzmetal angina.
congestive
one-vessel
heart
failure,
involvement
Wackers
in 20%,
et
found
have
al
two-vessel involvement
in
32-45% and three-vessel involvement in 35-68% respectively
at
post-mortem
examination.376
The
extent of coroary atherosclerosis
conform well
with
these
in
distribution
the
present
Brosius
findings.
and
reported critical involvement (>75% lesion) of
stems
in
anteries
right
20%
in 100%,
coronary
of
patients,,
of
of
left
arteries
in
94%
of
in
series
Roberts
left main
descending
anterior
circumflex arteries
and
84%
necropsy
and
of
patients
respectively, which appear to be more serious than those
- 109 -
our
in
proximal
lesions
fatal
cases.377
left
anterior
fatal
in
The
preponderance
descending
inyocardial
coronary
infarction
acute
of
arterial
been
also
bas
emphasised by other workers.378
incidence of coronary thrombosis
Our
than
lower
those
series.
reported
However
interpreting
caution
finding.
this
thrombosis
been
controversial
the
stenosis,
as
(13-95%),
be
many
for
is
post-mortem
when
taken
between
relationship
infarction
has
Earlier
years.
a varying incidence of coronary
depending on
severity
infarcts,
should
The
issue
post-mortem reports gave
thrombosis
other
and acute myocardial
coronary
a
most
in
(18.72)
and
age and
the
length
extent of
coronary
of
artery
and the presence of certain complications such
cardiogenic shock,
as well
the care and energy
on
as
expended in the search, and the interest and experience of
the
prosector.
73-75,379
association
close
The
coronary thrombosis with acute myocardial
led
earlier
workers
to
believe
that
infarction has
acute
infarction is caused by coronary thrombosis.
classical
concept
patbogenesis
of
number of investigators
numerous
pathological
Barolde have
suggested
was
in the 1970s.
studies,
that
workers
coronary
of
myocardial
However this
by
challenged
a
Basing mainly on
like
Roberts
thrombosis
is
and
the
- 110 -
consequence
rather
than
72,359-363
infarct.
the
cause
of
experience
in
including that of ours, during
the
However
coronary angiography,
precipitating
more
recent
early stage of acute myocardial infarction, has reiterated
the classical concept, in that a much higher incidence (>
90%)
coronary
of
thrombosis
relationship was identified.
longer
durations
constant
after
complications. 27,77,380
therapy
infarct
size
cardiac
complications
support
to
and
symptom,
occurrence
the
recent
at
spatial
but
the
years
acute
relation
of
no
results
of
limiting
the
mortality
and
in
short-term
bore
of mechanical
encouraging
decreasing
casual
the
of
Th
in
appropriate
The incidence decreased with
onset
relationship with
thrombolytic
with
stage,
lend
thrombosis
further
with
the
pathogenesis of acute myocardial infarction.
SUNMARY
7.5
Post-mortem
Chinese
with
represented
comprising
fatal
a
195
examinations
acute
were
myocardiat
nonselective
45.4%
consecutive
hospital
myocardial infarction in Hong Kong.
the
acute
infarcts
were
performed
correctly
of
on
infarction,
a
deaths
fatal
89
who
series
from
acute
In 83 patients (94%),
identified,
and
old
Infarct scars or patchy fibrosis were found in 21 patients
- ill (2062). Of the 85 sudden deaths 33 patients (38.82) had
no definite mechanical complication and therefore could
have died of primary arrhythmjas, and ten patients (11.8%)
rupture in the free ventricular wall with cardiac
tamponade.
Two
other patients had rupture of the
had
interventricular septum and one more patient had rupture
of papillary muscle.
Evidence of significant coronary
atherosclerosis was identified in 94.2% of patients, with
one-vessel disease in 18.7%, two-vessel disease in 33.3%
and
three-vessel
disease
in
of
42.7%
patients
respectively. Critical Lesions were present in the left
main stem in 8%, in the left anterior descending artery in
45.3%, in the circumflex artery in 82 and in the right
coronary artery in 17.3% respectively. Occlusive coronary
thrombi were identified in 18.7% of patients.
These
pathological findings were compared with reports on fatal
tnyocardial infarntions from the Western countries.
Table 40
Clinical Features cf Fatal Nyocardial Infarction
Features
Pos t-morteTa Done
(89 patients)
No Post-mortem
(106 patients)
P-Value
Mean Age + SD
64.3+13.0
69.6+10.3
NS
MaLe
Female
56 (62.9)
33 (37)
55 (51.9)
51 (48.1)
NS
Infarct Age, Mean+SD
Median
2.9+4.9 days
0.9 days
5.1+6.5 days
(21)
9 (10.1)
10 (11)
46 (43.4)
15 (14.2)
Infarct: Nbn Q
Anterior Q
Posterior Q
(5.6)
56 (63)
28 (31.5)
12 (11.3)
60 (56.6)
34 (32.1)
NS
NS
NS
Shack
Heart Failure
Dysrhythmia
32 (35.9)
61 (68.5)
52 (58.4)
22 (20.7)
81 (76.4)
56 (52.8)
NS
NS
NS
Urea> 60 mmol/L
20 (22.5)
2 (3.0)
10 (11.2)
28 (46.7)*
22 (20.7)
2 (1.9)
17 (16.0)
35 (43.7)+
NS
NS
NS
NS
Mode of death
Shock
Heart Failure
Sudden death
Others
16 (17.9)
20 (22.5)
43 (48.3)
10 (12.4)
20 (16.0)
37 (34.9)
42 (39.6)
7 (6.6)
NS
NS
NS
NS
History of:
Hypertension
DM
Old Infarct
Conduction Defects
RBBB
LBBB
ORB
19
5
* Out of 60 patients
+ Out of 86 patientS
DM: Diabetes Mellitus
ORB: Complete heart block
): Figure in percentage
(
< 0.05
2. days
5
(4.7)
<0.01
NS
NS
Table 41
Post-morten Findings in AMI (1971-80)
Total Deaths
195
Post-Mortem Done
89
(1.5.6%)
Infarct Identified
83
(93.3%)
Cardiac Rupture
13
(14.6%)
Coronary Atherosclerosis
71* (94.7%)
Coronary Thrombosis
j4* (18.7%)
Old Infarct
Patchy ïibrosis
9
(10.1%)
12
(13.5%)
LV Aneurysm
i
(1.1%)
Intramural Throinbi
4
(4.5%)
* Out of 75 patients
Table 42
Coronary Pathology In Acute Myocardial Infarction (75 Patients)
Normal or <. 50% lesion
4
Atherosclerosis > 50% Lesion
71
(5.3%)
(94.7%)
Critical Lesione
l-V
14
(18.7%)
us
5
2-V
25
(33.3%)
LAD
34
3-V
32
(42.7%)
CtRCUM
RCA
* Critical
)75% reduction in lunilnal area
6
13
(8%)
(45.3%)
(8%)
(17.3%)
Figure 10
myocardial
Acute
cardiac
rupture,
complicated
by
infarct
tear
in
free
left
the
ventricular wall is demonstrated.
Figure 11
:
appearance of acute myocardial
infarct, with localised softening, yellowish
discoloration and haemorrhagic changes.
Macroscopic
- 112 CHAPTER 8
A CORONARY PROGNOSTIC INDEX FOR THE CHINESE
INTRODUCTION
8.1
As was discussed in the previous chapters, acute
myocardial infarction (AÌ.I)
coronary artery disease
correct prognosis is
clinical
its
difficult
number
a dangerous presentatiot of
Obviously,
Chinese.
the
in
severity
often
prognostic
makes
literature
the
In
indices
AMI
for
pioneered by Peel
*
.
developed
Helmers
Kimball
and
Killips
Norris
by
385
23
1960s
386
They
can
al.383
et
and
Chapman
al.,1°
et
HennLng.
and
the
in
are
a
be
The first group
Hughes
al.,382
et
there
these
and
in
prediction
such
classified into three large categories.
was
its
importai.t, but the wide variatiot
make.83'381
to
of
is
and
further
was
Gray,384
and
relied
on
the
analysis of bedside clinical features, described in either
subjective
or
objective
terms,
including:
age,
shock,
congestive heart failure, cotduction or rhythm disorders,
oliuria,
respiratory
concentration
and
level
cardiac
rate,
of
consciousness.
importance of these parameters was
more
scientifically
by
The
(SGOT)
relative
estimated empirically
and expressed in arbitrary weightings at
assessed
enzyme
first,
discriminant
and then
analyses.
- 113 The results were expressed in the form of clinical subsets
or index scores relating to different rates of mortality,
actual prediction of deaths. Most of these
indices are imprecise, empirical and open to criticism.
The second group emerged in the next decade and
was used mainly in coronary care units.
Based on the
analysis of heemodynamic data, Bleifeld, Verdouw,
or of the
Forrester, Weber, Henning, Rotinensch and Meyer, among
others, constructed similar clinical subsets and index
scores relating to mortaiity.38 396
The third group of indices focussed more on the
direct assessment of infarct size397 and other
factors
using
cardiac
enzyme
CCPK)
release, 398-400
and
echocardiographic 401-402
radionuclide studies. 403-407
it related these to
myocardial
*
mortality either absolutely or quantitatively.
The two latter groups of prognostic indices are
more objective and scientific, but they also require more
sophisticated equipment and technical expertise aud
therefore may not be widely applicable in developing areas
lice mainland China and Hong Kong where resources are
limited -
therefore, addressed this important
issue and constructed a more practical and economic system
for assessing the prognosis of AMI in the Chinese, who
We
have,
114 -
account for one quarter of the world's population.
MATERtALS AND METHODS
8.2
reviewed
We
admitted into on
of
666
Consecutive
the
three medIcal
patients
zriits
with
AMI
MedicaZ
B
Unit) of the Queen Elizabeth Hospital in Hong Tong between
1971
and
1981.
Their demographic details and management
in hospital have been described in the previous chapter.
these,
Of
had
644
complete
records
clinical
of
informations available for analysis.
Four hundred and seventy patients were admitted
into
general
Coronary Care Unit
hospital fox
of
174
(ccU).
patients
(27.0%)
the
into
Patients were usually kept
three to four weeks.
in
The hospital deaths out
644 patients within four weeks were analysed and
the
seven
and
wards
clinical parameters
in
the
initial
three days
of
admission in association vith mortality were delineated by
an univariate ana1ysis
The Chi-square test with Yates'
correction was used to assess the statistical significance
of the respective mortality rates.
In
(x1Y1
X6Y5
+
+
numerical
the
X2Y2
X7f7)
construction
+
X3Y3
for
the
weightings
(X1,
33
prognostic
of
a
+
X4,4
mortality
X2,
X3,
+
in
X4,
ZY
index
+
hospital,
X5,
X6
- 115 x7)
and
were
given
with mortality.
allocated,
adverse
to
the
seven
parameters
associated
Numerical values ranging from O to i were
depending
factors
the
on
and
the
absence
presence
or
proportional
influence
of
the
of
the
different subsets of these parameters on mortality.
These
weightings
seven
were
then
substituted
these
for
parameters in each patient and the relative importance of
y7)
(1,
parameter
each
was
assessed
analysis.
y5,
and
Y6
of
each
X4,
(XY)
of
X5,
each
patient was
products.
found
the
as
Y1,
in
proportion
or
numerical
K7),
parameter,
The
gave
Y2,
These
weightings
the
prognostic
Y5
or
a discriminant
prognostic parameter.
by
X6
Y5,
Y4,
644 patients by
designated
5 were
multiplied
X3
the
Numbers
importance
when
in
Y3,
Y21
final
index
Y3,
Y4,
to
the
values,
(Xi,
X2,
weightings
for
each
constructed by the summation of these seven
The Y values and the prognostic indices for all
patients were worked Out by an IBM 3031 computer at the
Chinese University of hong Kong, using the SF55 computer
programme described by Kim and Kohout. 408-409
8.3
RESULTS
8.3.1
Factors Chosen and Survivals
Sixty-five
patients
(10.1%)
had
previous
-
-
1.16
infarction and 270 patients (4%) had previous history cf
angina
pectoris.
(23.8%)
had
One
hundred
non-Q-vave
and
infarcts,
fifty-three
290
(45.0%)
patients
anterior
Q-wave infarets and 201 (31.2%) posterior Q-wave infarcts.
The
clinical
features
of
these
included liypotensioti
(15X),
cardiomegaly
congestion or
(38%),
cardiac
the
forms
edema
of
supraventricular
flutter,
hours),
tachycardia,
ventricular
early
ventricular
fibrillation,
pericarditis
(40%)
in
(rate> 100/min.),
atrial.
ectopics
tachycardie
(40%), pulmonary
arrhythmias
tachycardie
sini.is
patients
644
fibrillation
(within
or
first
72
or
primary
ventricular
(3.3%),
elevated
serum urea
(>10 mmol/L)(27%) and conduction disorders in the form of
RBBB
(12%),
LBBB.
(3%)
and atrioventricular block
(11%).
One hundred and seventy-one patients (26.6%) died, mostly
of heart failure (332), cardiogenic shock (28.3%), primary
arrhythmias
(27%)
or
sudden
death
of the
of
uncei-tain
cause
patients (15.2%) in
the CCU died compared with 145 patients (30.9%) in the
general wards. 0f the 210 patients in the period 1971-76,
119 patients
52 patients (24.8%) died compared with
(16.5%).
(27.42)
Twenty-six
in
the
Out
period
1977-81.
174
Advanced
age
( ) 70
years), hypotension (systolic BP<90 mmHg), cardiotnegaly
(cardiothoracic ratio> 55%), pulmonary congestion or
- 117edema, elevated serum urea level ( > 1.0 mmol/L), cardiac
arrhythmias and anterior Q-wave infarction (particularly
in association with RBBB), were ominous factors and
mortality was significantly higher when they were present
Ultimately seven factors were
(p ¿ 0.01) (Table 43).
chosen to express the prognostic index.
8.3.2
Factors Not Included in the Index
Factors which were analysed and found not to be
significantly related to mortality included: previous
of
history
angina
or
infarction,
pericarditis,
hypertension, atrioventricular block and peak levels of
SCOT (Table 44).
Formulation of the Prognostic Index
The numerical weightings (X and Y) of these seven
factors are shown in Table 45. According to the completed
B.3.3
index, these 644 patients could be divided into subgroups
with gradually increasing mortality ranging from 1.6% to
100% (Table 46, Figure 12).
8.4
DISCUSSION
As
was
reviewed and discussed in the previous
chapters, the clinical pattern of
AMI
in
the
Chinese
to the classic picture in Western countries with
respect to their clinical features, complications and
conforms
- 1L8 -
short-term prognosis.
AMI are
years older
ten
general,
In
in
our
their Western counterparts
than
and this couLd account for
Ciinese patients with
the higher hospital mortality
Like most Western
series.
reports,
a
trend
decreasing mortality has been witnessed in recent
of
years,
when most patients are treated in the CCU in the initial
few days.
All these studies,
including the present
one.,
unanimously emphasize the adverse effects of advanced age,
cardiogenic
heart
shock,
cardiac
failure,
arrhythmias,
bundle branch block, as well as the nature arid location of
infarcts
on
AMI.3011'14'7
9 21,99,170 173,189 190,192 193,254,327,
410-411.
mortality
the
.
.
Our index is similar to Norris
of
prognostic index
in the analytic approach and methods of construction, but
more
prognostic
cardiac
arrhythmias
tachycardia,
ectopics
or
fibrillation),
block.
factors
Most
striai
(sinus
and
serum
elevated
these
factors,
hypotension and heart failure,
of extensive infarcts,
urea
including
early
supraventricular
or
fibrillation or
tachycardis
of
considered
are
flutter, ventricular
primary
and
in
ventricular
bundle
branch
additional
to
are believed to be markers
the size of the infarct being the
main determinant of the prognosis during the acute stage.
-
1_1 9 -
Ventricular dysrhythmias occurring in the later clinical
course have been reported to correlate more with long-term
iaortality, but no significant adverse effects on their
short-term outcome could be identified in the present
study. The adverse effect of elevated serum urea observed
by us concurs with the ominous nature cf renal failure and
oliguria during AMI reported previously.4l2
All of these factors are
expressed in readily
available, precisely measureable and objective terms, thus
avoiding the bias found in the subjective parameters used
by many pioneers. Hypertension did not have a significant
adverse effect on the short-term prognosis, which concurs
with
the
of
flnd1ngs
Gibson. 411
Kibe
and
Chapman
reported a close correlation of peak SGOT with hospital
mortality.167'313 There was a tendency towards higher
mortality in patients with an SCOT level above 300 lU
compared
difference
with
was
those with
not
lower
peak
Levels,
statistically significant.
but
the
This
is
partly accounted for by the early death of certain serious
AMI patients before they could acquire a higher SCOT level.
All patients with high-grade atrioventricular
paced in the present series. The
mortality in A1 with or without atrioventricular block
and
therefore
significantly
differ
did
not
block
were temporarily
- 120 -
atrioveiitricular block was not included in the
construction of the prognostic index. The localisation of
infarct position by electrocardiographic criteria is not
Accordingly3
we
adopted a sitapla
very specific.'67
classification of its localisation into anterior infarct
atero1ateral and
anteroapical infarcts, as well as posterior infarct, which
embraced both inferior and strictly posterior infarets.
Similarly, no differentiation has been ind between
which
also
included
anteroseptal
infarctions and a more
practical classification, Q-wave or non-Q--wave infarction,
12,168-169
The non-Q-wave infarctions,
has been adopted.
like many reported previously, appeared to be more
thriving during the acute stage. ¿i.14-417
potentially important
the
simplicity,
Por
prognostic parameters were identified as single factor in
a preliminary examination by an univariate approach in the
present study, and were subsequently subjected to a
trausmural
or
non-trausmural
multivariate discriminative analysis.
In theory,
such a
rise to a slight
distortion of the assessment due to confounding effect.
This could be avoided if all the clinical parameters could
be included and assessed by a multivariate discriminative
analysis. Of course this will entail a more comprehensive
preliminary
processing
could
give
- 121 -
data-base
in
all
patients
more
arid
analytic
coniplex
package.
was
As
disc.issed
prognostic
factors
interacted
with
chapter
in
mentioned
each
other
earlier
the
of
coexisted
the
in
many
3,
and
patients.
same
Therefore., the actual importance of each individual factor
could
not
accurately
be
estimated
by
the
univariate
analysis methods used in many earlier reports, when single
prognostic factors were considered independently.
present
survey,,
multivariate discriminant analysis was
a
used
systematically
the
seven prognostic
complicated
prognostic
study the
to
under
relative importance
taking
factors,
relationships.
factor
In the
The
account
into
consideration,
these
important
more
the
of
the
higher
the
The calculation
numerial values will be designated to it.
of the index for each patient entails the consideration cf
these
seven
available
work,
but
simple
parameters
no
and
and
simple
requires
sophisticated
quantitative method to
objective,
bedside,
equipment.
It
readily
arithmetical
provides
assess clinical severity.
a
high
index would conceivably unmask the high-risk patients who
dserve
more
regimen,418419
and
attention
while
a
low
a
index
more
would
energetic
identify
a
low-risk group for earlier ainbulisation and discharge from
- 122 the
CCIJ
from
and
the hospital.420
would
This
lead
the better utilisation of limited national resources.
appeal
greatest
subgrouping
the
providing
an
randomization
of
index
this
clinical
severity
objective
and
of
AMI
guideline
coniparing
large
The
capability
its
is
and
of
therefore
assessing
for
numbers
to
patients
of
treated by different methods in different centres.83
The simple, practical and economic nature of this
index will also be very attractive
AMI patients
for the assessment of
in many other Asian-Pacific countries which
in many respects are similar to mainland China and Kong
Kong.
8.5
SUMMARY
A
coronary
prognostic
index
for
(CPI)
the
prediction of mortality of patients with acute myocardial
infarction (AMI) has been devised with the data obtained
from 644 Chinese patients in Hong Kong.
with
CPI,
patients
with
increasing
AMI
hospital
could be
According to this
divided
into
subgroups
from
1.6%
to
mortality
100%,
depending on their ages, blood pressure, heart size, serum
urea level1 positions and types of infarcts, the presence
of
pulmonary
congestion
initial three days.
and
cardiac
dysrythmia
in
the
This simple and convenient CPI could
- 123 -
be useful for
he objective assessment and stratification
of AMI in the Chinese, as well as in many other developing
countries in the Asian-Pacific region.
TABLE 43
Adverse Factors for Survival in AMI (1971-1981)
0ccurrence()
Factors
When present
When absent
inortality(Z)
mortal ity (Z)
p-Value
Age
59 yr
34.2
60-69 yr
36.0
70 yr
29.8
Blood pressure (lowest systolic)
90 unuflg
<90
Hg
32/220(14.6)
56/232(24.2)
831192(43.2)
<0.05
<0.00l
85.2
14.8
117/549(21.3)
54/95 (56.8)
<0.001
X-ray
CTR >55Z
77/387(19.9)
<0.001
69/401(17.2)
66/162(40.7)
36/81 (44.4)
106/259(40.9)
65/385(16.9)
<0.001
<0.001
<0.01
26.7
94/172(54.7)
77/472(16.3)
<0.001
23.8
32.1
17/153(11.1)
64/207(30.9)
9.3
31.2
3.6
34/60(56.7)
50/201(24.8)
39.8
94/257(36.6)
Lung field
Normal
Congestion
Pulmonary edema
Arrhythmias*
Urea
62.3
25.2
12.6
40.2
>10 mmol/L
Position of infarct
Won-Q-waves
Anterior
+ RBBB
Posterior
LBBB
6/23 (26.1)
<0.001
.0.00l
0.0l
<0.01
*Arrhytbmiassinus tachycardiac, supraventricular tachycardia, atrial
fibrillation or f1utter early ventricular premature beats, primary
ventricular taebycardia or fibrillation.
TAELE 44
Factors
Factors Not Included for
Occurence(%)
the
construction of Prognostic Index
When present mortality(%)
When absent niorta1ity()
p-Value
Angin a*
39.8
64/256(25.0)
107/388(27.5)
)
Previous infarct@
10.1
17/65 (26.2)
154/579((26.6)
> 0.5
Ilyper tens ion
24.4
38/157(24.2)
79/392(20.2)
)
0.5
Pericarditis
3.4
5/22 (22.7)
166/622(26.7)
>
0.5
Anterior
5.8
8/17 (47.1)
96/275(34.9)
> o.].
A-V block Posterior
27.6
16/54 (29.6)
35/142(24.6)
>
8GOT
45 unit
45-300 unit
300 unit
19.8
62.3
28.0
14/63 (20.6)
87/401(21.7)
70/180(38.9)
A-V b1oc1c
*
Angina = angina pectoris on effort.
@ Previous infarct = ECC Q waves with no evolutionary ST or T changes.
# Hypertension = BP.l60/95 mmBg.
0.5
0.5
>0.5
>0.05
TA.LE 45
CPI for
he Chinese
Factors
Age (x1)
59 yr
60-69 yr
> 70 yr
(X)
(Y)
0.3
0.5
2.1
i
Systo1c pressure (x2)
Heart size (x3)
CTR
90 miuBg
0
<9OmmHg
L
55%
0
2.5
0.1
i
Lung field (X4)
Normal
Couges ted/edema
O
0.7
i
Urea (x5)
10 miaolfL
O
>10 wmol/L
L
Arrhythmia (X6)
Absent
Present
0
2.5
1.2
L
Infarct position (X7)
0.2
0.4
0.6
Non-Q -way e s
Posterior or LBBB*
Anterior
Ant + RBEB@
Ant + Posterior
i
L
(x) X (Y)
*LBBB = Left bundle branch block.
Right bundle branch block.
@RBBB
CPI
3.8
TABLE 46
Pronostjc Index and Mortality in AMI
Index
No. of
patients
2
62
1
1.6
2-3
211
13
6.2
4-5
182
39
21.4
6-7
102
55
53.9
8-9
66
46
69.7
9
15
78.9
2
2
100.0
644
171
26.6
c
10-il
l2
Total
Mortality
(No. of patients)
Mortality
(Z)
Figure i.2:
The coronary prognostic index for hospital
mortality.
A stepwise increase in mortality
rate is shown from 1.6% (coronary prognostic
index less than 2), up to 100% (coronary
The number
prognostic inder 12 or greater).
of patients
falling
prognostic
into each
group is also shcn.
loo
)p.
I-
g
IM
L)
o
z.
0-1 2-3 4-5 6-7 8-9 10-11 >12
PROGNOSTiC
iNDEX
- 124 CHAPTER 9
VALIDATION 0F A CORONARY PROGNOSTIC INOEX
FOR THE CHINESE - A TALE OF THREE CITIES
INTROEUCTION
9.1
A simple coronary prognostic index (CPI)
prediction of mortality of patients with
infarction
(AMI)
been
has
previous chapter.
This
devised
'cohort'
and
for the
acute myocardial
described
in
the
644 Chinese patients
of
with AMI could be divided into subgroups with increasing
hospitaL mortality from L.6Z to
ages,
blood
pressure,
heart
100%,
depending on their
the
size,
pulmonary congestion, blood urea level,
of
cardiac
conduction
positions.
arrhythmias
defects
This
in
and
initial
the
characteristics
and
index could provide
presence
of
presence
the
three
days,
infarct
of
an objective guide
for the assessment of AMI patients and stratify different
grades
of clinical severity,
economic nature of this
widespread application
other
developing
resources.
accepted
and
for
essential
to
before
it
countries
this
application,
bave
to
its
the Chinese communities and in
Asian-Pacific
general
practical and
CPI would certainly lead
in
However,
simple,
The
CPI
is
with
iore
it would be
verified
and
limited
widely
desirable
validated
among
- 125 groups
different
of
AMI
patients
different
in
Chinese
communities.
present
The
paper
evaluates
its
efficacy
when
being applied to different groups of AMI patients in Hong
Kong, Guangzhou and Shanghai.
14A!HRIALS AD 4ETllODS
9.2
from three
Six general hospitals
Guangzhou
Kong,
patients
Unit
Eight
survey.
present
of
ANI
with
Shanghai
and
hundred
admitted
and
into
Hong
in
the
Chinese
'University
Nedical
(1976-79),
Unit of the Queen Elizabeth Hospital
-
eighty-six
the
Queen Mary Hospital
the
included
were
-
cities
(QEH)
Medical
'B'
(1981-83) and
the Prince of Wales Hospital (PWH) (1984-86) in Hong Kong,
the
Affiliated
First
Hospital
the
of
Sun
Yat
Sen
University of Medical Sciences in Guangzhou (1977-81), the
Renji
Hospital
(1978-82)
in
and
(1982-86)
Shanghai were
Hua
the
The
reviewed.
Shan
data
Hospital
of
patients (30.5U, who were admitted into QER and PWH
270
in
Hong Kong, were collected prospectively gnd those of the
other 616 patients were reviewed retrospectively under the
coordination of
data entry
prognostic
one
cardiologist.
form (Appendix 4)
parameters
is
specially designed
A
used,
including
and
age,
the relevant
presence
of
- 126 -
hypotension,
cardiomegaly,
pulmonary
cardiac
cotigestion,
arrhythmias, elevated serun urea, bundle branch block, the
nature
and
location
infarcts
o
(67.3%) were males and 290
ages ranged
rc
36
to
95
were
registered.
(32.7%) were
feta1es.
596
Their
years with a mean age of 65.7
years and the majority of pati.ents
(70.7%) wera above 60
years
according
of
age.
AMI
was
diagnosed
WiO
the
to
criteria described in the previous chapters.6°
Most patients in song Kong (91%) were treated in
the Coronary Care Unit (ccu) for the initial 3-4 days and
78% of patients
in Guangzhou and Shanghai stayed
CCU for the initial 1-2 weeks.
in
the
general
wards
patients managed in
te
with
the
in
The other patients stayed
bed-side
monitoring.
All
general wards initially had their
ECG monitored for at least 72 hours, and those in the CCU
were monitored throughout
their
stay
in
the
CCU.
Their
investigations were similar in both general wards and CCTJ,
and their treatment of any cardiac complication, followed
standard
the
patients
there
lines
as
described
in
Chapter
3.
Most
in Hong Kong stayed in hospital for 2-3 weeks if
was
no
complication,
and
complications were encountered in
for
4-6 weeks
if
early
the acute stage.
Most
patients in Guangzbou and Shanghai stayed in hospital for
an
average
of
6-8
weeks.
Hospital
mortality within
4
- 12.7 -
weeks was delineated and registered in the present survey.
Coronary
The
Prognostic
Index
was
(CPI)
calculated by the method reported in the previous chapter.
Excluded from the present survey were another 63
patients from these three cities whose clinical data were
with
incomplete,
more
one missing
than
CPI parameters.
These 886 patients were stratified according to their CPI
and the respective mortality were
subsets
predicted
those
by
correction
Yates'
significance
subsets.
of
the
was
exact
assess
to
different
the
Fishers
used
Chi-square
The
CPI.
was
with
test
statistical
the
mortality
test
compared with
rates
applied
in
the
cases
in
involving small numbers where the Chi-square test was not
applicable.421
as
P
statistically
value ¿Z
0.05
conventionally
was
The
significant.
taken
Mantel-Hanszel
Chi-square test was used to compare the mortality between
the original CPI group and the tested groups in Hong Kong,
Guangzhou
Shanghai,
and
taking
consideration
Into
the
variations among different CPI scores.422
RESULTS
9.3
The clinical parameters
for
in these three cities were
the
CPI
the
patients
in
Hong
Kong
were
the construction of
similar,
older,
except
with
a
that
higher
- 128 -
incidence cf elevated urea,
cardiac arrhythmia and right
bundle branch block complicating anterior
(Table 47).
24.3%
Guangzhou and
These
48).
according
infarct
The hospital mortality were 26.4%, 22.2% and
in Hong Kong,
(Table
Q-wave
to
groups
3
the CPI
Shanghai respectively
of patients were stratified
(Table 48).
Por each
city and for
the whole group, these AMI patients could be successfully
stratified
into
seven
clinical
increasing mortality from 0%
The
lower mortality
in
to
subsets
100%
with
stepwise
(Table 48
and 50).
Guaogzhou was accompanied with
a
higher proportion of patients having lower CPI scores when
compared with those
in Shanghai or Hong Kong.
(Table 49)
(> 0.05).
On the whole,
subsets
the actual mortality trend of the
correlated well with
that predicted by
which was devised by working on
patients
although
in
a
1971-80
possible
(X2
the
figures
5.2 P> 0.2)
lover mortality was
the
of
the
(Figure
detected
in
CPI,
AMI
13),
the
former groups with CPI scores between 6 and 7 (Table 50).
9.4
DISCUSSION
The incidence of AMI among the Chinese has been
increasing and the majority of these occur in developing
areas
like
Hong
Kong,
mainland
China,
Taiwan
and
- 129 Singapore. 70, 100-101, 186, 188
Apart
from
having
a
sound
statistical foundation, a practical and useful index for
these areas must be simpLe, economical, easy to derive
from readily available clinical parameters described in
objective terms, and should not require the use of
sophisticated
this Context, this CPI
appears to bave fulfilled all these requirements and is
therefore practicable in the assessment of clinical
equipment.
In
severity and stratification of Chinese AMI patients.
fact, this has been confirmed by the present study which
lEi
evidenced
a
good
actual mortality,
correlation between the predicted
and
successful stratification of AMI
patients in these three cities, Lt strongLy supports the
widespread
and a
application
of
this
CPI
in
the
Chinese
communities.
The patients included in the present survey were
recruited unselectively from six general hospitals in Hong
Kong and China and therefore could be taken as truly
representative of AMI patterns in the Chinese.
Sixty-three patients were excluded from the present survey
Some of them
because of insufficient cliiical data.
(46.3X) were seriously il]. and died soon after admission.
However, they only represent a small portion of the 886
Their exclusion would not have
patients included.
- L30 -
affected
our
evaluation
subsets
into
and
since
the
patients
corresponding
were
stratified
mortalities
were
compared accordingly.
overall
The
Chinese
is
higher
decreasing
a
Western
amang
the
in agreement with our earlier report (Chapter
and this had not changed much
whereas
of MIL
mortality
countries
mortality
over
the
the past decade,
over
reported
was
most
in
period.1734848
same
The
majority of patients in the three cities were older than
Western
their
attacks,
having
judging
failure
recent
and
Western
mortality
in
such
Hong
more
also
account
Kong
and
that in Guangzhou.
serious
cardiogenic
as
cardiac arrhythmias,
series.12'14''5.
would
scores
had
and
AMI
the higher proportion of patients
from
complications
cardiac
heart
CPI
counterparts
compared with
as
Similarly
for
the
shock,
the
higher
higher
overall
Shanghai when compared with
In fact the increasing ages of the AMI
patients and the seemingly more serious attacks in recent
years
the
could mask and discredit
advances
made
in
the
overall mortality of AMI.
the beneficial effect of
treatment
modalities
on
the
Nevertheless a uniform tendency
of decreasing mortality was seen among those with moderate
severity (i.e. index scores between 6 and 7)
cities.
The
number
of
patients
in
certain
in all. three
subsets
of
- 131 -
patients in Guangzhau and Shanghai
were relatively small,
and accordingly could Recount
the wide variation
the
corresponding
mortality
on the whole,
However,,
subsets
in
the
for
between
these
in
cities.
two
the actual mortality trend of the
three
cities
correlated well
predicted by the prognostic index.
with
that
This observation and
comparison have clearly illustrated the potential value of
this CPI in comparing different AMI patients in different
centres over different periods.
The absolute mortality of
these subsets will change over a long period of time, but
as long as
CPI
these can be updated from time
can be used as
groups
evaluating
from different
efficacy
the
this
a reference when comparing different
AMI patients
of
time,
to
of
the
centres,
or
when
treatment
different
regimens for AMI.
9.5
SUMMARY
order
In
Prognostic
Coronary
mortality
Chinese
in
patients
Index
Acute
of
six
(CPI)
Myocardial.
general,
from
confirm
to
this
general
patients),
Guangzhou
patients)
respectively.
(212
CPI
the
efficacy
for
patients)
and
could
to
Hong
in
They
(AHI)
applied
hospitals
a
prediction
the
Infarction
was
of
be
new
of
in
the
886
AMI
Kong
(435
Shanghai
(239
successfully
- 132 -
stratified
into
seven
increasing mortality.
clinical
The
subsets
with
stepwise
overaj.L mortality tallied with
that predicted by the original CPI.
The efficacy of this
CPI
for the prediction of AMI mortality among the Chinese
is
verified
and
its
application
in
assessment of AMI patients is recommended.
the
objective
Table 47
Age
59
Clinical Parameters of AMt in 3 cities
Hong Kang
Guangzhou
Shanghai
(435)
(212)
(239)
Z
Z
29.4
36.6
33.9
30.7
36.8
32.5
25.1
35.6
39.3
2545
19.8
19.7
43.2
42.0
43.1
42.1
40.6
41.4
>60 mg/lOO mi.
31.7
21.2
20.9
Cardiac arrhythmias*
52.0
40.1
36.0
Non-Q--Infarct
LBBB
10.0
2.6
36.1
37.3
9.9
12.7
2.8
38.7
37.7
3.8
10.5
3.8
35.1
54.4
2.1
4.1
4.2
4.2
60-69
j 70
Hypoteris ion
BP9O miHg
Cardiomegaly
CTR)55%
Lung field
Congestion/aedema
Blood tirea
Q-Infarct-Posterior
-Anterior
Anterior + RBBB
Ant + Post
* Sinus tachycardia, supraventricular tachycardia, att-ial
fibrillation, or flutter, early ventricular premature beats,
primary ventricular tachycardia or fibrillation.
Table 48 PROGNOSTIC INDEX POR
(I IN THE CHINESE
- VALIDATION IN 3 CITIES -
INDEX
HONG KONG
GUANGZHOU
(1976-1986)
(1977-1982)
(1979-1985)
z
Z
2
SHANGHAI
2
10(0)
2-3
122(8)
4-5
126(20)
15.6
83(25)
30.1
89(10)
11.2
6-7
97(38)
39.2
23(8)
34.8
45(19)
42.2
8-9
55(28)
54.8
11(8)
72.7
24(18)
75.0
10-11
22(18)
71.4
1(1)
100.0
12(11)
91.7
12
O
6.6
3(3)
100.0
435(115)
26.4
2(0)
92(5)
0
212(47)
o
5.4
-
22.2
o
69(0)
O
239(58)
0
-
24.3
Table 49
STRATIFICATION OP MI IN HONG KONG
GUANGZflOTJ 1ND SHANGHAI
Hong Kong
1971-80
Index
Z
cf
Guangzhou
77-86
AMI
77-82
Z of AMI
Shanghai
78-86
Z of AMI
<2
9.6
4.8
9.4
2-3
32.8
29.7
43.4
27.2
4-5
28.3
30.8
39.2
37.2
6-7
15.8
20.9
10.8
18.0
8-9
10.2
11.9
5.2
11.3
3.0
4.0
0.5
6.3
0.3
0.8
0
0
26.6%
25.1%
10-11
12
Mortality
22.2%
0
23.8%
Table 50
COMPARLSON OF PREDICTED (CPI) MORTALITY AID
ACTUAL MORTALITY OF AMI IN 3 CITIES
tndex
Hong Kong
HI(-Guangzhou-Shanghai
(1971-80)
(1976-86)
Total Deaths Mortality X
Total Deaths Mortality
<2
62
11
1.6
12
0
2-3
211
13
6.2
283
13
4.6
4-5
182
39
21.4
298
55
18.5
5-7
102
55
539*
165
65
394*
8-9
66
46
69.7
90
54
60.0
10-11
19
15
78.9
35
30
85.7
2
2
100.0
3
3
100.0
644
171
26.6
886
219
24.7
12
1
0.02
0
figure 13
Hospital
stratified
The
mortality
of
patients
AMI
coronary prognostic inder.
pattern of the original patients front
by
Hong Kong (1971-80) (labelled with 'square')
and that of Hong Iong - Guarigzhou - Shanghai
group (1976-86) (labelled with 'circle') are
ciitlind.
100
90
Q HK Mortality
80
o
HK-GZ-SH Mortality
P >0.2
70
60
50
lb
30
20
o
0
2
k
5
8
10
Coronary Prognostic index
12
14
- 133 CHAPTER 10
GENERAL SUM1ARY AND CONCLUSION
10.1
General Summary
A multifaceted epidemiological survey of coronary
artery disease and, in particular, acute myocardial.
infarction in Hong ICong, Taiwan and mainland China in the
period from 1960 to 1984 has confirmed their lower
prevalence in the Chinese, which is roughly one-eighth to
one-quarter of the average Western figure but similar to
that of the Japanese. It has, however, been increasing
over the past 20 years, predominantly due to aging of the
Chinese population, and possibly to suboptirnal control of
certain coronary risk factors. In China, there is a
prevalence gradient from north to south, being highest in
ßeijing and Tianjin, moderate in Shanghai and lowest in
Guangzhou; the figures for Hong Kong and Taiwan like those
of Shanghai, are in the middle ranges.
In a bcohort? of 666 AMI patients admitted into
a general hospital in
Hong Kong in the period from 1971 to 1980, the sex ratio
was 1.9:1, the male preponderance decreased with age and
the ratio became reversed (0.8:1) above the age of 70
one of the three medical units
years.
in
The mean age was 63.6+10.2 years, being higher in
- 134 -
females
the
(68.3+11.9
years).
The
higher than in Western patients.
from
came
the
lower
class1
mare
the
years
patients
popular
development
the
to
10
highlighting
class,
from
apart
professional and executive
of
There were more admissions during the cold seasons,
AMI.
and
The majority o
socioeonomjc
susceptibility
their
are
tneans
number
the
admissions
AMI
o
inversely
with
mean
ll-30°C,
and
secondarily
atmospheric pressure,
temperature
air
a
varied
with
over
mainly
a
sudden
a
pattern similar
to
that
and
range
of
drop
in
found
in
Beijing, Bombay and Lisbon.
By ease-control comparison,
cigarette smoking is
the most consistent associated risk factor
and
at
all
ages.
Hypercholeterolaemia
in both
sexes
the younger
(in
patients) hypertension, and overweight are associated with
AMI
in
the males only,
but
an association with diabetes
mallitus has not been convincingly demonstrated.
Unstable angina was
but
definite
no
pattern
present
of
in 5.2% of patients
prodromata
identified.
Prolonged precordial pain was
symptom
8O9%,
females,
symptoms.
in
had
no
and
pain
of
but
presented
be
the presenting
patients,
16%
could
with
mostly
older
nonspecific
A high level af alertness is required for their
prompt detection.
Anterior QWav infarcts were present
- 135 in
46.2%,
posterior
Q-wave
infarets
non-Q-wave infarct in 21.0% of patients.
incidence of clinical conip1ications
heart
(13.5%);
the
in
(45.1%)
tachycardie,
elevated
(12.7%)
blood
and
arrhythmias
supraventricular
or
bLock
bundle
right
(11.3%);
Pericarditis,
(24.87.).
primary
flutter,
or
fibrillation;
A-V
arid
urea
cardiac
sinus
fibrillation
tachycardie
block
of
There was a high
including hypotension
(38.6%);
forms
atrial
ventricular
branch
failure
and
31.4
in
and
an
mostly
of
early onset type, was present in 3.3% and the late-onset
pericarditis described previously by
uncommon.
Dressier)
Hospital mortality within four weeks was 29.5%
(195/666), being higher in the females (36.7%).
higher
than most recent Western figures.
higher
mortality
incidence
very
was
of
related
was
to
6
The relatively
higher
and
ages
Twenty-two
complications.
patients died within
older
These are
percent
of
hours and 48% of deaths occurred
within 24 hours after admission.
Causes of death included
heart failure (29.2%), cardiogenic shock (18.5%), primary
arrhythmias
death
(22.1%)
and
cardiac
cf uncertain causes
incidence
of
underestimated.
free
The
was
wall
latter
rupture
present
rupture
conformed
Sudden
(5.1%).
in
may
to
15.4%
and
have
the
the
been
classical
findings with a high proportion of older ages, female sex,
- 136 -
incidence
higher
of
postinfarctjon
hypertension,
occurrence within initial four days after admission.
and
RBBB
wIth typical qR pattern (whether isolated or combined with
left fascicutar block) and A-'V block complicating anterior
Q-wave infarction were ominotis
a high incidence of
with
mechanical and rhythm disturbance.
LBBB appeared to be a
more chronic lesion with moderate mortality.
To test the hypothesis that a coronary care unit
could salvage more patients
mortality in
the impact of CCU on hospital
the Chinese was
evaluated by a prospective
concurrent study of two comparable groups of AMI patients
younger than 70 years of age and admitted at random into a
CcU (iii patients) or the general wards (92 patients) of a
The patients initially treated
general hospital.
CCU bad
the
a
the
in
lower mortality (15.3%) compared with those
general
wards
(29.3%)(p< 0.05),
with
in
sudden
fewer
deaths, but there was no significant difference in their
mortality if patients older than 70 years were included.
In order to benefit from such coronary care in the acute
stage,
possible
'cohort',
into
it
AMI must
with
patients
such
was
a
found
onset of symptom to
coronary
that
be
care
admitted
as
soon
unit.
In
our
the median delay
time
as
AMI
from
CCtJ admission was 6.1 hours, with a
median delay of 2.8 hours in the prehospital phase, mostly
patients' hesitation in seeking help, 24
minutes in hospital handling procedures and 2.9 hours in
the general wards. These delays are slightly longer than
due
to
the
most Western series.
Post-mortem examination of 89 fatal AM patients
revealed the presence of significant mechanical defects
potentially salvageable by surgical correction in 14.6%,
including rupture of free left ventricular wall (11.3%)
cardiac
tamponade,
and
acute
rupture
of
with
interventricular septum (2.2%) and of papillary muscle
Infarcts
(1.1%), presenting with severe pump failure.
Significant
coronary
identified in 94.3%.
were
atherosclerosis was present in 94.2Z with critical
lesions in left main stem in 8% of patients1 in the
proximal left anterior descending artery in 42.7%, in the
circumflex artery in 8% and in the right coronary artery
Recant obliterating
in 18.7% of patients respectively.
coronary thrombosis was identified in 18.7% at post-mortem
which
could well be
an
underestimation of the actual
incidence at the onset of AMI.
Advanced age (70 years), hypotension (systolic
cardiomegaly, pulmonary congestion
or oedema, elevated serum urea level (> iO mmol/L),
or
sinus
forms
of
the
in
cardiac arrhythmias
blood pressure< 90 mm),
- 138 -
supraventricular
flutter,
early ventricular
tachycardia or
anterior
mortality
atrial
ectopics,
fibrillation in the
Q-wave
infarction,
were
RBEB,
with
tachycardia,
ominous
(p. 0.01).
fibrillation
primary ventricular
initial
particularly
factors
Apart
or
72 hours,
association
in
associated with
from
advanced
and
higher
age.
these
factors are markers of extensive infarcts associated with
poor prognosis.
for
the
A simple coronary prognostic index (CPI)
prediction
AMI mortality
of
in
the
Chinese has
been devised by multivariant regression analysis of these
seven
simples
objective
The AMI
parameters.
and
easily
available
cohort' could be divided by the CPI
(from"( Z to>l2) into subgroups with
mortality
from 1.6%
clinical
to
100%.
increasing hospital
CPI could provide an
This
objective guide to the assessment of AMI patients and the
stratification of different grades
of clinical
severity.
The CPI was subsequently applied to 886 AMI patients from
six
general
Shanghai.
hospitals
in
Hong
Kong,
Guangzhou
and
They could also be successfully stratified into
clinical subsets with stepwise increasing mortality, which
tallied with those predicted by the original CPI.
10.2
Conclusion and Recommendation
The
present
study
documents
and
confirms
that
- 139 -
coronary artery disease and, in particular, AMI in Chinese
are
four
eight
to
times
less
Coliimon
than
Western
in
subjects, but have been increasing in the past 20 years.
The
size
population
of
risk
at
is
large
we
and
are
expecting a bigger problem from coronary artery disease in
the years
to
come.
warranted
in
planning
future
most
in
More consideration on
of health
Chinese
programmes
communities.
issue
this
the
in
While
aging
is
near
is
a
contributing factor to such an increasing trend, more work
is required to delineate the relative significance of, and
offset the changes
factors
in
in the socioeconomic and coronary risk
the
process
of
cigarette
association
hypercholesterolaemia
patients,
measures
launching
with
of
modernisation.
smoking,
AMI,
close
The
hypertension,
particularly
in
and
younger
indicates that more positive primary preventive
are
of
needed
for
effective
their
contro].,
anti-smoking
including
campaigns,
detection and proper treatment of hypertension,
the
the
and the
recognition and adoption of cholesterol-lowering life
styles and habits on national basis. tany of these
factors coexist in an individual and more work using
multivai-iant discriminative analysis is required to
delineate more objectively the significance of each factor
in the Chinese.
- 140 The Cljflj1 and pathological patterns of AMI in
the Chinese conform to the classical picture but
overwhe1ed by the higher ages of patients, higher
proportion
of
females
and
more
serious
spectrum
of
cLinical seventies as suggested by the higher incidence
of
complications
and
higher
hospital
mortality.
The
changing trend recently reported in Beijing, where AMI is
more prevalent, may probably hallmark a beginning of a
change towards the current Western pattern with younger
ages, lower incidence of complications and lower hospital
mortality. Nevertheless, the serious nature of AMI in the
Chinese should be recognised and a more energetic approach
should be endorsed for its prevention and treatment,
including the intensive and prompt treatment of unstable
angina,
the
infarct-size-limiting
regimens
and
thromboLytic therapy for early reperfusion of the occluded
Coronary arteries.
A relatively high proportion of patients died of
mechanical defects and cardiac rupture. With the greater
availability of monitoring and resuscitating facilities,
more patients will benefit and fewer will die of cardiac
dysrhythmias, but mare w-iii die of pump failure or cardiac
rupture
in
potentially
the
future.
salvageable
Some
by
of
these
surgical
defects
are
correction.
- 141 -
IecognitiOfl of suci
AMI in the
]-990s
complications as relatively common in
is neded
and improved methods of their
early diagnosis must be developed.
The
assojatjon
close
AMI
of
occurrence
and
meteorological factors w111 induce patients suffering from
coronary artery disease to be CautiOus when travelling to
other
places
travel.
in certain rjdeal
with
contrasting
climates.
They
should
seasons in order to minimize the
meterologica]. difference between the places, should
exposure
extreme
to
temperature ranges
avoid
and strong wind,
and should limit their activities while adapting to other
new meterological. environments.
The
prognosis
hypothesis
of
AMI
that
salvage
and
care
CCU
can
improve
patients
more
has
the
been
critically tested and confirmed in the present study.
the use of the COU in the initial
data strongly support
period for patients younger than
patients
has
advances
in
yet
myocardial
thrombolytic
for
and
AMI,
personnels
unit
to
be
to
and
therapies1
the
70
although
infarction,
inyocardial
COU,
years suffering from
benefit
the
salvaging
are
such
becoming
with
the
such treatment.
as
to
older
revolutionary
Many
confirmed.
facilities, will be
carry out
Our
B-blockers
first-aid
required
or
treatment
experienced
the most appropriate
The establishment of
.-
142 -
such a CCU in every community hospital should be endorsed
and
inip1eiented.
However,
at
least
50%
our patients
of
failed to get into the CCU within 6 hours after onset of
symptom,
delay
a
sophisticated
mitigating
treatment
education are required
and
these will
include
office
campaigns,
against
nodalities.
to
More
appointing
more
health
public
public health
cautious
counselling
coronary
on
new
of
shorten the prehospital delay,
patients
of
relatives by primary health workers,
booklets
use
the
attacks
experienced
education
issuing educational
vulnerable
to
their
and
medical
patients,
staffs
the
in
emergency department of the general hospital, direct
Ccii
admission from the emergency department and the creation
of more CCU beds.
More action should be taken to ensure
efficient turn-over and optimal utilization of
such
use
as
of
quicker
Ccii
beds,
the training of more experienced CCU staff,
isoenzyme CPK-MB and radioisotopic imaging
more
and
reliable
screening,
AMI
for
and
of patients at
identification of certain subgroups
the
a
the
lower
risk for early discharge from CCU.
Seven
clinical
simple,
parameters
objective
including
and
ages,
pulmonary
hypotension,
cardiomegaly,
arrhythmias,
elevated blood urea
readily
and
available
presence
congestion,
of
cardiac
characteristics
of
143 -
-.
infarct have been delineated
the
fatal
likely
outcome.
coronary
A
indicative
be
to
stratified
be
increasing
verified
into
seven
mortality.
another
in
8ubgroups
The
AMI
886
has
CPI
'cohort' can
stepwise
with
successfully
been
patients
from
provides
in
in
the
quantitative
a
severity.
AMI
high
A
Chinese
index
would
Its wide
recommended.
is
method
unmask
high-risk
the
a
It
clinical
assess
to
patients who deserve more attention and
general
six
hospitals in Rang Kong, Cuangzhou and Shanghai.
application
a
index has
prognostic
been devised from these factors and our AMI
of
more energetic
regimen while a low index would identify a low-risk group
for earlier ambulation and discharge from the CCU and from
hospital.
the
assessing
It
provides
randomization
and
an
objective
comparing
guideline
large
for
numbers
cf
patients treated by different methods in different centres
or
over different
time.
absolute mortality
The
of
the
subsets of severity may change over a long period of time,
but
this
as
long as
can
CPI
these can be updated
be
used
as
an
from time
objective
to
reference
time,
for
comparison.
The simple, practical and economic nature of this
index will also be very attractive
AMI patients
for the assessment cf
in many other Asian-Pacific countries which
in many respects are similar to China and fang Kong.
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myocardial. infarction.
Circulation 1980; 61:996-1003.
407. Horowitz RS, Morganroth 3.
Immediate detection of early high-risk patients with
acute inyocardial infarction using two-dimensional
echocardiographic, evaluation of left ventricular
regional wall motion abnormalities.
Am Heart 3 1982; 103:814-22.
408. Kendall M, Stuart A.
The advanced theory of Statistics
1968; 317.
Vol.
III,
London
409. Kim JO, Kohout P3.
Multiple regression analysis: subprogram regression.
In: Nie NH, Hill CH, Jenkins 3G, Steinbrenner R, Bent
H
(ed).
science.
320-67.
SPSS-statistical package for the social
New York, McGraw Hill Inc 1975,
cd.
2nd
410. Fox ICH, Tonilinson 1W, Portal RW, Aber CP.
Prognostic
significance
of
acute
hypertension after myocardjaj. infarction.
r '1ed J 1975; 3:128-30.
systolic
411. Gibson TC.
BLood pressure levels in acute myocardial infarction.
Am Heart 3 1978; 96:475-80.
412. Hutton I, Pack AI, Lindsay N, Laurie TDV.
Clinical significance of renal haatnodynamic
myacardial infarction.
Lancet 1970; 2L23-5.
in acute
413. lUbe 0, Niisson NJ.
Observations on the diagnostic &nd prognostic value
of saine enzyme tests in myocardial infarction.
Acta Med Scand 1967; 182:597-610.
414. Tharavaro S, Knee RJ, iCleiger RE, et al.
In-hospital
prognosis
of
patients
with
nan-transmural and transrnural infarctions.
Circulation 1980; 61:29-33.
first
415. Rigo P, Hurry M, Taylor DR, Weisfeldt ML, Strauss KW,
Pitt B.
Heinodynamic and prognostic findings in patients with
transmural and non-transiura1 infarction.
Circulation 1975; 51:1064-70.
416. Kutter AM, DeScanctis RW, Flynn T, Yeatman. LA.
Non-trausmural myocardial infarction: A comparison of
hospital and late clinical course of patients with
that of matched patients with transtaural anterior and
transmural inferior niyocardial infarction.
Am J Cardiol 1981; 48:595-602.
417. Bayley N, Hunt D, Pennington C, Sloman JO.
Subendocardial niyocardial infarction.
Aust NZ J Med 1982; 12:166-9.
418. Lie KI, Liem KL. Scbuilenburg RH, David OK, Durrer D.
developing
late
patients
identification of
Early
in-hospital ventricular fibrillation after discharge
from the coronary care unit.
Am J Cardiol 1978; 41:674-7.
419. Bigger JT.
New directions and new uses for risk stratification
the
post
hospital
infarction.
J Med 1979; 67(1):2.
A
in
phase
of
acute
inyocardial
420. Swerance 11W, Morris 1CG, Wagner CS.
Criteria for early discharge after acute myccardial
infarction. Validation in a community hospital.
Arch Intern Med 19B2; 142:39-41.
421. Armitage P.
Statistical methods in medical research.
Oxford: Blackwell 1971; 131-8.
422. Mantel N, Hanszel W.
Statistical aspects of the analysis
retrospective studies of disease.
J Nat Cancer Inst 1959; 22:719-48.
of
data
from
Appendix
Record Form For
MI Patients
PERSONAL INPORMATION
NAME
I.D. No.
M.I.
C.C.U. No.
SEX (N/F)
WEIGRT(kg)
OPD year
AGE
:
liEIGHT(ia)
OCCUPATION
1) Labourer
2) Clerical
5) Businessman 6) Executive
Professional
Driver
3)
7)
4) Housemaker
8) Others
o
Occupation Status
1) Full-time
2) Part-time
5) Reduction in work
3) Retired
4) Quit work
6) Reduction in work
o
Please give one of the reasons below
].)
Because of cardiac symptoms
2) On advice of physician
3) Persan reasons
PERSONAL
INFORMATION
H i story
Present episodes
Chest Pain
Circumstances
1) exertional
Duration (hours)
Severity
2) rest
++
+
2)
1)
3)
Site
2) jaw
1) precordial
3) sleeping
+++
o
3) epigastrium
4) others
Associated Symptoms : (TJP)
Shortness of breath
Sweating
Syncope
Palpitation
G.I. Symptoms
Time information available ? (T/F)
Time elapsed before admission
Arrival to clinic (urs)
(mm)
Seen by doctor
Arrival to casualty (hrs)
Seen by doctor in casualty (mm)
Admission to ward (mm)
Admission to C.C.U. (mm)
4
PERSONAL INFORNATION
Past history
History of Angina available ? (Y/N)
Duration (months)
Nocturai. angina (Y/N)
1ecant deterioration (1/N)
:
Previous A.M.I.
Documented
i
:
1)
0
2)
L
3)
2
4)
3
5)
>3
History only (Y/N)
Time since last A.MI.
years
months
Other medical history available
(Y/N)
Hypertension
Diabetes Heliltus
C.V.A.
Valvular Heart Disease
C.O.A.D.
Collagen Disease
Renal Disease
Gout
Hyperlipidaeiaia
Functional State : i
Grade I
3..
2. Grade II 3. Grade III 4. Grade IV
Current Medication information available 7 (1/N)
:
:
Nitroglycerine
B Blocker
Antihypertens ive drugs
Potassium
Digitalis
Others
Long acting Nitrate
Calcium Antagonist
Diuretic
Antiarrythinic drugs
Aritilipaexnic drug
PERSONAL INFORMATION
Personal History
Hobbies information available 7 (1/N)
Athletic Hobbies
Moderate Hobbies
Light Hobbies
Abandanded
Curtailed
years
Curtailed for
Reasons for abandonding/curtailing hobbies
2. On advice of physician
i. Because of cardiac symptoms
Smoking Habit Information avaiJ.able 7 (1/N)
Regular 7 (1/N)
cigar/day
cigarette /day
Amount :
years
Stopped for
years
Duration.
Alcohol information available 7 (1/H)
Regular 7 (1/N)
oz/day
Amount :
Stopped for
years
Duration
Family History available? (1/N)
Ischaemic Heart Disease
Diabetes Mellitus
Gout
0
years
Hypertension
C.VA.
Sudden Death
PHYSICAL EXJU4INATION
General Conditions
In pain
Pallor
Obesity
:
(Y/N)
Dyspnoea
Cyanosis
Overweight
Orthoprzoea
Sweating
Xanthalasnia
Xanthoina
Limbs
C. V. S.
r.V.P.
1) cold
:
2) warm
1) normal
(systolic)
/Itnn Hg
Pulse.:
Regular ? (1/N)
Rate
1mm
:
B
Volume
Apical impulse
Site
ICS
Type
1. Normal
Ascultation
Triple Rhythm 3rd NS
Murmer -
2) increase
BP (diastolic)
3.)
Normal
/rruu Hg
2) Weak
2. Abnormal
4thHS
NR:
Gallop
¡
VSD:
Fericardial Rui
Click (1/N)
(1/N)
PHYSECAL EXrtMINATION
Respiratory System
Air Entry
(Y/N)
R1onchi
1ffusion (Y/N)
Lung ease
Abdomen
Liver
(1/N)
Ascites (1/N)
2) Decrease
1) Normal
crepitation
(1/N)
Consolidation (1/N)
3./4
3) > 1/2
l
2) 1/2
Below
osta1 margin
cm
Is X.R.C. information available ? (1/N)
X. R. C.
rum :
1) PA. film
c.'r. ratio
(1/N)
Lung Congestion
Pleural effusion (1/N)
Pulmonary oedema (1/N)
2) AP. film
3) portable
C. G.
i) SR 2) A' 3) 'LtJ
:
eats/in
Rate
L) Nomial 2) Leit 3) Right 4) Indeterminad
Ventricular hypertrophy :
1) LVH
2) RVfl
A-V conduction detect
i
Rhythm
ORS a>d.s
:
1) ist degree 2) 2nd degree
3)3rd degree 4)WPW
Ventricular conduction defect (Y/N) RBB LBB LAU L?H
ysrhythìnias
P.V.C. :
1) occasional 2) frequent 3) irn.iltif ocal 4) salvos
Sinus bra oadia
Supraventricular tachycthia
J\triaJ. f jiDrillation
Atrial flutter
Nodal rhythm
Idioventricular rhythirL
Ventricular tachycardia
Ventricular fi1rillatjon
Others
Diagnosis
Present
(Y/N)
Site of Changes
Anteroseptal Anterolateral Inferior- True
Posterior Posterior
1112345
;.T. elevation
V6
T aVLIIIIIaVVIT.1IaV1!
ew L2atfloJ.oqlca
wave abnormality
- A.11.X.
:
i) Non-Q-wave
2) Q-wave
LA}3ORATORY INVESTIGATION
DAY
1
DAY
3.
DAY
2
DAY
3
DAY
4
( gnLk_)
11gb.
I
I
I
I
r
I
1
edicatiofl
rrquency Options
Responses Options
Z1edication
:
O. N/A
O. N/A
Prssence
1.
qc5.
Good
Dose
:1..
4hs 6. g5
2. bd 3. tds 4. qid. 5.
3. No
2. Partial
Frequency Duration Response
(days)
(v/N)
tab
TNG S]:
N itro-o itmerit
in.
Nitroderm
Isoket
Betaloc (oval)
Bataloc (IV)
ag/day
Lignocairle
ing/min
Malat
ing
ing/hr
ing
ing
Xscptin
Diltiazem
Dopaaina
Dobutamine
Captopril
Minipress
Heparin
Dipyridamole
Dipyridamole
t-PA
Aspirin
mg
ig/kg/min
ug/kg/min
mg
mg
units/day
ing stat(IVI)
mg/day arai)
ing in 2 HflS
mg/day
mg/day
mg/day
mg/day
Wararin
D igoxin
Morphine/Pethidine
Medication
Frequency Options
Responses Options
Medication
:
:
o
1.çd
O
I. Gcód
Dose
N/A
N/A
Presence
2. bd 3. tds 4. gid 5. q4hs 6. q5
2. Partial
3. No
Prequency
uration
tasponse
(days)
( r/N)
Lasix (oral)
Lasix (XV)
Navicrex K.
Potassium (oral)
Potassium (IV)
DM treatment (oral)
DM treatment (insulin)
ing
ing
tab
inIlLO i
tab
unit
Intervention
Temporary Pacing (Y/N)
Transcutaneous (Y/N)
Haemodynamio monitoring ('i/N)
Fluid Infusion (Y/N)
ransvaous (L/N)
:
cc.
L.V Cine (YIN)
Coronary Cine (Y/N)
Respirator (Y/N)
Electrical Counter shock (Y/N)
:
Progress
Complication
Presence
Days cf onset
(JN)
(after admitted)
DuraUcn
(days)
H.ypotension
HeartJrailur
Siri.usradyr i
Sia
Mri1
+VL1
rh41rrdj?
'ltair
SVT
tovntrt'u1- -hy±hîit
PVC
PVC
VT
I5olated
Sa1vrs
v-F
kY lnck T
AV_B1nck
-v
1fl(-J
T
1
rr
AV Blok_TT
Progress
Complication
Presence
(Y/N)
Days of onset
(after adaittad)
Duration
(days)
LflBT
RDBB
L/U
-
£neumon1a
CVA
Renal CaU.ure
Other complication
-
Qu.tcon%e of patient
2. Dead
1. Alive
1
Life status
days
Died after admitted to hospital for
days
Discharged after admitted to hospital for
Transferred to ward after admitted to hospital for
days
Management of Acute Myocardial tnfarction
Routine procedure
are
Uncomplicated
patients
generally
hospital for (IO - 14) days.
During the acute stage (72 hours).
1)
Monitor the patients with CML1 Lead.
Grourd electrode applied to R shoulder.
(+) electrode applied to R4 i.c.s.
(-) electrode applied to L shoulder.
2)
I.V. drip 5% dextrose q24 hours.
3)
Rourly B.P. and pulse.
4.)
Q
via polymask
6
except
(60%)
Litre/tnin.
kept
in
those
with COAD.
& 0. chart.
5)
I.
6)
EncoUrage use of bedside commode.
7)
Ordinary diet with
no
added
salt
or
unless
gravy,
complicated by heart failure.
8)
C.V.P. line with heart failure or shack.
9)
Daily E.C.G., W.B.C., E.S.R., S.G.O..T.,
for 3 days and then whenever necessary.
io)
11)
12)
13)
14)
Na/a,
Urea
Laxative e.g. Agarol or 11g. paraffi.n z±± b.d., p.r.n.
g t.d.s. and nocte
Valium (z - 5)
failure).
or severe heart
(unless
in shock
Treatment of pain: petbidine 50 - 75 mg.
Morphine gr. I - 1 (avoid in
4 (elderly)
6
Nitroprusside,
Reart failure: Diuretic, Vasodilator Dobutaline,
Terbutalifle,
Hydrallazifle,
Prazocin,
Dopamine, Nitroglycerine, ± DigOXÎfl.
Persistent angina:
and
-btocc.e.r.
Nitroglycerine
(oral
or
topical)
15)
Ventricular arrhythmia: - Correct hypolalaemia
- Lignocaine as first line
drug in acute phase
- Disopyramide
- Mexiletine
- Tocainide
16)
2°
17)
Patient mobilisad after first week when uncomplicated.
higher
grade
prophylactic pacing.
or
A-V
block
-
consider
APPENDIX 3
Treatment of Arrhythiaias in Acute Myocardial
Infarction
I.
Sinus
Bradycardia
or
wandering pacemaker.
Indication of treatment
arrest
with
junctional
or
a) Rate' 50/min.
b) Symptomatic - nausea,
sweating, confusion.
e) hypotension.
Atropina 0.2 - 0.6 mg IVI slowiy over L min.
Repeat 0.6 mg IVI if no response.
Consider
pacing
if
bradycardia
and
symptoms
temporary
pers is t.
II.
Atrial premature beats.
No treatment required.
Watch for onset of other atrial arrhythmias like
Atrial Fibrillation, Atrial flutter) PAT.
III. Sinus Tachycardia: a) Impending complications.
b) Inappropriate reaction - use
s-Blockers.
IV.
Atria1. Fibrillation
Vent. rate 130/min. not associated with heart
failure or hypotensions
fligoxin.
Vent. Rate 130/min. or associated with heart
failure or hypotension.
Electroconversion,, then digoxin for maintenance.
V.
PAT-without block - vaga1 stirn., if failed, parenteral
Verapamil or Disapyrainide, Electroconversioti.
-with block - exclude digitalis toxicity.
a)
In absence of heart failure
- Dilantin IVI 100 mg/over 5 min. slowly and
cautiously not exceeding 300 mg
in 30 min.
1Ml 250 - 500 mg over 2 min.
Inderal IVI 0.5 mg over 2 min. up to
3 - 4 mg within 15 min.
Caution
:
i) Small dosage increments given
slowly, particularly if digitaLis
intoxication or heart failure
suspected.
2) E.C.G. monitoring.
3) Atropina and isoprenaline at
hand to counteract excessive
slowing.
b)
In presence of heart failure Vasodilators + diuretics.
Vent. rate Z. 120 observa
Vent. rate
120
If dignitatis overdosage - treat accordingly.
If not digitalis overdosage - use digitalis or
verapamil.
'
VI.
AV Block
Anterior In faretion
Indication for prophylactic
pacing catheter introduction.
1)
RBBB + LAHB
"
+ LPHB
2)
U
3)
alternating with LBBB.
+ 10 AV block.
4)
"
U
5)
+ progressive heart
Inferior Infarction
Try atropina
fa i lure.
Indication for pacing
Complete Heart Block
i)
Nobitz Type 2 Block
2)
Indication for pacing
Failure of Ned. Bc and:Mobitz Type 2 block
sigh grade bLack with
3)
wide Q.R.S.
I)
2)
4)
RateZ. 60/min. with
low cardiac output.
VII.
Junctional tachycardia
Exclude digitalis intoxication
Electroconvers ion
Inderal
Verapamil (5 - 10 ing ivt)
Disopyramide
Am i o d a r o n e
VIII.
AV dissociation - observe
Atropine if symptomatic.
IX.
Vent. Extrasystole
Indication of R 1) Short coupling time
QR1/QT( 0.85.
2) Occurs iii salvos of 2 or more
in &uccession.
3) Multiform or multifocal.
' 5/min.
5) Parasystole.
4)
R Lignocaine
Or
Bolus
75 mg
2 mg
Infusion/mm.
5'
50 mg
3 mg
10'
50 mg
4 mg
Maintenance 1 - 2 mg/mm. (300 - 600 mg into
15'
50 mg
4 mg
500 ml. of 5. dextrose q6h)
Caution: hepatic faiLure, CHFI elderLy.
Side effects hypotension, sinus bradycardia,
A-V block or other conduction defect,
tinnitus, visual disturbance, headache,
convulsion, drowsiness, respiratory
depress ion.
followed by oral Disopyramide, Mexiletine,
:
X.
Quinidine or Procaiiiamide.
Disopyramide IVI (L..5 - 2) mg/kg over 5 minutes,
followed by infusion 0.4 mg/kg/hour.
Mexiletine - Initial bolus 150 mg over (2 - 5) minutes
Infusion 200 mg over next 2.5 hours, then
(0.5 - 1) ing/min.
Vent. Tachycardia
I) Commoner type: of brief self limiting paroxysms of 4 20 successive ectopic beats1 commence with 'R on T'.
R: lignocaine, procainamide, Disopyramide, Mexitetine,
electroconvers ion.
2)
XI.
Malignant type sudden onset, rapid rate and sustained.
Immediate electroconvers ion
Lignocaine while preparing for electroconversion
(AIVR)
Idioventricular Rhythm.
Innocuous, observe or atropine.
Xli. Ventricular Fibrillation 1)
2)
Primary VF - unexpected event occurring in the absence
of shock or heart failure.
Immediate D.C. defibrillation and other measures of
cardiac resuscitation.
Secondary VF - a terminal event of circulatory failure.
Appendix 4
Assessmert Form for the
Index in the Ciìnese
'IJ_!À
C
Tf
Verification
of Coronary Prognostic
?TiJi4&"
I143
X
F7LCTORS
AGE (X1)
(X)
Y
-
GO-G9
05
>70
i,
2.1
..
HLOOI) L'kJSUkE (Xi)
>9Omnh1ii
2
r
H1AIe[' SIZE (X)
0
<55%
>55%
LUNG FIELD (X4)
)IT
1
rr
.- '.
NORMAL
o
i
* *
UREA (X!I)
0
<60
>60
2.5
i.
kRRHVTHMIA (X1)
ABSENT
1RESENT
0
,t.
i
ÇÇ
NPARCT 1'OSTION (X7)
SEI
0.2
1OSTLR[OR
0.4
-re.
¿
L8
L8B
ANTERLOR
0.4
0.6
1
4frI
ANTRBBS
E (XxY)
i.
1NOEX
CORORARY PROGNO5TC INDEX FOR CHINSE
X1Y1 +X1Y X3Y3+X
4-ì-X,Y X1Y i-X7Y7
L41
<
(Y)
CHAPTER 13
ACKNOWLEDGEMENT
take
I
to
Professor
niuch
David
pleasure
Todd
express my indebtedness
to
and
R.J.
Dr.
Barnes
their
for
encouragement and advice, without which this thesis would
not have been attempted.
wish
I
thank
to
Professor
M.G.
Nicho11s
Professor D.M. Davies, Professor Joseph C.K. Lee, Dr. Y.M.
Lam and Mrs.
their
Joyce Y.H.
precious
for reading this
Luk
comments
suggestions
and
thesis
are
and
deeply
apprec iated.
Many
Donnan
are
thanks
epidetniological
to
contributions
his
for
also
due
data
of
coronary
Professor
of
artery
Stuart
age-specific
disease,
Dr.
Lawrence F.M. Lai for his collaboration in evaluating the
impact of coronary care unit on survivals of patients from
acute myocardial
in Hong Kong,
infarction
Dr.
C.O.
Pun,
R.Y.C. Wang, Professor ZZ Huang, Dr. H. Ma, Professor R.H.
Dai and Professor D.Z.
Huang
for
their coLlaboration
in
the validation of a new coronary prognostic index for the
Chinese, Dr.
Sham Pak of the Hong Kong Royal Observatory
for providing meteorological data of Hong Kong,
G.M.
Rodrigues
Meteorology
and
of
Portuguese
Geophysics
for
National
bis
Dr. Hante
Institute
encouragement
of
and
precious advice, Dr. D. Saw and staff of pathology unit of
Queen
the
Elizabeth
Hospital
post-mortem examinations,
performing
for
staff of
the
Sing
Centre for their cooperation and permission
to
the
Tac Medical
to get access
the clinical records, Ors. Y.M. Lam and S.M. Hsu of the
Chinese University of Hong ICong
advice
on
statistical
their assistance and
for
calculation,
Hon.
the
Director of
Medical and Health Services for his permission to use the
case notes from the hospitals, the staffs of Medical Unit
B
and
and
C
Hospital,
and
of
the
Coronary
Care
staffs
Unit
Queen
in
Elizabeth
of Medicine
and
Coronary Care unit of the Prince of Wales Hospital,
for
of
Department
their cooperation and high efficiency.
The medical media
University of Hong Kong at
services
unit
of
the
Chinese
the Prince of Wales HospitaL
was particularly co-operative and obliging in my request
for art work and photographs; my secretaries Hiss Angela
Ho and Iris Leung and research assistants Miss L.Y. Ho and
Cheng
Suzanne
provided
prompt
and
valuable
clerical
supports.
Last, but not
thanks
to
the
least,
I
owe
a heartfelt vote of
to Mrs. Frances Tsui, who devoted much of her time
typing
of
this
thesis
and
whose
perseverence is matched only by her ability.
patience
and