Myocardial infarction community registers: results of a WHO international collaborative study coordinated by the Regional Office for Europe

PUBLIC HEALTH IN EUROPE 5 REGIONAL OFFICE FOR EUROPE World Health Organization Copenhagen 1976

No. 5 MYOCARDIAL INFARCTION COMMUNITY REGISTERS Results of a WHO International Collaborative Study coordinated by the Regional Office for Europe Not for Sale Distributed by the REGIONAL OFFICE FOR EUROPE World Health Organization COPENHAGEN 1976 Note D a t a and e xc e rpts from "Public Health in Europe " m ay b e r eproduce d provided th a t th e source of the reprinte d t ext is acknowl edged . For r ights of reproduction or tr anslation of the articles in toto , a pplication should be made to the R egiona l Office for E u rope. The Office welcomes such a pplic a tion s . Author s a lone a re r es ponsibl e for views exp r essed rn signed a rticle s . 11 Reissued under ISBN: 9789289023665 (print) in 2025. Originally published under ISBN-10: 929020124X. ISBN 92 9020 124 X ISSN 0300-4880 © World Health Organization 1976 Staff of collaborating centr e s For eword Introduction. 1. Background to the project 2. Methodology 3 . Results. . . CONTENTS ANNEX I Operating protocol . ANNEX II Supplementary tables and figures ANNEX III Publi cations of collabora ting ce ntres. iii Page 1 10 1 1 20 25 46 139 165 224 STAFF OF COLLABORATING CENTRES Collaborating Centres 1 l . GOTHENBURG (Sweden) Director: Dr G. Tibblin Collaborators: Dr L. Nerko (Chief , Medical Department I, S a hlgr en Hospital) Dr J. Fodor Dr L. Wilhelmsen Dr D. Elmfeldt Dr A . Vedin Dr c . Wilhelms son 2. PRAGUE 4 (Czechoslovakia) Director: Collaborators: Dr Z. Hejl (Depa rtment of Medicine II, Institute of Clinical & Experimental Medicine) Dr Z. Petrzllkova Dr I. Stolz Dr H. Geizerova Staff of the Registry Medical staff of the Coronary Care Unit & Ward in the Depar tmen t of Medicine II, Institute for Clinical and Experimental Medicine Dr K. Bergmann Professor J. Tesar and staff (Institute of Forensic Medicine) Dr V. Lukes (Assistant Director of Health Services) l The numbe rs preceding the names of the centres are code numbers allocated for data processing purposes only. 1 3. BUCHAREST 4 (Romania) Director : Collaborators: Dr O. Ioan (Scientific Director, AS CAR) Dr P. Andreescu Dr A . Caulea Dr v. Cuneseu Dr I. Lobel Dr Liliana Desio s (Pathologist) Staff of the Register, including Ms M. Cornusea Staff of the Ministry of Health Staff of the Centre for Cardiovascular Diseases, a nd the physicians and medical auxiliary staff of Bucharest 4 . 4. BUDAPEST (Hungary) Director: Collaborators: Dr I. Gyarfas Hungarian Institute of Cardiology: Profe ssor G . G a bor (Director, Department of Medicine) Dr G. Lamm (H e ad, Department of Health Organ- ization and Epidemiology) Dr J. Duba (Department of Health Organization and Epidemiology) Municipal Health Services of Budapest Dr F. B a rtha (Head of Budape st Office) Sta ff of the R e gistry Heads and staff of Departments of Medicine of Semmelweis Medical University District Hospitals Heads of Departments of Pathology of Semmelweis Medical University District Hospitals Institute of Forensic Medicine District doctors of the Register area 2 5. COPENHAGEN (Denma rk)1 Directors: Professor A. Tybjaerg Hans e n Mr K. Kjeldson (Danish Institute for Clinical Epi- d e miology ) 6 . DUBLIN S. (Irela nd) Directors: Collaborators: Dr G. Dean Dr A. R a die 130 family doctors serving the area Consultants a nd p a r a m e dic a l staff of 16 Dublin hospitals Dublin City Coroner an d p athologists Staff of the C a rdiac Ambulance Service Staff of the Hospitals Bed Bureau The Irish H eart Foundation Chie f Medical Officer a nd staff of the Department of Health 7. HEIDELBERG (F e d e r a l R e public of G e rmany) Directors: Collaborators: Profe ssor P. Christian (Director, Institute a nd D e p a rtme nt of Clinical Medicine, Heidelbe rg Univer sity Medical School - Ludolf-Kr ehl II) Profe ssor E. Nussel (Department of Clinical Social M e dicine) Professor G. Sche ttler (Director, Heidelberg Medi- c a l School - Ludolf-Krehl II) Mr W. Boll (Dir e ctor, Rehabilitation Foundation, Heide lberg) Professor G. Wagner (Director, Institute for Docu- mentation, Information and Statistics, The German Cancer Research Centr e ) Administrative staff of the University Medical School 1 Contributed to the planning of the project, but results not available for analysis in this publication. 3 8. HELSINKI (Finland) Directors: Collaborators: Dr P. Siltanen Dr M. Romo Research Depa rtme nt of the Finnish Heart Associ- a tion 9. TOWER HAMLETS (London, United Kingdom) Director: Collaborators: Dr H.B. Tunsta ll Pe doe Professor J. N. Morris (Dir e ctor, Medical Research Council Social Medicine Unit) Dr W. Brigden (Consultant Cardiologist, London Hospital) Dr E. Lawson McDona nd (Consultant C a rdiologis t, London Hospita l) Mr D. Clayton (Statistician) Ms P. Cox (Data collection) Ms E . Bourke (Data collection) Ms P. Moreph (Data collection) Staff of the London Hospital, Whitechapel, MR C Social Medicine Unit, Department of Health and Social Security, Computing Centre, University of London 10. NIJMEGEN (Ne therlands) Director: Collaborators: Dr B. V. B ekker Staff of the Re giste r Dr K. Kubat Dr J. Deppenbroek Ms H.S. Beekman Members of Steering Committee (Chairman: Dr J. G. Plette) Physicians, nurses and administrative staff of Radboud Hospital, Canisius Hospital and Wilhelmina Hospital General practitioners in Register area 4 1 0. NIJMEGEN (Netherlands) (contd) Collaborators: Municipal Health Service of Nijmegen Central Bureau of Statistics, The Hague 11. TAMPERE (Finland) Directors: Dr E. Linko (Head, Medical Clinic, Tampere Central Hospital) Dr R. Ruosteenoja (Project Manager) Collaborators: Dr O. Leskinen Dr P. Kunelius Dr T. Veneskoski Ms 0. Lahti (Re search Assi stant) 12. WARSAW - Wola, Ochota & Centre (Poland) Directors: Professor Z . Askanas Dr S. L. Rywik (Institute of Cardiology, Medical Academy of Warsaw) Collaborators: The following staff of the Institute of Cardiology and Dr w. Dr J. Dr B . Dr J. Dr J. Dr M. Dr T. Dr M. Dr H. Dr J. Dr E. the Departments of Medicine of the Medical Academy, the Central Postgraduate Teaching School, and municipal hospitals: Mikolajczyk Dr A . Kotowska Korewicki Dr T. Kuzawczyk Szozypior ow ski Dr M. Liberda Bielicka Dr D. Lothamer Cybulska Dr W. Napiorkowska Der endow ska Dr D. P~zitiska Feltynowski Dr z. Przybylska Grzeszkowa Dr T. Puchalski Hofman Dr J. Vaedtke Juskowa Dr T. Wojnar Kapuscinska 5 13. LUBLIN (Poland) Directors: Collaborators: Professor M. K~dra (Department of Cardiology, Institute of Internal Medicine, Medical Academy of Lublin) Dr J. Bednarzewski (Coordinator) Dr M. Markiewicz Dr ·N. Ruminski Dr B. Rymar Dr I. Pruszkowska 14. INNSBRUCK (Austria) Directors: 15. KA UNAS (USSR) Directors: Collaborators: Professor Braunsteiner Dr F. Dienst! Profe ssor Z . Januskevicius (Kaunas Medical Insti- tut e ) Profe ssor J. Bluzas (Coordinator) Professor J. J ankeviciute (Pathologist) Dr N . Misiuniene Dr M. Milasauskiene Dr K. Blozneliene Dr A. Mickeviciene Dr A. Seskevicius 16. BOULOGNE (France )1 Directors: Dr Lucie L a porte (Director, Medico-Social Research Division of INSERM) Dr J. L. Richard (Director, Cardiology Section of INSERM) 1 Contributed to the planning of the project, but results not available for analysis in this publication. 6 17. BODEN (Sweden) Director: Dr C. Furberg (Head, Department of Clinical Physiology) Collaborators: Dr L. Lundkvist Dr K. Svardsudd Ms I. Forsman (Nurse) 18. SOFIA (Bulgaria) Director: Professor N. Mavrodinov (Chairman, Cardiology Department, Medical Academy of Sofia) Collaborators: Assistant Professor J. Belov Dr G. Kussitas ev Dr N . Naumova 30. PER TH (Western Australia) Director: Dr D. Pole (N.H.F. Research Fellow, University Department of Medicine) Collaborators: Dr R. Reader (Director, National Heart Foundation) Professor M. McCall (University Department of Medicine) Dr C. Fortune Dr P. Connor Dr K. Cullen Professor D. Curnow Professor R. Joske (Chairman, University Department of Medicine) 7 Dr S. Mine Dr J. Robinson Professor W. Simmonds Mr A. Stenhouse (Statistician) Dr O . B. Toffler Dr T. Welborn Ms N. Lloyd (Nursing Sister) Dr W. Davidson 31. TEL AVIV - Chulon a nd Bat Yam (Israel) Director: Collaborators: Dr D. Brunner (Institute of Physiological Hygiene, T el Aviv Universi ty, Medical Department A, Government Hospital Donolo, Jaffa-Tel Aviv) Dr S. Altman Dr J. Levi Dr N. M e shulam Dr F. Ze rikyer Dr J. Weisbord Ms N . Garin-Kol BERLIN - Erfurt - P asewa lk (G e rman De mocratic Republic )1 Director: 50. BERLIN 51. ERFURT: Dr S. Bothig (R e se a rch Group on E pide miology and Pr even tion, Fa culty of Medicine, Humboldt Uni- versity, Berlin) Staff of the Register Dr I. Schne ider Dr R. Aurisch Dr H. Dusold Dr K. Br e itkr e u z (District C a rdiologist) Dr K. S a jkiewic z (Institute of P a thology, Faculty of Medicine, Humboldt Uni ver si ty) Profe ssor H . -G . H e inrich (Oskar-Ziethen-Hospital, M e dical Clinic I) a nd sta ff Dr K . P feife r (Oska r- Z i e then-Hospital, P a thological Depa rtme nt) Dr R. H e cht (Konigin-Elis a b e th-Hospita l, M edic al Department) a nd sta ff Dr H. Schaedel (Medic a l Academy, Medica l Clinic) Dr G . Strube (Medic a l A c a demy, Department of Pr eventive C a rdi ology) Doc. J . Kn a ppe (M e dic a l A cade my, Depa rtment of Preventive C a rdiology) Dr F. Vollma r (Medical Academy, Institute of Pathology) l The work of these three centr e s was coordinated by a single director and the data from them were usually combined. 8 51. ERFURT (contd) 52. PASEWALK Professor H. Fiehring (Medical Academy, Medical Clinic) Dr C. Markgraf (District Hospital, Medical Depart- ment) Dr J. Weirich (District Ho spita l, Medi c al Depart- ment) Dr E. Moos (District Hospital, Medical Department) Dr H. Feist (District Hospital, Pathological Depart- ment) WHO REGIONAL OFFICE FOR EUROPE (Copenhagen, Denmark) Dr Z . Pisa (Coordinator of the project) Dr V. K a llio Dr P. Rhomberg WHO HEADQUARTERS (Geneva , Switz e rland) EDITORIAL GROUP Mr K. Uemur a Ms M . Gander Dr Z. Fejfar Dr B. V. Bekker Dr Z. Fejfar Professor J. Morris Dr Z. Pis a Dr D. Pole 9 Statistical analys is and data processing Dr P. Rhomberg Dr M. J. Romo Dr S. Rywik Dr H. D. Tunstall Pedoe FOREWORD In 1965 the European governments asked WHO to direct mor of its activities to the field of cardiovascular diseases. In response to quest, the WHO Regional Office for Europe elaborated a long-ter ramme in the field of cardiovascular diseases. -The programme an international collaborative study of the registration of acute m this re- prog- ncluded infarction in populations, which I felt was particularly appropriat for a number of reasons. Not only is ischaemic heart disease a major scourge in the industrialized nations, but there appeared to be no means a ailable for dealing with it efficiently at the community level. In order to develop new methods of control, it was necessary to take a fresh look at t e natural history of the disease. Consequently, there was a clear need for accurate data on the incidence of myocardial infarction and on its outcome, not only in individual countries but over a wide range of centres differing i their problems, facilities, and attitudes. The initial experience with myocardial infarction registers d mon- strated the need for further research into medical certification, c mpara- tive studies of the prevalence of ischaemic heart disease, hyperte sion and stroke, and evaluation of health education in the prevention and tre tment of cardiovascular disease. It also led to the formulation of reco menda- tions on training, both in epidemiological methods in general and i coron- ary care and rehabilitation in particular. The evaluation of vario s features of health care was also initiated. The data presented in this publication are the product of a uni outstanding cooperative effort carried out throughout the European egion of WHO and elsewhere. The Regional project of the WHO Myocardial Infarction Com nity Registers is nearly comple ted, and this is where the real work beg ns. We have presented the facts, and it is now up to the individual coun ries to assess them in detail, to d etermine which ones h ave special appl"cation to local conditions, and to integra te the findings into their own plan for the improvement of health services. It is our hope, too, that for t e scientific world, this publication will constitute a source-book of r li a ble facts, which will permit them to test existing hypotheses and hope£ lly to generate others. Leo A. Kapno, M. D. WHO Regional Director for Eu ope 10 INTRODUCTION Cardiovascular diseases have a worldwide distribution. them, such as arterial hypertension, rheumatic fever and rheum disease, cerebrovascular lesions, and certain congenital malfor are common in all countries, although there may" be local differe e of their clinical manifestations, etiology, and pathogenesis. Other , such as ischaemic heart disease, Chagas disease, and cardiomyopathi s of unknown etiology, are found only, or predominantly, in certain ge graphic areas or among specific groups of people. 1 On a worldwide scale, cardiovascular diseases can be consi ered to be the major cause of death. In 1967, in about 50 countries in all contin- ents where statistics are available, cardiovascular dis eases acco nted on an average for 37 % of all deaths, the number being higher than th of deaths caused by cancer, accidents, or infectious diseases. 2 a slight decline in the expectation of life for males between 1958 a This trend, which appears to be due to cardiovascular diseases an pre- dominantly to ischaemic heart disease, 3 is not yet apparent in wo en but may become so soon. The high mortality from cardiovascular diseases is associat only with the aging of the population. Analyses of data from 29 te logically advanced countries shows that in 1967, 39 % of deaths in aged 25-64 years were due to cardiovascular diseases (fig. 1 ). Is heart disease accounted for about 7 5 % of these deaths. Fur therm mortality from ischaemic heart disease has been increasing more in younger than in older subjects (fig. 2). en haemic re, apidly There is no doubt that in affluent societies ischaemic heart di ease is the most important single cause of premature death and disabilit among men at an age when their contribution to society is most valuable. Con- trol of ischaemic heart disease is therefore of the utmost importan e in these societies. There are, however, considerable variations int e standard of medical care availabl e . Whereas some communities h ve 1 World Health Organization (1969) International work in card o- vascular diseases, 1959-1969, Geneva 2 World Health Organization (1970) Vital statistics and c a uses of death, Wld Hlth Statist. Ann., 1967, Vol. I 3 Wld Hlth Statist. Rep., 1972, 25, No. 5, 330-342 11 Fig. 1 Q.) t,,() rd ~ 50 40 ~ 30 u '"' Q.) P.. 20 0 MAJOR CAUSES OF DEATH AS PERCENTAGES OF ALL CAUSES OF DEATH: MEAN VALUES FOR 29 COUNTRIES Both sexes: a ll ages Males: 25-64 years Females : 25-64 ye a rs WMO 10801 ~ all CVD (A70, A79-86) 1 LJ Arteriosclerotic Heart Disease (A8 l) 1 - Cerebrovascular Diseases (A70) 1 ~ Malignant Neoplasms (A44-A57) 1 [Jill Accidents, Poisoning and Violence (A El 38-AEl 50) 1 1 International Classification of Diseases, Seventh Revision (List A) 1.2 Fig. 2 MORTALITY IN MALE SUBJECTS: '1a CHANGES IN 1955-1961 - AVERAGES FOR ALL COUNTR ES 50 45 40 35 30 25 20 15 10 5 0 -5 - 10 0-34 35-44 Ischaemic heart •~sease ~ • / \ Cereb:i:ovascular / diseases / \ .-o._ 0 ---- --- --0 45-54 55-64 65-74 75 Age-groups Source: Epidemiological and Vital Statistics Report, 20, 535-710 13 o change modern hospitals with the latest technical facilities, others experience difficulty in ensuring adequate care for the majority of the people. Even in areas with excellent facilities, prevention and control programmes do not reach all members of the community. In view of these problems, WHO decided in 1959 to undertake a long- term programme in the field of cardiovascular diseases, and activities tailored to meet the specific needs of the European Region were initiated by the WHO Regional Office for Europe in 1965-66. 1 In its first phase, which covered the period until the end of 1972, the Regional prog- ramme concentrated mainly on problems related to the control of ischaemic heart disease in the community, the main reason being that for financial reasons it was not possible to cover the whole field of cardiovascular dis- eases immediately. Furthermore, ischaemic heart disease is the most prevalent among the cardiovascular diseases in the European Region and it was therefore felt that by dealing with this problem first a substantial contribution towards the control of cardiovascular diseases could be made and experience could be gained that would help in developing control prog- rammes for other cardiovascular diseases. In view of the extent of cardiovascular diseases in the community, it was understood from the very beginning that all the organizational measures that were considered necessary for the establishment of an efficient com- munity control programme had to be integrated with the existing systems of medical care as organized in each country or area. Because of the variety of systems of organization of medical care in the different countries of the European Region, the programme concentrated specifically on de- veloping and testing methods that could be applied by the public health authorities in the countries interested in establishing comprehensive cardio- vascular disease community control programmes, suited to their own con- ditions. In its first phase, the programme included projects dealing with the prevention of ischaemic heart disease; the collection of better information on the extent of the disease in the community and its impact; and treat- ment, including rehabilitation and long-term follow-up of patients. An intensive training programme supported all these activities (fig. 3). In 1971, a second phase , covering the years 197 3-1977 inclusive, was approved. In this phase, the programme is being expanded and projects are being started dealing with the public health problems of hypertension, 1 From 1964-1973, the officer responsible for the promotion and implementation of the Regional Office programme was Dr Z. Pisa. 14 ..... Ul Fig. 3 p R £ V £ N T I 0 N CARDIOVASCULAR DISEASES PROGRAMME OF THE WHO REGIONAL OFFICE FOR EUROPE , 1968-1972 Incidence of lsc haemic H,..· ,1rt D1 ■ <!a& L· ..ind l-lypertens1on Eva l uation of Health Educ a tion 1n Ca rd1ovas<.u l.i.r D1 ■cascs - Training 1n Epidem1olog1ca l Method ■ Evalua t ion of the Progrcs ■ of the Regional C VD Program~ Study on the Evaluation of Co ron a r y Ca re Training in Co ronary Care - Study of the Effect ■ of Rehab - ilitation in Patient ■ with CVD T ra ining rn the Rehabilitation of Patients Wlth C VD Development of Training Ce ntre s for the Reh,1.biltta- tion of P.lhcnt ■ with CVO F 0 L L 0 w u p stroke, 1 rheumatic fever and rheumatic heart disease, 2 congenital heart malformations , 3 and chronic chest diseases leading to cor pulmonale (fig. 4 ). Fr om the very beginning it was felt necessary, before making general recommendations on the basis of the project findings, to prove the applica- bility of the organizational measures recommended in pilot areas. As a first step, therefore, close collaboration was established with many scientific institutions throughout the region (fig. 5). At the same time, contacts we re developed with the respective public health authorities in each country. Through active participation in the projects of this prog - ramme, each of the collaborating scientific institutions should become a nucleus around which national activities directed towards the development of a community control programme in the field of cardiovascular diseas e s can develop. The role of the WHO Regional Office for E urope was to p romote the activitie s, to coordinate them, and to assist in the implementation of the r ecommendations in each country. The entire programme has been exe cuted in close collaboration with WHO headquarters, as well as with the International Society of Cardiology and its different Councils, the E uropean Society of Cardiology, the Council of Europe and its Rehabilita- tion Committee, and the Ischaemic Heart Disease Register Group of Socialistic Countries (fig. 6). Proposals for the design of individual projects and the methods to be used in their implementation were formulated by a number of working groups convened by the Regional Office . These groups also prepared in- struction manuals, or protocols, which have been followed in certain studies. From the beginning, the project on the establishment of ischaemic heart disease registers was considered to be central to the whole prog- ramme . It was expected that the registers, established in a well-defined 1 World Health Organization (1971) Community control programmes for stroke and hypertension. Report of a Working Group, Geneva, 1971 (unpublished documents CVD/71. 3 & CVD/7 2. 1 2 WHO Meeting on Community Control of Rheumatic Fever and Rheumatic Heart Diseases (1972) WHO programme on rheumatic fever prevention. Re ort of a Consultation held in Cairo, 19-22 Februar 1972, Geneva {document CVD 72. 2 3 World Health Organization, Regional Office for Europe (1972) Congenital heart diseases in Europe. Report on a Working Group, Copenhagen, 13-16 September 1971 (document EURO 8213) 16 ...... -J Fig. 4 DESCRIPTIVE CHART OF THE CARDIOVASCULAR DISEASES PROGRAMME OF THE WHO REGIONAL OFFICE FOR EUROPE FROM 1973 ONW ARDS / -- - ,,, ,,, .,,,, ...... ,,, .,,, /~d/, ,' ,' vv '( I I \8, 8 / ' 8HD1 / ' / ..... / -- ,,.. to be appli e d acco rd ing to needs of respec tive countries I . . I Organizational means1 I 1Training of personne l 1 I I Studies I I T- Regional Co-ordination Centre v~u~ion of Progress I ... Community CVD Control Programmes Abbreviations ( used for this figure only) : AH CCD CHM CVD CbVD RHD - arterial hypertension - chronic chest dise ases leading to cor pulmonale - congenital heart mal-1 formations - cardiovascular dis e ases - cerebrovascular disea ses ic heart diseases - rheumatic heart diseases * ... ......... ,.,_,, ,. ... "' R 1 .... . .... - • M • bllll • II • " C T H E W HO EUROPEAN R EGION ,, .. , 1 8 .... •n•IIS"'""' I I OD * \ L\JB,I.. I.., •O I / I ' ' ' svt'""'RU'f ' - '.,,' OD •- _ \ ... - - - M Oie. OW' /',<JC 9.s.c EURO CVD PROGRAMIvIE wHo HQ Fie.6 ORCANIZATIONS COLLABORATINC IN THE WHO RECIONAL OFFICE FOR CARDIOVASCULAR DISEASES PROGRANIME C.E R.R C. .C .C : International Society of Cardiology = European Society of Cardiology = Council of Europe, Rehabilitation Committee _ Ischaemic Heart Disease Register - Group of Socialist Countries IHD Reg G. Soc. C 19 UROPE ,..]o0"" .I I population area, would furnish new data that could be used for the modern management and control of cardiovascular disease: the aim was to pro- vide the public health administrator with the information necessary for the more efficient planning of health services and for the evaluation of new methods of care for patients with myocardial infarction, and also to pro- vide research with a tool for studying the natural history of the disease. 1. BACKGROUND TO THE PROJECT During the y ear 1971, 19 communities made an intensive study of e very person below the age of 65 years believed to have suffered an acute myocardial infarction. The total population studi e d comprised 3 . 6 mil- lion people aged 20-64 years. Completeness of case ascertainment was ensur e d by a system of notification from doctors and health workers, by the scrutiny of documents and hospital records, and by making a ppeals, both on a personal basis and via the mass media. Every suspected case was registered, and information was recorded covering the medical his- tory, the timing of events, the subsequent course of the patient over the following 12 months, a nd the complications occurring. As it was hoped that the project would provide definitive answers to a number of vital questions, it was decided from the outset that the registers should cover not only hospital admissions , but should b e com- munity based. The following are the questions to which answers were sought. Exactly how much myocardial infarction occurs and which people in the community ar e specifically at risk? What proportion of these people make a satisfactory recovery and what proportion die? When death occurs following a heart attack, where does it occur and how much time do the medical s e rvices h ave for intervention? What do patients do when they experience the fir st symptoms of a heart a tta ck? How long do they wai t before calling for medical attention? When medical help is called, how long does the doctor take to come and how long is it before patients are admitted to hospital? How widely us e d is home treatment and is ther e any major benefi t in hospitalization? Is the acute pain of myocardial infarction the very first symptom of the disease or are ther e some features in the days and months preceding the attack that might allow prediction and pos- sibly even prevention of its development? What is the influence of smoking, obesity, and hypertension on the outcome? When and where do infarcts occur and are there any major differences from one community to another? Finally, what happens to patients after they leave hospital: do they general- ly return to work and do they benefit from any particular follow-up or re- habilitation programmes? 20 In Europe, cardiovascular diseases are the leading causes f death. As in most industrialized countries, ischaemic heart disease alo e is re- sponsible for one quarter of all deaths in European males, and it is the single most important cause of death in persons under 70 years o age . In addition, the incidence appears to be increasing and affecting y unger age-groups. For example, in Poland, the certified death rate fr mis- chaemic heart disease in men aged 45-54 rose from 78 per 100 0 0 in 1950 to 100 per 100 000 in 1970. These figures are typical of Eu ope as a whole.1 The public health importance of this disease is increased ev n further when the morbidity it produces is also considered. It is sponsible for total disability and long-term illness in middle age victims still have much to contribute to society and have heavy re e- hen the ponsi- bilities both to the home and at work. Community control of ischaemic heart disease It is not surprising, therefore, that in most of the affluent co considerable effort and expenditure have been directed over the las decades towards the management of this disease. A number of di approaches to the problem have been made , such as improving clin cal facilities, providing specialized transport in the acute attack, and ublic education. Although worthwhile benefits have been produced in the al management of patients, these approaches have not been followe by any significant reduction in reported mortality rates. In spite of exten ive research conducted into ischaemic heart disease over the last two ecades2 an integrated, full-scale attack on the disease in the community has not yet been launched . Few data are available about the occurrence of acute myocardial infarction in the community, with respect to its frequen y, its antecedents, and the characteristics of the early stages of the acute attack . While the hospital phase of the disease has been subject to intensive re- search and the application of space-age technology, the natural hist ry of the disease outs ide the hospital has been largely ignor ed. R apidly atal attacks, for example, remain an unresolved major problem. It is becoming clear to health authorities that the various aspe health care for ischaemic heart disease must be coordinated into an all control programme. Such a programme must provide for preve measures, improvements in detection and diagnostic facilities, rati developments in treatment, especially of the rehabilitation phases, education of health personnel and the public. It should be closely associ - ated with research and with data collection, and it should incorporat pro- visions for organizing implementation and evaluation. 1 Wld Hlth Statist. Rep., 1974, 27, 24-39 2 WHO Chronicle, 1974, 28, 55-64; 1974, 28, 116-125; 1974, 8, 190-199 21 A community control programme of this magnitude can be designed and run effe ctively only if a reliable and comprehensive information sys- tem exists . Advantage s of a register It wa s considerations such as these that l ed to t h e conception and later the inception of community registers of acute myocardial infarction as the most appropriate means of collating the informati on needed. Being based on the community, such registers would not be prone to the bias of hospital series. They would include all cases, whethe r tr eated at home or in the hospital, and would also include rapidly fatal cases not reaching the medical services. Their closeness to the community would make it easy to follow patients who le ave hospital and to chart their progr e ss as they return to normal activity. Thus, the registers would provide a total picture of the disease as it affects the community, would highlight problem areas , and would indicate where treatment faciliti e s were most in need of improvement. In other words, they would provide exactly the information system needed to develop and test which methods would be feasible and worthwhi l e components of a wide-scale community control programme. In a ddition, the uniformity and precision with which the methodology of compiling a register could be defined would allow it to be extended to other communities. A benefit to be expected from the use of standardized procedures of case finding and data recording in as many centres as pos- sible, wa s that pooling of the data would allow common features to b e se en more clearly. It could also highlight differenc es b e tween centres, both within a country and internationally, so that precise comparisons could be made and the effectiveness of different systems and the influence of prevail- ing conditions assessed. Another advantage of a standardized methodology is that the popula - tion accurately studied is greatly increased. In this study, the population aged 20-64 years who were covered by the registers in 19 centres amount- ed to 3. 6 million. By using numerous centres, t h e amount of m edical manpower that could be mobilized for the study was far greater than any single country could provide. WHO participation The involvement of WHO was central to this plan. the project depended on the need for: (1) establishment of precise diagnostic criteria; (2) selection of suitable communities; The success of (3) coordination of methodology and development of a standardized procedure of case ascertainment; 22 (4) collection of data and combined statistical analysis; (5) integration of the registers with other international with the design of community control programmes. To achieve these aims required a high degree of internation laboration with periodic working groups and smaller committees and nated through a permanent secretariat. This was organized larg ly from the WHO Regional Office for Europe, with assistance from WHO ead- quarters (Geneva) especially in the field of data processing and st tistical analysis. Pilot studies Following previous experience in Edinburgh, 1 the First Wor Group in May 1968 recommended that pilot registration and revie be established in a number of communities. The rationa le behin sign of these pilot studies was that registration should give a defi reliable statement of the presentation and natural history of myoc infarction in the community in order to: (1) provide measures of the local need for services by g1v1 in- formation about whether the existing services were adequate their tasks, both in the early and the late stages of the disea (2) provide a basis for the evaluation of existing and propos methods of management by comparing the results for groups anaged in different ways; (3) provide a more complete clinical picture of the early na history of the disease than can be obtained from hospital case , to help in the study of etiology and pathogenesis and thus sugge s methods of preventing the large number of fatal episodes occ rring soon a fter the attack; and (4) help research by providing representative cases for stud and a sampling frame for clinical trials, a nd by allowing different studies to be related to the total community problem. 1 Armstrong, A. (1968) Edinburgh community study of acute coronary disease. In: Julian, D. G. & Oliver, M. F., ed., Acute o- cardial infarction, Proce edings of a Symposium sponsor ed by the U iver- sity of Edinburgh in September 1967, Edinburgh & London, Livingst ne, pp. 299-304 23 The requirements for notification of patients and the data to be col- lected for the register were clearly set out in a protocol for the myoca rdial infarction pilot registers, which was adopted almost without change for the definitive study. I Centres were informed in detail of: (1) who should receive notifications; (2) diagnostic criteria for notifying patients; (3) provisional classification of notified patients; (4) estimation methods for the seve rity of the attack; (5) minimum background information to be collected: (a) sociodemographic, (b) previous medical history; (6) intervals at which follow-up should be done and information to b e collected; (7) methods for obtaining completeness of information; (8) method of checking completeness of notification and registration. In order to give pilot registers a good chance to succeed, areas were preferred that satisfied the following criteria: (1) presence of epidemiological and cardiological skills, interest and enthusiasm for the task, and the necessary resources to organ- ize a suitable study team ; (2) existence of medical services that would bring people with heart attacks to notice and could provide full treatment facilities; (3) full cooperation available from hospital and non-hospital doctors; (4) a study population, which could be that of a defined administra- tive area, for which recent demographic and social data were avail- able and which was l arge enough to yield at least 200 "heart attacks" in a year. The Group emphasized that considerable effort would have to be made to elicit the cooperation of both the public and the health professions if the registers were to succeed. It pointed out, for example, that in many countries it is not thought important to establish the exact cause of "sud- den death", except in the case of violence. 1 See Annex I 24 It was realized that, for each community, a principal invest gator should be appointed who could be responsible for the working of th re- gister and for coordinating the efforts of local participants. From the very beginning of the project, professional statisti WHO headquarters were involved in the design of records, checki completeness, and preparing tabulations of the findings in order t investigators and their governments as much information as possi It was soon apparent from the early results· of the pilot studi many of the objectives of registration could be achieved within a o e-year period of definitive collection. The protocol was therefore fin a liz d and in 1971 (a little earlier in some centres) 17 centres as representat ve of Europe as possible together with Tel-Aviv (Israel) and Perth (Wes ern Australia) registered 14 373 cases of suspected myocardial infarct on, and pooled their findings. The combined results of this collaborative tudy are presented in the following pages. 2. METHODOLOGY Objective s In 1967, a group of experts was convened by the WHO R egiona Of- fice for Europe to advise on the expansion of WHO's activities relat d to the control of cardiovascular diseases. One of the groupts recom enda- tions was that a system should be developed for compiling information on the occurrence of myocardial infarction in the community. It was ro- posed that this information system be designed to: (a) demonstr ate he extent of the problem in the community, (b) offer a means of monito ing the effect of changes in the management of the disease and differ ent types of intervention, (c) provide an independent assessment of th e validit of mortality statistics, and (d) permit the central coordination of rese activitie s by providing for a pool of patients who could be studied i tail and whose progress would focus attention on specific problem a The registration of a ll patients stricken with acute myocardia l infar in defined communities was chosen as the best tool for accomplishin these objectives. 25 Initial studies The first Working Group on the Establishment of Ischaemic Heart Disease Registers in 19681 outlined the minimum requirements of such an information system, based on the experience gained in community studies in Great Britain2, 3 and in the United States of America. 4 The pilot scheme, a modified version of the Edinburgh community study, 3 was tested in Gothenburg and Prague in 1969. There were dif- ferences between these two areas in the major difficulties experienced, owing to differences between the countries concerned in regard to the structure of the health services and the general policy of care and treat- ment. In the city of Gothenburg the medical services were centralized. Patients with suspected acute myocardial infarction were admitted to a single hospital as a rule either directly or through the alarm service and only occasionally through general practitioners. Thus, it was possible to base the register on regular checking of all hospital admissions and scrutiny of the ECG requests in the hospital. Relevant deaths outside hospital were traced from death certificates. The cases of suspected acute myocardial infarction managed at home formed a negligible pro- portion but, to cover these, a small mobile diagnostic team was provided. In Prague, on the other hand, the population under study was resident in a suburban district of the town, and a quarter of this population com- muted each working day to the centre of the city as well as to other areas . Many of those taken ill during working hours were admitted to hospitals outside the registration area and could be included in the register only with great difficulty. Hence, a great number of doctors, particularly general 1 World Health Organization, Regional Office for Europe (1968) Ischaemic heart disease re isters, Re ort of a Workin Grou , Co en- hagen, 27 -31 May 1 968, Copenhagen document EURO 5010 1 2 Kinlen, L. (1973) Incidence and presentation of myocardial in- farction in an English community, Brit. Heart J., 35, 616-622 3 Armstrong, A. (1968) Edinburgh community study of acute coron- ary disease. In: Julian, D. G. & Oliver, M. F., ed., Acute myocardial infarction, Proceedings of a Symposium sponsored by the University of Edinburgh in September 1967, Edinburgh & London, Livingstone, pp. 299- 304 4 Eisenberg, H. et al. (1961) Epidemiology of coronary heart disease in Middlesex county, Connecticut,J. chron. Dis., .!_±, 221-235 26 practitioners and specialists, had to be involved. Although domi iliary c a re of patients with acute myocardial infarction was an exceptio Gothenburg, th e vast majority of patients with acute illne ss were attended by a general practitioner before being sent to hospital. unlike Gothenburg, there were numerous medical departments sp over a wide area of the city, some of which dealt only with c ertai cupational groups. The success of the Prague register was, the very d e pendent upon the active collaboration of general practition When the investigators summarized their experience at th e Working Group on the Establishment of Ischaemic Heart Dis ease in April 196 91 it was concluded that a registration scheme would be designed tha t would be capable of application to widely varying of health care. Accordingly, a large number of experts from cli ical, pathological, epidemiological, and public health fields interested i JOmmg in a coope r a tive study were invited to a meeting held in May of tha year and an operating protocol for a collaborative register study was d awn up.2 Careful consideration was given to determining the sma ll e st amou t of informati on ne e ded to achieve the objectives. An attempt was ma standardize procedures, both with respect to case finding and to t way information was interpreted, so as to allow pooling of data from di ferent centres and compa rison of results . This "minimal" informa tion be sent from ea ch centre on a printed record form for analysis to he a dquarters (s ee Annex II). Each centre was encouraged, howev obtain additiona l items for its own use a nd analysis. Most centres sta rted building up their registers in The initia l operating protocol was refined on the basis of this initia ex- p erience by further working groups in 197 0, by which stage commu ica tion h ad been e sta blishe d with the 19 c entres p a rticipa ting in the final s udy . The final protocol produc e d in April 1971 was trea t ed as the definit ve version and all records were colle cted in a ccorda nc e with it. 3 1 Wo rld Health Organization, Regiona l Offic e for Europe Ischaemic heart disease re ist e rs Re ort of a Workin 27-31 May 1968, Copenhagen doc um e nt EURO 50 10(1 2 World Health Organization, Regional Offic e fo r Workin Grou on Ischaemic Heart Disease Re ist e rs O e r atin Pr 3 ~ o rld Hea_lth Organization, Regional Office for Europe (1971 Ischaem1 c heart disease r e isters Re ort of the Fifth Workin Gro eluding a second r evision of the operating protocol , Copenhagen, 26-2 9 April 1971 (document EURO 8201(5)) 27 Definitive study In order to obtain a statistically sufficient number of notifications, it was decided that the duration of the study should cover one year ts reg- istration with a follow-up period to last for 12 months after the acute at- tack. Registration was therefore maintained throughout the calendar year 1971 and the fate of each registered patient was investigated over the whole of 1972. In some centres, where the study had started earlier, the information was collected over a longer period (see tables 12 and 13 ). The areas covered varied in size from 22 000 to 351 000 inhabitants, with an age range of 20 to 64 years (see table 1 ). One centre (Copenhagen) attempted to cover 1. 5 million inhabitants but found that the agreed proto- col was too detailed and started using a simpler registration scheme. Data from this centre, as well as from Boulogne-Paris, which could not provide data for the whole study period, are therefore not included in this publication, but have been published separately. Each community had to be well defined demographically, as census data were indispensable for establishing exact incidence figures. In large metropolitan areas, such as London, Bucharest and Prague, only one section or district was chosen. In other instances, such as Gothenburg and Helsinki, an entire town could be taken as the observation area. On the other hand, places such as Innsbruck and Tampere included, in addition to the town, a large rural area. By the end of 197 O, 17 centres in Europe (and one each in Australia and Israel) were ready to participate in the study. Persons registered All per sons, male and female, in whom there was "any suspicion" that acute myocardial infarction might have occurred, who were 65 years of agel or below at the onset of the acute attack, and who were resident in the defined registration area, were admitted to the register, regardless of whether they were still alive or dead at the time of registration. The cut-off point of 65 years of age was chosen in order to keep the register to a size that was easy to handle, to exclude older patients with their multiple pathology, and to concentrate on an age-group that was easily accessible and in most countries still employed. However, certain centres registered persons of all ages and the data on those of 65 years of age and above were also processed locally. 1 Sixty-five year olds were registered so that subsequent corrections to birth dates would have less effect on the number in the highest age category analysed. 28 Table 1 MYOCARDIAL INFARCTION COMMUNITY REGISTERS Code No. Country Community Pop,1 lation (2Q-6L years} 01 Sweden Gothenburg 27 830 02 Czechoslovakia Prague 4 11 ( 960 03 Romania Bucharest 4 191 760 04 Hungary Budapest 312 810 06 Ireland Dublin City 67 620 ( south of canal} 07 Federal Republic of Germany Heidelberg 181 920 08 Finland Helsinki 332 120 09 United Kingdom Tower Hamlets, 93 320 London 10 Netherlands Nijmegen 132 510 11 Finland Tampere 96 )70 12 Poland Warsaw 350 ~40 13 Poland Lublin 137 WO 14 Austria Innsbruck 126 < 40 15 USSR Kaunas 186 <60 17 Sweden Boden 22 ~80 18 Bulgaria Sofia 274 : 80 30 Australia Perth 293 860 31 Israel Tel Aviv 121 110 50 )a Berlin 51 ) German Democratic Republic Pasewalk 253 l rn 52 } Erfurt TOTAL 3 570 1 IQ a Combined results from Berlin (GDR), Erfurt and Pasewalk a rE presented for most of the tables. 29 Persons whose permanent residence was in the registration area and who had suffered an acute attack outside this area were searched for and included in the register, 1 and per sons who were not resident in the area of the study at the time of the attack, for example tourists or people work- ing temporarily in the area, were excluded. Principles of registration The duration of the acute episode was arbitrarily considered to be four weeks. If reinfarction occurred during this period, it was recorded as a complication and the patient was not readmitted to the register. Any recurrent attack after four weeks was considered a new event and the pa- tient was registered again, with a new registration number. Hence, the same person could enter the register several times during the observation period of one year. 2 The register was designed as a case register as this was considered to be the best way to give information on the true ex- tent of myocardial infarction in the community. The information collect- ed, however, could also allow the natural history of each individual patient to be described. Among patients who were seen alive by the doctor, notification was usually based upon the occurrence of char a cteristic retrosternal pain. However, it was not intended that a patient with obvious angina pectoris of effort3 only should be notified. In some cases pain was not prominent and the clinical picture was, for example, dominated by dyspnoea, sense of suffocation, indigestion, syncope, general malaise, sweating, or acute heart failure . Provided that suspicion of an acute myocardial infarction was entertained, however, these cases were also registered. The occur- rence of other clinical manifestations or laboratory findings may also have led to the registration of some patients. Not all the medically una ttended deaths in patients who died before being seen by any doctor were "sudden deaths", as some of the patients had had symptoms for several hours or even days. Information on these cases was collected from the doctor who had signed the death certificate or who had treated the patient and from the medicolegal authorities and departments of pathology. In addition, in some centres interviews were 1 This search proved impossible in centres 13 (Lublin), 14 (Innsbruck) and 30 (Perth), unless patients rapidly returned to the area or were documented in it (death certificate, sick leave , etc.). 2 This occurred only in 6. 5 % of patients. In most of the tables "cases" refers to episodes of the disease rather than persons, but the errors thus introduced are small. 3 Defined in Annex I, p. 157 30 arranged with relatives and others perons who could give information on the circumstances unde r which death had occurred and on the pr e vious ' medical history. Initial information (Record "Jll") Once the patient had been admitted to the register, the Initi c: 1 R e cord Form was completed as soon a s pra cticable, but at the latest witl- in the ensuing four weeks . This record form was completed if possible by dir- ect interview a t the patient 1s b e dside. Alternatively, informa tiOI was ob tained from hospita l c a se note s, general practitioner ts r e cords, c r intervie ws with r e latives. The list of the information obtaine d may be seen in table 2. Table 2 INITIAL INFORM ATION OBT AINED ON A LL REGIST E RED P A TIENTS De mographic information De tails of a cute a tta ck Timing of acute a tta ck Imme dia te medical history P a st m e dic a l history First r e corde d clinical d e t a ils Ag e , s e x, source of notific a tioh t o r e giste r Pla c e , tr a n s port us e d De l a y b e for e calling doctor, b e or e b e ing e x a mined, before r e c e i v: n g a ntiarrhythmic trea tme nt, b e f c r e a rriving in hospita l Pr e s e nc e of a n gina , othe r che st p a in, tiredne ss, breathle ssne ss, p a l )ita - ti ons My o c a rdi a l infa rction, a n gi na, st rok e , cla udic ation , di abe tes , hy pertension, w h e the r smoke r H not a nd a mount smoke d Pr e senc e of shock, h eart r a t e , eart rhythm, r e spir a tory r a t e , blorn pr e ssur e , weight and heigh t a nd sourc e of this info rma tion 31 First review (Record "Jl2"/lst) Four weeks after the onset of the acute attack or on discharge from hospital if this was earlier, the patient was reviewed for the first time. This first review provided an opportunity not only for recording the com- plications that had occurred since onset, but also for establishing a diagnostic classification of the patient. In order to keep observer varia- tion to a minimum, all cases were diagnosed by the register staff from the documents that were• available . The diagnostic cate g ories we re: (1) definite acute myocardial infarction, (2) possible acute myocar dial in- farction, (3) n ot a cute myocardial infarction, and (4) fatal c ases with insufficient data. The :rules for e stablishing these diagnostic categories can be seen in Annex I and are illustrated in the form of a decision-tree in fig . 7. The decisions taken at each point are logical consequences of the evidence avai l able. The autopsy findings in fatal cases are first considered and if these are inconclusive the next consideration is the history (which , of course , is the first consider a tion for s urvi ving patients). Electrocardiographic evidence is considered next; in patients with some history, if the diagnosis has not been reached by this stage the serum enzyme levels a r e examined. Finally , in patients with some history but inconclusive investigations, and in fatal cases with no history, a decision is made on the basis of the clinical evidence of ischaemic he a rt dis ea s e . On such evidence , however , cases can only b e plac e d in the c a te g ory "possible a cute myocardial infarction" and then only in the absence of in- formation tha t would permit an alternative diagnosis to be established. This formal diagnostic classifica tion was designed in an attempt to duplicate the thinking of physicians in the current state of knowle dge. Any such a tte mpt, especially on an international scale, must of course be in the natur e of a compromise. Its main advantage, however, was to reduce subjective interpretation of the data as much as possible. Follow-up reviews (R e cord forms "Jl 2" /2nd & 3rd) A se cond review was performed in patients with a diagnosis of pos- sible or definite myocardial infarction three months after the acute attack and a final review after twelve months. On the s e occasions, information was obtained, either through interview or from the patient's regular medical practitioner, as to the patient's clinical state, the details of any rehospitalization that h a d occurred, and the development of complications (see table 3). D ea th record (R e cord form "J13") If at any time in the first 12 months the patient di ed , a separate death record was also completed. This record, together with a First Review Record , was a lso filled in for patients who were dead when first registered. The de a th record contained the following particulars: the time of death, the place, whether witness ed , how recently there had been a medical consultation, and an International Classification of Dis eases 32 w w ~ DECISION TREE FOR ESTABLISHING A DIAGNOSIS OF MYOCARDIAL INFARCTION Diagnostic criteria (for mor e details see Annex I, pp. 157 et seq.) HISTORY: ECG : ENZ : AUTOPSY : typical, 2 = a typica l, 4 = none , 9 = no data definite, 2 = equivoc al, 3 = other, 4 = none, 'I = no d a ta elevated, 2 = equivoc a l, 4 = normal, 9 = no data positive , 4 = negative . 5 = patient a live, 9 = no data ECG: ENZ: EVIDENCE: Y: N: Electrocardiographic findings Serum enzyme levels Clinical or autopsy evidence of previous !HD or for another diagnosis Yes No Table 3 INFORMATION OBTAINED AT REVIEWS (28 DAYS, THREE MONTHS, ONE YEAR) Timing Number and date of review State of p atient Whe the r alive or dead; if in hospital, degree of recovery R e hospita liz a tion How frequently rehospitalized again during the year, discha rge diagnoses, number of days spent in ccul and ward, whether systematic rehabilitation instituted Complications Congestive cardiac failure, shock, thrombo- embolism , cardiac arrest, reinfarction , angina , other Diagnostic criteria History• e l e ctrocardiagram, serum enzyme s, (1st review only) a utopsy findings, alternative diagnosis made 1 CCU = coronary care unit. For definition see Annex I, p. 151 coding of the c a use of de ath as certified either on clinical grounds or from the autopsy. Some centres recorded both certifications if they were available separately. When a pati e nt in the register died, one further review form was completed. The records for each patient therefore consisted of at least an initial record and a first review, and in fatal cases a death record; in those patients with a positive diagnosis who survived long enough there was a second review, and in some also a third review. As the initial record was contained on four punchcards, each subsequent review on one card , and the death record on one card, the number of computer cards for each patient in the register varied from five to eight. A decision-tree showing the sequence of actions taken may be seen in fig . 8 . A patient who suf- fered a second myoca rdial infarction after the first review had been per- formed was re-register ed as a completely separate event and the follow -up reviews were performed for both events independently. 34 F ig . 8 DECISION-TREE SHOWING COURS E OF ACTION TAKEN FOLLOW ING RECEIPT OF NOTIFICATION OF A SUSPECTED CASE OF MYOCARDIAL INFARCTION (MI) ,::: s ~ I'l2.e ~~tres only -------i Stop Too old Lives outside area Re infarction re-register Registrat ion First review Second review _______ --4- -- - Third review Stop Stop _ _. ___ _ t I I I Stop ) Death: fill in record Stop Centres "not" screening: 2, 4, 6, 12, 18, 31, 50 35 I I I I The procedure used to review a patient after a registered episode depended on lo.cal cir.curnstanc.es and especially on the type of health serv- ice organization in his place oi residence. A patient visiting an out- patient department was regularly checked. In some centres special cardiac outpatient clinics were establi-shed for the purpose of this study. This applied particularly in places wher•e only one central hospital existed, while in larger cities or towns it was found practical to mail a questionnaire to the person concerned. In places where the patient wa s normally followed up by a general practitioner, cardiologist, internist, health service centre, etc., a postal questionnaire was sent to the responsible doctor and the re - view record forms completed accordingly. Information was collected in some centres by sending a medical student, nurse, or other assistant to obtain the necessary information through an int·erview with the patient at home. Completeness of the register If the register was to be of value, it· was essential that it should con- tain the highest possible proportion of all relevant cases arising in the population under study. A careful survey was therefore made in each centre to trace ali the cases in question and to e nsure that the informa tion on them was as complete as possible. Although the sources of r elevant information differed from place to place, the following main approaches were observed by all centres: (a) Hospital surveillance. There were several ways of achieving full registration of hospital patients: regular. visits to medical wards and coronary care units, scrutiny of all electrocardiograms requested within the hospital, and surveillance of admission and discharge records. Further checks were carried out by surveying necropsy r e cords and als o by checking retrospectively the discharge diagnosis from the diagnostic index. (b) Death certificates. All death certificates in the study area were frequently and regularly scrutinized. Any death with a mention of is- chaemic heart disease was followed up by enquiries to the doctor who signed the certificate, and included in the register if appropriate. Copies of certificates of deaths occurring in the area under study were retained in the register, if this was legally permissible. (c) Medicolegal authority. Clos e liaison with the medicolegal authorities was essential for coverage of medically unattended de aths. The a uthori- ties in nearly all centres provided informa tion about all such deaths, in- cluding autopsy reports. (d) Social insurance records. Wherever feasible, insurance records were routinely checked. This was a particularly useful way of tracing patients who were treated at home. Depending on the organization of the health service and local practice in regard to transfer of a patient with acute myocardial infarction to the 36 hospital , retrospective checking of records of general prac titioners was of great value and was c arried out at regular intervals in certain centres . When the registers were being built up initially, contacts were made with general practitioners, health centres, medical wards , hospital reception staff, ambulance personnel, telephone alarm services, pathological de- partments, medicolegal authorities , and police stat ions, According to the local circumstan ces , some registers also institu ted a surveillance of records held by these agencies. These contacts were maintained through - out the registration period (see tabl e 4). Monthly newsletters, similar to the specimen in fig . 9, were sent to the collaborating doctors in the field as a kind of periodical reminder . Progress reports were presented in some centres at seminars and lectures . Telephone calls and personal visits were also made by the register team to strengthen the contacts and to obtain complete informa- tion on an event (see table 5 ). In order to facilitate the cooperation of general practitioners and specialists in internal medicine, arrangeme nts were made to have all the filling-in of forms done by register staff. Some centres established a telephone tape-recording system to receive notifications from general practitioners, and the telephone was a l so used by police a u thorities, emergency services, etc ., to dictate notifications . It proved useful to obtain information on events occurring in the evenings, a t night, or during weekends . In the case of a death , an interviewer or a questionnaire was sent to the certifying doctor and, in some centres, to the witness of the death or to relatives , in order to obtain accurate information. If a pati ent did not report for one of the reviews, or if no reply was made by the pati e nt or general practitioner , an interviewer went to the patient t s home in order to determine what had happened (t a ble 6 ). Feasibility stu dy A pilot study in registration was underta ken in 197 0 in which a ll collaborating centres took p a rt. This tested the feasibility of the oper- ating protocol and also provided experienc e of running a register und e r the conditions of each particular place. In the pilot phase specia l a t- tention was paid to building up the system of the local regist e r. Each was headed by a doctor who was the principal investigator and who s e lect- ed the staff and obtained th e financial resources necessary for accommo- dation, staffing and e quipm ent. It was found that, after the initia l testing of procedures, a good d eal of work could be delega ted by the doctor to specially trained medical students or nurses and even to secretarial staff. In p a rticular, the completion of r e cord forms and interviews were per- formed by junior staff in many c e ntres. In a few centres, however, most of the register activities, including interviewing and checking the completeness of information, were done exclusively by doctors. Never- theless, all centres had one common factor: there was one principa l in- vestigator in charge of the coordination of the work and of the final che ck- ing of the quality of the data. 37 <.,.) CY) Table 4 No . of Centre l 2 3 4 6 7 8 9 lO 11 12 l 3 14 15 17 18 30 31 50 Name of G.P. Centre records Gothenburg - Pi:ague + Bu c harest + Budapest - Dublin - Heidelberg - Helsinki - Lof\\ion - Nijmegen - Tampere - Warsaw - I Lublin t I Innsbruck t Kaunas + Boden - Sofia t Perth . Tel Aviv - Berlin - ACTIVE C HECKING OF SOURCES OF REGISTR ATION Hospital Hospital ECG I Death Autopsy Social Medicolegal admiss io n discharge insur a n c e Other sources r eco rds r ecor ds re co rds I ce rctificate s rccoFds re c ords authori t y - + -I - + I + - + Erne r gency service I + + + t + ! + + - + + I - + -I - + Emerge ncy service + I + I - + + I - + Ambulance service I I + + I + I I Cardiac bed bureau - I - - - I ' Random I I - + - + I + I . - sample + + I - t I + + + P olice records I I + + I - + . - + Emerge ncy service ' I + + - + + - " Ambulance service I ' ' + + - I + .. I + ! t I ! I I I + + - ' + + . + Emergency service I I ' I I + + ! + + + I - + Emergency service I I I + + + ;, I + I t + + + + I + i + - + Emerge ncy serv ice + t . t I + I - + - + t I - I + i + + + Ambulance s ervice t I I police records I I t + - + + - + Hom e nurses t ambulance s ervice + + - t + - + ' t + - + + I - + Fig. 9 SAMPLE NEWS L ETTER SEN T TO COOPERATING DOCTORS Reference · IN THE COMMU NI TY TOWER HAMLETS CORONARY PROJECT 39, Walden Street, Stepney, London, E1 2AL Telephone : 01 • 790 6638 W A N T E D 0 N S U S P I C I O N I To>1er Hamlets Co rona ry Pro Ject NewslPtte!' No . ~ T!'.e Sur•,cy : 1a £ no:-1 bPe- n 1n ope r at1on for ~: x mont1.s :i.nd U'l"f' ~00 not1f!.crt t 1on o f suspf>ct.ed c o r ona r ies :.ave bee n rece1.vrd . Ho,10ver, we are s till m1ss1 ng cases be c au se people 'ces it t e about t elli n g us of douL tful cases . Please not1fy us f.r,:;t and co nf 1rm t r.e d1agnos1s afterwards . We are intcres,;;r-;-;, all new Crtscs of suspPcted acute coronary d 1s('aUP - 'N ' n t : 0 r 1 t is 1n, t,a lly called coronary tl.romLos1s , c o r ona ry insuff1c1cncy , crnscp ndo angina or n.yocard1al i nfarc t i on - i n r Psid.,n t ,:; of To:-1er Hamlets (posta l districts E . 1 , E . , , E . 3 a nd E . 1/4) wl.o are und~r G5 . If you r.ave a case r.ng J,:; up (Te l. No . 790 66}9 ) and g ive us I.is (or r.er) name , age , ho me addres s and wt .ere we can find h1m . We woul a ratl.er sear aLout t i.e same case several t iffio S ti. an no t at all . If l.e ts be1ng manai;ed at ~ e can , tf you ,nsl. , do an e lectrocard iogr am and cardiac enzymes wt.e n we go to see r.im if t hese are not otr.e rwise avatlabl P . Tl.e P roJect Office i s now Lei ne run by a n., • .., Assis t an t , M1ss An i t a O•Callagl,an , ,;l.o will be pleasPd t o take y ou r notiftcation and an swe r any queries . Anyone wl"o would l,ke t o vi sit the Pro Je Ct r.eadquarters will be ve ry we lcome . Peopl e are now ba ck f r om their :.olldays . [f y ou ,.ad any pat 1P nts wno ,.ad co r onaries •.ktls t ~ or ~ wnre on holiday pl e a se [ Pt us know . Better a lat e not ifica tion than not at all. We arn hopi ng to ho ld an opP n meet,ng to discus s progrPss , n t he next few wee k s . Please pin tr1s up . Thank you for all your hP lp H . D. Tun s tall Pe doe , MA MRCP ., Pro Ject Sen1or Registra r LONDON HOSPITAL CARDIAC DEPARTMENT MEDICAL RESEARCH COUNCIL SOCIAL MEDI CINE UNIT 3 9 Table 5 SPEClAL FEATURES OF l NDIVIDUA L CENTRES Centre Cen tr e Special Features I Nu. I I I Goth e nburg Hospi t a l pati e nts only but prospective studies show th a t less th an 5 % I of cases we r e dealt with o utside hosp ital. 2 Prdgue 4 As few gene r al pr ac titioners were willing to no t ify , their records were ac tive ly c he cke d. I I 3 Bucha r e st 4 Families as well as pa t ients followed up. I I I (, Dublin I Free ECGs and enzyme analysis pro,·1 ded for pa t ient s tr ea ted a t home. Newspape r de a ths colum ns s canned. I I I 7 Heidelberg Re views do ne by v1s1 ts to general pra c tllloners . I I 9 T ower Hamle t s , Lo ca l opt ions empha.sized so cia l scienLe aspects (sociologist part of London team) . Ve r y mobile populallon Cdus cd difficul t ies in follow - up . ! I 10 NiJmegen Automatic telephone us ed to take notifi ca t ions. lnillal difficult y of I I linking "c ause oi death 11 with pe rs onal dat a . I II T am per e Most r egi,; ter activity ca rried out by trained nu rs e . Very few I ca ses notified by gene r al pract i tioners . ' 12 W a rsa w Form s fil led in by a spe ciall y tr ained group consisting of doc tors c lo sely co llabo rating wjth th e r e_gister. 13 L ublin " " 14 lnnsbruck M e di ca l stude nts h el ped co llect data. Diffi cu lt t o collect a ny patient information from medi co leg al cases. P os tal qu e st1onn a1 r e a ls o not ve r y suc ce ssful. 15 Kaunas Relati ve s we r e i nterviewed i n cases of death. Autopsi e s are obligato r y on all ca ses of death in th e ci t y. 17 Boden The only mainly rural reg1 ste r (77 15 km 2). Very far north with midnight sun 1n summer . Proble m of having no patholog is t for area. 18 Sofia Meetings were held between chiefs of polyclinics. 30 Perth Computerized progress reports sent t o general practitioners to maintain interest . Special analysis of e ffe cti vene s s of mobile coronary ca re W1it. I 31 T e l Aviv All general practitioners are e mployed by a si ckness fund on a salary basis. They do not treat acute illness at home. ECG was taken at review per iode. 50 B e rlin Two c it y are a s and a rura l a re a (P asewalk) used for c ompa rison 51 Erfurt purposes . (Note : data for thes e areas have been combrned for 52 Pase walk most of the results.) 40 Table 6 METHODS USED IN REVIEWING PATIENTS Visit Postal questionnaire to: Telephone enquiry to: No. of Name of to/ by Review of cent r e centre General hospital documents General pati e nt practitioner Pati ent practitioner Patient 1 Gothe nburg + + + + - - 2 Prague + - - + - - 3 Bucharest + - - - - + 4 Budapest + - - - - - 6 Dublin + - - + + + 7 Heidelberg + - - - + + ..,. ...... 8 Helsinki - + + - - - 9 London + + + + + + 10 Nijmegen + + - + + + 11 Tampere + - - + - - 12 Warsaw + - - - - - 13 Lublin + - - + + - 14 Innsbruck + - + + - - 15 Kaunas + - - + - - 17 Boden + - - + - + 18 Sofia + + + + - - 30 Perth + + + + - - 31 Tel Aviv + - - + + + 50 Berlin + - - + + - Type of information needed Record forms designed by WHO, after testing in pre-pilot studies, were translated and printed by investigators from each of the participating centres. As is usual in any cooperative study in places with different cultural features , the operating protocols had to be amended several times to ensure that the guidelines would be clear to everyone and to remove all ambiguity . The basic recording system, however, did not require any modification. The English-language forms are included in Annex I. Local options In the design of all three record forms (see "Data processing") a number of spaces on the punchcards were reserved for the recording of local options by the centres. In many, the place of birth, marital status, information on occupation and social class , and a more detailed medical history were included. Questions concerning dietary habits were added in some centres, and in others changes in smoking habits after the acute myocardial infarction were recorded. Detailed accounts of the drug treatment and of the laboratory findings were provided by many centres. A more detailed description of the time between the acute onset of the attack and the admission to the hospital was undertaken by some centres, while others concentrated their investigations on the question of return to work. One centre studied the behavioural aspects of the patient ts attitude towards medical care under the circumstances of acute myocardial in- farction. Finally, a few centres compared autopsy studies of morpho- logical changes with clinical and laboratory findings. Meteorological data were available in nearly a ll centres and details of water hardness in some, and these data were sent also to Geneva for standardized processing. Standardization and intercentre comparability A common operating protocol, which is attached as Annex I, was drawn up by the representatives of all participating centr e s to be the "bench book" of the operations. Although each register took special pre- cautions to ensure comparability of the findings, validity testing was applied to as many procedures as local circumstances permitted. Thus, it was not possible to standardize the methodology of serum enzyme an- alysis or the reagents used for the determination, but advice was given on interpretation of the findings. Similarly, the electrocardiograms were read by local cardiologists, other doctors or technicians and were checked by a member of the team, but not centrally. However, a series of test electrocardiograms was prepared by WHO and sent to each centre for evaluation, in order to check the reliability of its readings. The five working groups convened by the WHO Regional Office for Europe provided opportunities for the participants to make personal con- tacts, to discuss each other's experiences , and to acquaint themselves with the problems in other centres. From time to time, the WHO 42 Regional Office for Europe colle cted reports from the centres and dis- tributed n ewsle tters informing the m of each other's progress. At a later stage , tabulations based on preliminary results were prepa red and sent to all c e ntres. This allowed inter centr e comparison and where vari- ations were caused by misinterpr e tation of the protocol the errors could b e r e ctified in time. A very useful tool for standardizing the proc e dure of completing the record forms was the use of sample case histories . Nine sample c a se histories, prepa r e d by Dr H. D. Tunstall Pedoe, 1 were sent to a ll partici- pating centres during the r egister year and their respons e s compa r e d. In order to look into the specific problems of diffe rent registers "on the spot", consultants were s e nt round before and during the study period. They discussed with the r egister teams l ocal pr ocedu r es for admissi on to the register a nd assisted in clarifying points that were causing unc e rtainty. In pr evious y ears, collabor a tors from s e v e ral register area s h ad a tte nded courses on m e dic a l st a tistics a nd epidemiology sponsor ed by WHO or by the Internationa l Society for Cardiolo gy. 2 This common tr a ining progr a mme and p e rsona l acquaintance proved h e lpful in maintain- ing close contacts between the c e ntres. Mutual visits of individual m e m- bers of register teams to other registers also h e lped to incr ea s e the spirit of coope r a tion a nd to improve the st a ndardi zation o f proce dur e s. Data p r oc e ssing The following three types of r e cord forms were us e d in th e study: 3 (a ) Initial Record Form (Jll), completed at r egistr a tion (b) Review Record Form (Jl 2), completed a t: - 1st review a t 28 d ays aft e r onset or on ear li e r discharge from hospital; 2nd review at 3 months after onset; - 3rd review at 1 year a ft er ons e t (c) Death Record Form (Jl 3), complete d at de a th. 1 Director, Tower Hamlets Register , London, England 2 A 10-day Inter na tiona l Teaching Seminar was a rranged by th e Council on Epidemiology a nd Pr evention of th e Internationa l Soci ety for Cardiology. • 3 See Annex I 43 Thus, on a patient who survived one year, the review record was completed three times, in addition to the initial record. For a patient who died earlier, besides the death record form records were completed up to the next review after death. The data acquisition scheme is shown in fig, 8, The number of record forms completed on a patient thus varied according to the length of survival. Table 7 gives a summary: Table 7 FORMS PRODUCED FOR DIFFERENT CATEGORIES OF PATIENTS P a ti e nt c a t e gory R e cord forms Patient diagnosed as "not Jl 1' J1 2/lst infarction" Patient who died before J11, J12/lst, J13 registration Patient who died between J11, J1 2/lst, J13 registration & 1st review Patient who died between 1st J11, J12/lst, J12(2nd, J13 and 2nd reviews Patient who died between 2nd J11, Jl 2/lst, Jl 2(2nd, Jl 2(3rd, and 3rd reviews J13 Patient alive at 3rd review Jll, J12/lst, J12(2nd, J12(3rd When a registered patient suffered a further myocardial infarction after 28 days, he was re-admitted to the register. A new registration number was given and the patient was followed up according to a new timetable. However, he continued to be followed up also according to the original timetable. In some instances this resulted in a complicated review schedule and, in one case, a patient had to be reviewed according to as many as six different schedules as he had five episodes of reinfarc- tion over a 12-month period but spaced at intervals exceeding 28 days. The different sets of records relating to the same patient were linked to each other by means of the registration number given at the time of the previous episode which was entered as an item in the initial record form. Central data processing was carried out at WHO headquarters, Geneva, Record forms were prepared in duplicate by most centres and one copy was kept by the centre while the other copy was forwarded to Geneva. Four of the centres produced punchcards themselves and sent the cards to Geneva instead for processing. Records were despatched regularly from each centre to Geneva as they were completed. 44 Da t a verification and editing A quick visual check was m ade of the forms or punchcards received in Geneva to d e tect missing information in the identifica tion of patie nts , such as centre code, registr a tion number, date of registration, date of birth, sex, and r e view number. In addi tion, ambiguous markings were clarified. Forms with imperfec t identification or major missing items we r e returned to the c e ntr es for completion. Da ta conta ine d in the r e cord forms were then keypunched and added t o the computer tape fil e eve ry two months. The data were screened by the computer for invalid code s and logica l inconsistenci es. The l a tter include d inconsistencies in time records, such a s call to doctor r ecorde d as occurrin g ear li er than onset. Consistency of definitive di agnosis with the criteria (r e corded a t th e 1st r evi ew ) wa s a lso scrutinized by computer. Some of the e rrors dete cted wer e due to incorr e ct keypunchin g a nd could b e corr e cted immediately. Othe rs we re due to faults in the forms and had to b e refe rr e d b a ck t o the c entres for corr e ction . Considerable tim e a nd effort were spent in this d a t a cleaning work , A compute r progr a mme wa s d eve l oped to incorpor a t e revis e d da t a a s we ll a s new d a t a into the tape in one ope r a ti on . In spit e of the standa rd r e cord forms and procedur e s agr ee d upon by the inve sti ga tors, ther e wer e minor diffe r enc e s in coding pr a ctice a mon g th e centres . Th e se coulcl be a djuste d by a n editing progr a mme . In a ddition , variab l e s that were not r ecorded dir e ctly but th a t needed to b e d e ri ved a nd us ed fr e quen tly in cl a t a a nalysis were comput e d a ncl in- SC'rted into the ed it e d t a p e . These includ e d: (1) age computed fr o m dates of birth a nd ons e t ; (2 ) time int e rva ls b e tween ear ly events, e .g., from ons e t t o c a ll to doctor; (3 ) int e rva l s b e t wee n onse t a nd r evi ew s; (4 ) 1n fa t a l cases , i nterva l b e twee n ons e t a nd d ea th. Int e rim d a t a a n a lysis was c a rrie d out during thC' running of th C' registers to monitor the compar a bility a nd m a in fe a tur e s of daL1 from t· lw cen tr e s and t o r evi ew th e r e sults a t meetings of investigc1 t ors . Seri ,,s of comput e r pro gr a mme s were d eve loped to displa y th e dat a in frC'(]UC'17c\· ,]is tributions , to study the re l a tionship b e t ween factors, a nd to ;in;i l ysC' <;• ir\ivorship and r ecove ry status. 45 3. RESULTS Population studied This is the first analysis of the combined results to be presented from the 19 centres cooperating in this study. In each centre the accurate geogr a phic boundaries established allowed the baseline population to be determined from census data. This analysis covers the total experience o f myoc a rdi a l infarction in a population of some seven million people, h a lf of w hom w ere a ged between 20 and 64 years. Deta ils of this popula - tion ;i. r e shown in t able 8 . As mentioned in Ch a pter 2 (page 28) , it was d e cided in most centres to concentrate on the registration of patients below the ag e of 65; central analysis of data from all registers was restricted, the r e for e, t o th e a ge-group 20 to 64 years. The centres varied consider ab ly in size. Boden was the smallest with a baseline population (in the 20-64 age -group) of only 22 000, whereas i n Wa rsaw, the largest centre, it comprised 351 000 p e ople. The ave rag e siz e of the 1 9 communities was 1 88 000 p eopl e in the 20-64 age-group. The age compos1t1on of the popula tion a lso differed from one com- munity to another . Table 9 shows the percentages of the population in five-year age -groups and it can be seen that the preponderance of older p e ople was greates t in London, P ragu e , Berlin (with Erfurt and P a s e walk), Budapest, Gothenburg, and Boden. Those centr es with the young e st popul ations were Tel Aviv , Kaunas, Lublin, Sofia, and Nijmeg e n. A des cription of th e tota l population with respe ct to age and sex is of considerable importance when considering many of the conclusions drawn. When the population pyramid for this tota l popula tion is drawn (fig. 10), seve r a l interes tin g features become apparent. Firstly, there is a greate r proportion of younger and a smaller proportion of middle- age d persons in the European population compared to industrialized countries e lsewhere, fo r example , th e United Sta tes of America. 1 This is especially marked in the c a s e of males but is also present for f e males . A second and more str iking feature is that the reduction of numbers with age is not a uniform trend in the populations of the European communiti e s in this study. In p ar ticular the re are fewer persons aged 50 to 54 than there are either 5 5 to 59 or 60 to 64. 1 Unit e d Nations Demographic Year Book, New York (1971 ), Ce nsus of I. IV. 70 46 Table 8 Centre 20-39 M F 1 67 190 62 500 2 27 260 29 590 3 46 800 46 870 4 73 440 77 500 6 16 640 17 67 0 7 49 630 46 350 8 85 350 97 880 9 19 960 18 830 10 38 930 36 320 11 25 200 27 190 12 81 950 88 480 13 37 900 42 300 14 34 160 33 060 15 55 130 56 000 17 5 220 5 030 18 72 670 7 3 680 30 70 940 72 180 31 29 87 0 31 840 50 63 250 64 200 Total 901 490 927 47 0 Total males: l 702 710 Total females: 1 867 440 Total 3 570 150 POPULATION STUDIED {20 - 64 years) Numbers studied by age-group and sex 40-44 45-49 50-54 55-59 60-64 M F M F M F M F M F Totals 13 690 13 500 16 290 16 350 14 340 15 100 14 300 15 440 12 060 14 07 0 274 830 6 7 50 7 000 6 840 7 450 3 920 4 520 5 650 7 230 6 050 7 7 00 119 960 12 530 12 830 l O 97 0 12 47 0 6 360 8 360 8 7 50 9 990 7 47 0 8 360 191 760 16 480 18 800 16 530 19 830 11 210 12 780 16 910 19 41 0 13 250 16 67 0 321 810 3 120 3 7 50 3 27 0 3 980 3 000 3 7 20 2 950 3 680 2 610 3 230 67 620 9 870 9 690 8 310 l O 810 5 310 7 540 6 820 l O 010 7 110 10 47 0 181 92 0 15 230 16 6 50 13 330 17 27 0 11 590 16 51 0 11 600 17 820 l O 680 18 210 332 120 5 640 5 340 6 200 5 7 50 5 430 4 97 0 5 470 5 510 5 110 5 110 93 320 6 630 6 720 6 330 6 600 5 260 5 650 5 020 5 580 · 4 430 5 040 l 32 51 0 4 680 5 310 4 000 5 350 3 240 4 680 3 550 5 160 3 030 4 880 96 270 24 400 25 810 20 340 22 97 0 11 11 0 14 490 12 500 17 580 12 660 18 6 50 350 940 8 600 8 500 6 300 7 000 3 900 4 700 4 000 5 300 3 800 5 600 137 900 6 190 6 400 5 190 7 120 4 330 6 280 4 870 6 450 5 140 6 850 126 040 11 140 12 160 7 150 9 790 4 660 6 480 5 010 7 840 4 640 6 960 186 960 l 160 l 200 1 200 l 27 0 l 330 l 27 0 1 180 l 230 I 180 1 11 0 22 380 21 220 20 370 11 680 11 650 12 860 12 410 11 240 l O 780 7 850 8 16 0 27 4 580 17 990 18 110 17 7 00 17 520 14 050 14 590 13 170 14 200 11 150 12 260 293 860 7 210 7 490 7 230 7 290 5 390 5 510 6 110 5 990 4 080 3 180 121 190 13 440 15 140 9 260 14 360 6 910 11 440 9 640 15 7 50 11 890 17 900 2 53 180 205 97 0 214 770 178 120 204 830 134 200 161 000 148 740 184 96 0 134 190 174 410 3 570 150 "'" r:¥J Table 9 Centre I Gothenburg 2 Prague 3 Bucharest 4 Budapest 6 Dublin 7 Heidelberg 8 Helsinki 9 London 10 Nijmegen 11 Tampere 12 Warsaw 13 Lublin 14 Innsbruck 15 Kaunas 17 Boden 18 Sofia 30 Perth 31 Tel Aviv 50 Berlin ) 51 Erfurt ) 52 Pasewalk ) POPULATION AT AGE 20-64 YEARS AND STUDY PERIOD OF AMI REGISTRATION Year Population Agl' composition (%) Rl'gistration period of census aged 20-64 20-3'! 40-4-1 4, -4'1 5ll-54 55-5 <1 60-64 for this report !'16'1 274 830 47.2 9 4 11. l/ l U., IU. 8 4_ 5 Jan. 1471 - Dec. I 971 1970 119 960 4 7. 4 11. =, 11. q 7.U I (I ' 11. 4 15 Mar. l'l70 - HMar. 1972 1971 I l/ I 760 48_8 I .i . .'. 12. 2 7. 7 <1_8 8. 3 Jan. 1'170 - Dec. 1971 1970 312 810 48.3 I I. 3 11. 6 7. 7 11. 6 4.6 Apr. 1g70 - Dec. 1971 1971 67 620 5U.8 Ill. 2 1 ll. 7 ll. q '1_8 8 6 Jan. 1970 - Dec. 1971 1971 181 920 52.8 10.8 11,. =, 7. I 'I. 3 q_ 7 Jan. 1970 - Dec. 1971 I l/ 7 I 332 120 55.2 '1.6 l/. 2 8.5 8.4 8. 7 Jan. 1971 - Dec. 1971 1971 l/3 320 41. 6 11. 8 12, 8 11. I 11, 8 11.11 May 1970 - Dec. 1971 1971 I 32 51 U 56.8 IU. I ".8 8_2 8.U 7.2 June I 970 - May 1972 I l/70 % 270 54. 4 IU.4 q_ 7 8.2 'I . I 8.2 Oct. Jlj70 - Dec. 1971 l ')70 3 50 l/40 48.6 14. 3 I.'.. 3 7.3 8.6 8.4 May 1970 - Dec. 1971 Jl/70 13 7 'IIJII 58.2 12 . .J li.f, (; 2 6 -. I (,. 8 May J47U - Dec. 1971 1971 126 040 53. 3 IU. (I ".H 8.4 ll_lJ l/ -. ") Jan. l'-171 - Dvc . 1471 I <170 186 960 5'1. 4 I ' -__ , <j I 6. 11 (,. ,, 6.2 Jan. 1471 - Dec. 1972 1971 22 380 4 5 8 111. '> 11.U 11. 6 It>. 8 Ill. 3 Jan. 197 I - Dec. 1971 J'-16:; 2 74 580 5 3. 3 15. I H. , 'I. Z 8. (I 5.8 Jan. !'171 - Dec. I 971 [ '171 2 'l 3 860 48. 7 IZ. 3 1 L. 11 "· 8 '!. _; 8.U Oct. !'!70 - Sept_ 1';171 1972 121 190 50. 'I 12. I l!..ll 'I. (J IU. ll 6.0 Jan. 1971 - Dec. 1971 1970 2 53 I BU 50.3 11. 3 ,, . 3 7.2 IU.U 11. 8 Jan. 1'171 - Dec. 1971 Fig. 10 AGE/SEX DISTRIBUTION OF TOTAL POPULATION COVERED BY REGISTERS COMPARED TO THAT IN THE USA (1970) Male Female ---------165, _________ _ ·----------450-----------...... Study population United States 8 7 6 5 4 3 2 0 2 3 4 5 6 7 8 o/o of population 20 - 64 This 11 waist 11 which is typical of the population pyramid of most European countries, is of particular significance in the study of diseases such as ischaemic heart disease whe r e the brunt of the illness falls on the section of the community entering middle age . The main factors respons- ible for the ''waist" in thos e centres that show it a re probably the loss from soldier s and civilians killed in th e Second World War, and the reduction in birth rate and high infant mortality that occurred in the wake of th e First World War due to such diseases a s influenza. It is p a rticular ly fortunate tha t th e re were contributions to the tota l regist e r population from th e Swe dish, Isr ae li, and Australian centres, where th e s e featur es are not obs e rved. The non-uniformities are not, the refor e , a s m a rke d a s they would be if taken from an individual country, but the overall p a tter n must be conside red in relation to those features of myocardial infarction tha t might vary with age and sex. One interesting sequel of this distribution of the population is that the "waist", which wa s s ee n in the 50-54 age-group in 1 97 1, will shift upwards and will progressive ly involve older age-groups. Thus, over the n ext d e cade , th e public health authorities in Europe can expect a tempor ary diminution in th e overall incidence of diseases of late middle age, such as myocardial infarction , followed subseque ntly by a trend for the s e conditions to be pr e s ent more frequently in younger people. Materia l ana lysed T a bles 10 and 11 show the number of record forms receive d in G eneva from each c e ntr e by the end of 1 97 4 a nd used in this analysis. The fir st r eview is complete, a nd of th e second a nd third review forms due approximately 95% have b een received and a re included. About 30 % of the registrations r e sulted in death. Excluding pati e nts registered who were later found not to have had myocardi a l infarction, the proportion is 41%. The calendar year 1971 was taken as the basic period of study and 197 2 as the year in which the final follo w -ups were performed. The data from centres that developed s a tisfactory procedures of patient reg- istration and follow-up before 1971 or continued the registration into 197 2 were also included , provided that standardized methods of case ascertainment and coding were used. Tables 12 and 13 show the number of patients according to the month of onset of attack. Except for Perth, which covered 12 months from October 197 0 to Septembe r 1971, all centr e s cove red 1971 completely and i n 11 centr e s a l onger p eriod wa s cove red . This permitt ed an in- crease in the amount and the accuracy of the data. Because the popula- tions varied greatly in size, th e numbe r of cases of myocardial infarction registered ranged from 7 2 in Boden (Sweden) to 1250 in Helsinki (Finland). 50 U1 ..... Table l 0 Centre 1 Gothenburg 2 Prague 3 Bucharest 4 Budapest 6 Dublin 7 Heidelberg 8 Helsinki 9 London 10 Nijmegen 11 Tampere 12 Warsaw 13 Lublin 14 Innsbruck 15 Kaunas 17 Boden 18 Sofia 30 Perth 31 Tel Aviv 50 Berlin 51 Erfurt 52 Pasewalk All centres Percentages NUMBER OF RECORD FORMS RECEIVED IN GENEVA AS AT 18. 2. 7 5, RELATING TO ALL PATIENTS UNDER 65 YEARS OF AGE WHO HAD BEEN PROCESSED Initial records First review Second review Third review Death records records records records 592 592 37 5 366 196 1194 1194 353 339 260 851 8 51 249 240 181 2074 2074 I 669 643 557 529 529 I 2'}2 265 I 171 524 524 I 355 I 334 199 1352 1352 749 720 613 653 653 340 I 314 271 I 935 935 550 I 416 295 432 432 221 ; 213 162 1894 1894 I 770 I l 001 422 I 421 421 I 209 I 205 86 288 287 I 191 169 l 09 431 431 240 236 168 94 94 51 48 31 288 288 154 142 92 989 989 5"/2 546 381 389 388 311 237 87 289 289 93 91 91 l 06 1 06 69 69 28 48 48 25 25 14 14 373 14 371 6 838 6 619 4 414 100. Oo/. 99. 9 "/o 47. 6 "/. 46. l o/. 30. 7 "/. \J1 N Table 11 Centre 1 Gothenburg 2 Prague 3 Bucharest 4 Budapest 6 Dublin 7 Heidelbe rg 8 Helsinki 9 London 10 Nijmege n 11 Tampere 12 Warsaw 13 Lublin 14 Innsbruck 15 Kaunas 17 Boden 18 Sofia 30 Perth 31 Tel Aviv 50 Berlin 51 Erfurt 52 Pasewalk All centres P ercentage s NUMBER OF RECORD FORMS RECEIVED IN GENEVA AS AT 18. 2. 75 RELATING TO PATIENTS UNDER 65 YEARS OF AGE WHO HAD BEEN PROCESSED, EXCLUDING THOSE DIAGNOSED AS "AMI NONE " Initial r ecords First revi ew S econd r eview Third r eview D eath r eco rds records records r eco rds 494 494 372 363 I 57 519 519 339 i 327 218 37 3 37 3 243 I 236 161 111 5 111 5 661 I 638 509 398 398 27 5 I 260 163 487 487 3 36 I 321 183 I 1250 12 50 ; 738 710 601 549 549 I 334 314 I 259 i 282 797 797 ' 549 415 ! 365 365 I 221 213 I 161 I 1099 1099 759 740 383 276 276 205 202 80 268 267 178 l 58 105 390 390 240 236 168 72 72 50 I 47 30 226 226 148 I 39 88 883 883 I i 572 546 380 295 294 220 l 6 I 85 167 l 67 93 91 83 105 105 69 69 28 36 36 25 25 11 10164 10162 6627 6211 4135 100. 0% 99. 9% 65. 2"/o 61. I '1o 40. 7"/o \.11 l.,J NUMBER OF PATIENTS UNDER h 5 YE ARS OF A G E BY MO!'/TII OF ON SET O F ATTA C K M onth 1 l J 4 6 7 K 9 10 I II I l 1 1 14 I 5 17 I 18 I JO I January 1970 0 zo I l1 lb I February I J J l !1 ZS I Marc h - J I so 74 JO l4 April 7Z so 109 l I lb I ll 2 May 50 16 89 ZO ll 16 I! oo l3 June SJ 40 I 07 l Z ZS II I ! Q j ! ZO July 48 ll 9b l} 16 : ZK ! " K I I l Augu at 44 l1 i 79 ! Z I lO 14 !H 9 4 i I 6 I Se ptem ber 43 27 I K9 ll l l ! I ! ,!_ f j 90 I b l October 49 45 I I 04 a 18 J(, 1; I K 101 I s 84 I ! I i November b4 l3 I 99 16 18 I •• " lb 103 I 7 100 December I 49 39 •• I 29 I K ·IO 10 17 1I l I I l 88 I J;i.nuary 1971 63 65 45 I 11 9 I 6 lb 101 16 19 ZO I 04 I I K I l IS II JZ I 86 February 45 42 65 I 87 I Z9 14 I I !7 H i lH : 24 105 14 I I I 24 9 I 7 61 March 68 56 46 93 29 22 I Ill 41 I 14 !l 111 ! 10 20 16 10 JO I 81 April 57 49 46 104 I l I 30 11 5 l l I ll 29 HZ I K I K !S 9 l b 69 May 58 I 38 I 14 ! I 09 29 ZS 10? ! 9 17 -- 114 I 6 I I K ll 6 24 87 Jun• 47 37 I )l IO I : Z I Z9 I Z6 17 .! ; II 9 3 Z4 1 1 ZS 9 JZ 76 July 45 18 IZ 90 K I 5 l .! K 2 4 .!.'J " h K IK 20 I K 11 l\ 89 Auauat 48 4l I 6 61 i I l 21 i.?2 I ZK .! 'j ,,, 7 I I u 1 1 • 6 II 84 Se ptember 45 JS l1 92 I Zl I K 91 30 I II 2 I Kl IS I 4 I H '! lO Hl OctolK-r 43 40 ll I HK 1 1 l1 10 9 19 !K IS I OZ I ll ; II 4 Zl 0 November ll 55 ZS I 0 7 2 I 17 106 ZS IO 29 HS 16 IS l S 7 Z l 0 Drcem~r 39 42 Z l % l4 I 7 I 04 I 29 12 2 I Ko I 17 I S I b I 24 0 January 1972 I I 73 ! I ' I I ll , (, I I; J'ebruary l 48 : I ... K I 0 Mar ch I 27 I I(, 5 ? I April J I I II 10 : l ' I May I I II 6 l b Jun• I l l 6 14 July I I l 2 ? I 14 Au1u•t I '' 7 I 1 l I September - i zo 6 ll i October JI I l I 7 i November I !b 6 19 I I i I Decem ber I -- I I 0 I Total 590 1194 836 2074 529 szz I ISZ 653 'I \ S I rn I 892 421 249 4 ll I 94 I 288 I 989 No regi s tr a tio n s m ~d .- dunnlf thu JMrlOd I JI ! so 5 1 i Sl T o tal : I 74 I I 88 20 9 I JOZ ! 378 I 4ZS I 362 - I 36 3 I I 365 537 I 560 4 [ 549 4l 29 12 J : 914 36 27 11 I 3 813 : 35 I 29 8 • 882 33 30 7 9 841 33 lO 7 I 4 841 41 l I • : J 835 ZS 40 J l 790 I ZK I 6 8 I l 686 I l b 16 • I J I 7 JI JS I 6 14 J 672 l 4 ZS ; 4 ! 681 27 19 I J j I 670 I 124 I 104 : 79 6 5 6 3 H 46 I I 38 i I 47 I 51 I I 51 I JJ 189 I 289 106 I 4 7 14 JI Z M onth I l ) January 1970 - 12 February l 23 M arch l l 20 Apri l !8 24 May - 20 14 June lb l 8 July 23 ll August 17 19 Scplrmbcr 20 ll Octobt"r 2 1 l l Nove m~r 21 10 I l 16 l l December January 1971 47 28 lO i Ff"brudry 39 18 27 March 59 ll LO I April 52 19 20 May 50 l J 14 Jun• 40 18 ll ' July 35 16 12 Augu•t )8 18 l l Septf"mber H l H 9 I Octobt· r 16 I, 6 ! Novf"mbt·r ll lb 14 Dece mbt.>r )l ll 7 : January 197 l I 34 I February l 25 ' March I l l April ) May June July i I Augu st - S e ptembt.-r Octob€"r Novrmber - Dect·mbrr Total 49l 519 l72 NUMBER OF PATIENTS UNDER bS YEARS OF AGE BY MONTH OF ONSET OF ATTACK , E XCLUDING THOSE DIAGNOSED AS "AMI NONE" 4 6 7 8 9 IO II l l I l 14 I 5 I 7 I 8 JO I ll 24 - I I l 8 25 i H 21 23 - I 59 19 2 l I 20 l I 4 2 I 5 ll ll 9 I H l 7 I I 61 19 ll lH lH ',4 16 I -4H l H l 5 lH 26 I 54 II i I I I I 42 l 7 I 7 l9 24 I ·1f) l l I 40 I I 7 ll lO I l1 I t 6 I '! I I l 65 l l I H - 25 l9 l? ' ',7 -I I ' 80 I ' I I 4H 10 l H l ll l4 l7 ',9 i', ' ' 87 -19 I lO l ', 16 l1 IS 70 II ' l 82 I I I - 56 l 2 24 ')0 JO i lH IS .,_, [ ', I ll I l H i 5 28 I 69 54 ll I l 2 II ', JO I l '> ll I 5'1 11 I 10 ll 8 I 7 I 52 55 lO I ll l 0H 10 lo 20 7 I 9 I 7 14 ' 5 24 7 1 I I I 4H l l l8 II 0 I l9 28 27 55 16 I 6 lJ I 9 17 S7 65 l} l4 I I 0 4 ll ll lO 70 11 I 7 ll I 4 19 HI 6 -l 14 28 II ', I II lb ll ·H 16 ll I 19 8 25 I 70 4', b l 5 Ill ll 25 i ll 5l l 5 lH l 7 l 10 18 78 I I! l l lO ' 10 1} ll I 24 17 l7 9 l l I 7 6 9 ' 77 5l '" 18 I HI I l5 I l7 14 -10 19 I l I 7 6 ' l J I 77 4', ? ! I % 14 24 lH a'i ll 6 II 4 ll So I 7 l 5 IOI I 18 I lb LO 5S I H 1 5 I l5 6 I 5 H ll IS % I u I 27 ' I 7 4 7 25 I 5 I I 6 I IH I ' I I I 25 I 5 I I 5 ' ! 35 7 9 i I ' I ll 5 H I I I l1 I I ? I 9 I I I 28 I 6 l', I I l l I 6 14 ' I I I 7 I I H II I i I 5 I 7 ll i 19 I ' 4 20 I lO ! ; l 16 I ll I b 19 ll l l 0 111 "> J?H 485 1250 549 797 365 I 09H l76 l ll l90 7l llb H8l - ~ No registrations madl· during this p,•riod J I 50 51 52 Total - - 59 I - 68 - . - 119 I 185 I - 214 - ! - l7l - - 235 - 227 I Z JI I I . - 364 I - 351 4 180 - H 19 I 12 j 619 lb 21 II 3 606 ' 2 5 12 8 7 647 26 l 7 I 7 4 621 l4 10 I 7 ) 638 32 ll I 7 l 628 I 17 23 I ) l 572 l) 7 8 I 52) I ll II I 8 ) 525 I ll 8 14 l !~ I 22 I 7 7 3 19 ll l l 3 4H I - ~, 57 ' - - . 58 - 59 43 - - 39 . - 34 - 4 3 39 48 - )l 295 167 105 36 10 l l l Source of admission to register Patients were registered following notification by a doctor to the register that a suspected myocardial infarction had occurred. The source of admission to the register was noted for each patient. Table 14 shows how the source of admission varies considerably among centres. General practitioners notified over a fifth of cases reg- istered in some centres (Bucharest, Sofia, Berlin, Budapes t) but few or none in the remainder. On the average, more than half of the patients were registered on the basis of the hospital admission record. The variations in the sources were due to the different medical organization in the various c entres; details of special local sources are shown in table 15. An analysis of the source of admission of cases in each diagnostic category can be seen in table 16. A breakdown of this table for each centre will be found in Annex II (table 57). Many of the sudden deaths were classified as "possible" a cute myocardial infarction and that is why, in this group, registration was based more frequently on death certificates and less frequently on hospital admissions. Frequency of myocardial infarction Table 17 and fig. 11 show the annual attack rate of acute myocardial infarction per 1000 of the population by age and sex. This table includes both definite and possible myocardial infarction categories. The average annual attack rate (computed by averaging the rate from all the centres) in the age-group 20-64 years was 3. 4 per thousand for men and O. 9 per thousand for women. The average rate in the 20-39 year group was 0. 3 for men and O. 04 for women, and rose in the 60-64 year group to 13. 2 and 4. 0 respectively. For men in the age-group 50-54 years, centres showing high incidence rates are Helsinki, Tampere, Dublin, Nijmegen, and Boden, and those showing low rates are Sofia, Bucharest, Berlin, Heidelberg, Innsbruck, and Tel Aviv (fig. 12). There is an epidemio- logical distinction between the attack rate and the annual incidence rate of acute myocardial infarction (table 18 ), which is defined as the rate of first attacks occurring in the year under study. This definition does not take into consideration the possibility of pre-existing ischaemic heart disease other than infarction; consequently the incidence of myocardial infarction is not strictly comparable with incidence as defined for some other diseases. However, it has the advantage that it is unaffected by re-attack rate and by varying fatality from the condition, both of which affect the attack rate. It therefore gives a more precise figure for the differing prevalence of ischaemic heart disease from one community to another, The attack rate, on the other hand, gives a measure of the burden of the specific condition on the community, e.g., on emergency care services. 55 u, 0-- Table 14 Sour c 1• Grneral practitioner Hospital adm 1 ssion Hosp. disch. re-cord ECG reco rd Drath cer tificatr Autopsy record Social ins. record I Mrdicolegal authority Othrr Unknown Total Number of patients I 2 0 0 I 77 65 ! 0 I 0 I I I 19 5 ' 0 I 0 2 i 0 9 I I 17 J 0 100 100 592 1194 SOURCF. OF ADMISSION TO REG ISTER FOR ALL PATIENTS U NDER b5 YEARS OF AGE ( In 1w rc ,·nta~rs) l I ., I 6 I 7 8 ' ) 10 II I' I - I I l 14 I 5 I 11 I I 8 lO H I I 9 I 4 I I I ,: I II I 9 0 L 6 I 0 I l I b: I 24 I 10 I 5 ' IO S7 69 57 7b 'JO 5H 44 56 55 4 3 55 I I L ! I 7 H ! I 5 0 I 0 I 7 5 J I J 5 6 0 0 I I 0 0 0 L 0 I 2 I 4 l 5 8 6 5 I '! 17 16 9 4 7 5 9 9 21 8 12 0 l 0 I 0 : l I I 0 0 I I 16 0 ' I I 0 0 0 0 0 s 0 0 0 0 0 0 I 0 I 0 0 6 H ' 0 0 0 II 0 0 I l II J 0 I 4 1 l ' 19 II lO ! 0 0 I 0 I 0 29 41 0 8 I I 0 0 0 I I I I I 0 0 0 0 I i l I 5 0 I 0 i 6 0 100 I 00 l I 0 0 ! I 00 100 100 I 00 100 100 I 100 I 00 100 I 100 100 100 851 lzoH I 5!9 I 524 I \Sl 651 9J5 4 JZ IH94 : 421 l88 4 JI I 94 I 288 989 JI 50 51 52 Total 0 12 64 2 9 85 bl ll 79 54 I 0 0 0 J 0 I J 0 I I II I 0 0 2 II I I I J 8 I 5 2 0 I 0 0 0 I 0 10 0 0 5 I I l 0 14 l 0 I l I 100 100 100 100 100 389 289 106 48 14 37 l Table 15 DETAILS OF "OTHER" SOURCES OF ADMISSION TO REGISTER Sources 2 3 4 6 12 13 15 Ambulatory examination at coronary care unit 196 7 1 Emergency service doctor 31 Emergency service ambulance 241 626 46 540 173 Recovery station 2 Registry team 41 2 Life rescue service 5 1 4 Laboratory 2 Cardiologist 13 Polyclinic 1 Private initiative 1 1 5 Anti-alcoholism service 1 Bed bureau 10 Daily paper death column 24 Hospital death record book 3 Hospital doctor 21 Casualty 3 57 \J1 CXl Table 16 Source Unknown General practitioner Hospital admission Hospital discharge ECG request Death certificate Autopsy record Social insurance record Medicolegal authorit y Other TOTAL SOURCE OF NOTIFICATION IN EACH DIAGNOSTIC CATEGORY Diagnosis Definite Possibl e Not Unknown infarction infar c tion inia r c tio n 165 1.0 27 0.9 10 0. 2 0 0.0 437 6. 5 291 10.0 520 I 2 . 7 0 0.0 4220 62 . 4 950 32. 7 2120 51. 9 0 0.0 250 3. 7 60 2 . I 8 2. 2 . 0 I I 2. 5 98 I. 4 14 0. 5 39 I. 0 0 0.0 536 7 . 9 935 32.2 85 2. I 5 62 . 5 I 30 I.? 87 3. 0 I 8 0. 4 0 0.0 53 0.8 16 0.6 24 0.6 I 12. 5 380 5. 6 200 6.9 65 I. 6 I 12. 5 597 8.8 324 11. 2 1120 27.4 0 0.0 6766 100.0 2904 100.0 4083 100.0 8 100.0 Blank Total 0 0.0 102 o. 7 3 21. 4 1251 9. 1 7 50. 0 7297 53.0 1 7. 1 394 2 . 9 0 o.o 1 51 1. 1 3 21. 4 1564 11. 4 0 0.0 235 1. 7 0 0.0 94 0. 7 0 0.0 646 4. 7 0 0.0 2041 14.8 14 100.0 13775 100.0 Table 17 A NNUAL ATTACK RATE OF ACUTE MYOCARDIA L INFARCTION PER 1000 POPULATION BY AGE A ND SEX Age - group Age- standardized Centre Sex attac k r ate I 20-39 40-44 45-4 9 50- 54 55-5 9 6U-64 20-64 I Goth enburg M 0, I 1 ,0 3 . 2 5 . 5 8. I 9, 7 2.6 F 0 , 03 0.2 0 ,3 0 , 9 2,0 3. I 0 , 6 2 Prague M o. 3 I . 8 3 ,4 7 . 5 I I , 5 12. 3 3,5 F 0 , 0 0, I 0, 4 I ,2 I. 5 3.4 0.6 3 Bucharest M 0. I 0,8 1.5 3 . I 4, 9 5,8 1. 5 F O, Ul 0,3 0,6 0 , 7 I. 0 2. 5 0,3 4 Budapes t M U. 3 2,4 3, 4 6. I 7 . 3 II, I 2, 9 F 0 , I 0,4 0 , 7 I , 7 I, 7 4. 3 0,8 6 M U,4 I, y 6, 9 10, q 13,8 15. 5 4, 7 Dublin F 0 , 03 u , 5 I . 8 2 , 8 3,4 5 , 4 I. 3 M U,3 I, 8 3. 7 4.4 6 ,8 q • q 2,6 7 Heidelb e rg F 0. U2 0, I U,3 U, 4 0 , 7 2, 3 U,4 8 He l s inki M U, 4 4,8 'I . 3 14, 5 21. 8 26.Y 7. 3 F U. I ll, 4 I. 7 2, 4 4, 3 8 ,6 I. 6 y London M u.6 4, U 4,8 8,U 11 , 4 15. 2 4, 3 F U,03 I , I I . 3 I. I 3. 5 5 , 4 I 2 M u . 3 3 , 3 5 ,2 q y 14 , I 17 , 8 4,8 10 Ni jm cgen F U, I U, 5 U,4 I. 3 2,4 5 _ 7 I. u II Tamper e M u . 2 4,4 6,8 13 . 3 16 ,2 25 , -1 6 , 2 F U, U U.U U. 7 I. y 2,6 7. I I , I M U,3 2 . 3 3. 4 5. 4 8,4 I U, " 3. I 12 War saw F 0 , 03 U, 3 I, I I. 7 2 , q 4, U U,9 M U.2 2.2 3. I 5. 5 7,2 4 . 2 2,6 13 Lublin F 0 , U3 U,3 U.Y U, 3 I. 4 2. 7 U, 5 14 Innsbruc k M 0 , 2 2 .U 3. 7 5,6 7. 3 I U, 2 2, 8 F U,U4 U,U U. 4 I. I I 3 2,8 U,5 M U,3 I . y 2. 4 5, 9 5. I I U,1 2,6 15 Kaunas F U,U U,2 U.3 0,8 l. 2 2,4 U,4 17 Boden M 0,2 2,6 3. 3 Y, U 12 , 7 16 . u 4, I F U, U U,O 2,4 3. I 6 , 5 2. 7 I . 4 18 Sofia M 0,2 0 , 8 3,2 2,3 4,2 7,0 I, 7 F 0 , 0 1 0 , I 0 , I 0.2 I. I O,Y 0, 2 30 Perth M 0,3 2 , 9 5 . 5 8 , 2 I 3, I 19,0 4 ,6 F 0 , 04 0,6 1.0 2. 5 4,6 6. 2 I, 4 31 Tel Avi v M 0,2 2. 2 4,5 6,8 8 , 2 19. I 3, 8 F 0 , 03 0,3 0,8 2. 7 4,3 6,8 I . 3 M U, 2 I . 4 3. I 3 6 9,8 8,9 2 . 6 50 Berlin F 0, 0 0. 4 0 ,6 I. 8 2. 5 4,8 0,9 51 Erfurt M 0. I I , 5 I . 4 2. 5 3 . 4 5,2 I. 4 F 0,03 0 , I o . 5 0, 2 I, I 0,9 0,3 52 Pase walk M 0 ,3 I. 5 4,6 3. 7 4,8 12,4 2.6 F 0,0 0 , 0 0,0 I. I 0, 7 3 . 8 0,5 1 The age composition of the total population in the study areas has been used aa the otandard for the computation of the age - standardized rate. 59 25 20 l 0 0 Fig. 11 ATTACK RATE BY AGE AND SEX, EXCLUDING CAS ES DIAGNOSED AS "AMI NONE" Attack rate for each centre : --Males --- - Females Average attack rate for all centres : --Males - -- - Females l Gothenburg 25 6 Dublin 20 10 0 20 40 50 60 Age 25 ~%~• ___ 2_P_r_a~g~u_e _____ ~_ 20 40 50 60 Age 20 l 0 0 20 40 50 60 Age 25 1',•-• ___ 3_B_ u_c_h_a_r_e~s_, ___ ....,.... __ 20 10 0 0 40 50 60 Age 25 %. 4 Budapest 20 10 0 20 40 50 60 Age 25 20 l 0 0 25 20 I 0 0 25 20 10 0 60 %. ___ 7_H_e_id_e_l_b~e_r~g~•----- 20 %, 20 "/ .. 20 40 50 8 Helsinki 40 50 9 London 40 50 / -.... 6 60 Age A ge Age Fi g . 1 1 {con td ) Attack rate fo r each cent r e · --M a les ---- Females Ave r a ge attack rate for a ll cent r es : "loo 10 Nijme gen 2 5 ...-------------- 20 I 0 / / 0 20 40 50 60 Age 25% ,_. ___ 1_2_w_ a_r_s_a_w ____ _ ~_ 20 I 0 0 2 "/o. 25 20 J O 0 20 Age 40 50 60 Age --Ma les -- -- Females '1c 14 Innsb r uck 25 ~·-·-------------- 20 10 0 20 40 50 60 Age ,r I 7 Boden 25 1 0 0 20 I 0 O 20 Ag e 25 '1c~•-• ___ 1_s_s_o_ fi_a _______ _ 20 10 0 20 Age 61 Fig . 11 (contd) Attack rate for each cent re: ---Males---- Females Ave r age a ttack r a te for all cen tr es : --M a les ---- Females 25 a · / 00 30 Perth a' / oo 25 50 Berlin 20 20 l 0 10 0 0 20 40 50 b O ,\ge 20 40 50 oO Age 62 0' I.,) Fig. 12 MAP OF T H E CENTRES SHOW ING Till:: R ELATIVE INCIDE:NCE OF MYOC\RDIAL INFARCTION (FIRST ATT1\ CKS. M :\ I.ES. 50-54 YEARS ) I 'l 'b ~ '.:,'5o\, ,, -; ~1 ) ; ! Ii?\ i_ °' 0·-... , a ) - ·--c-- '--"'· -i(i) i . 2 "·'"·, .-0 I r~--' ·- ., __ .I _ .J ~--- ,,..._~ -~' -0·-·- i - __ ,.. ' '" \ 0 i 4 / \ ;-·"'·,i'?' -- _ _ _, I I ( ' -- I ( ~ --✓ ' · ., . I _ ' · (j'\ , .~ \:_J ,') .- ·- . . ·- ·- · - 1'8 . ,.. ( 1,... - ·- ---~ ~ .- O ll igh ('-J 5 · -6 . H --.....___ I I O O O m e n ' 50-5 4 ) / 0 J'..ledium ( 5 · o-3 . H) / _I Q I ,ow ( 1. 5 - I . 4 ) Table 18 ANNUAL INCIDENCE RATE OF ACUTE MYOCARDIAL INFARCTION {1st ATTACK) PER 1000 POPULATION BY AGE AND SEX 1 Age-11roup Total Centre Sex 20-39 40-44 45-49 50-54 55-59 60-64 20-64 1 Gothenburg M 0. l 0 . 8 2. l 3.8 5.6 4. 9 1.8 F o. 03 0.2 0. l 0.6 1. 3 1.9 0 .5 2 Prague M 0. 3 1. 3 2. 3 5 . 1 6. 8 7.6 2. 4 F 0.0 0. 1 o. 2 0 . 8 0 , 9 2 . 7 0.5 3 Bucharest M 0. 1 0 .6 1. 2 2.0 3. 3 3. 5 1.0 F 0.0 0. 3 0.5 0.5 0.8 1. 6 0.4 4 Budapest M 0 . 2 1. 9 2.4 4. 7 5.0 7. 5 2 . 2 F 0 . 1 0.4 0.6 1. 4 I. 4 3. 3 0.8 6 Dublin M 0.4 1. 8 5. 0 7 . 7 I 9. 7 I 10. 2 3.4 F o. 03 0.5 1. 5 1. 7 2 . 4 3. 7 : 1.0 M 0 , 3 1. 3 2 . 3 3. 1 ! 4.6 6 . 6 I 1. 6 7 Heidelberg F 0.0 o. 1 0 . 2 0. 3 I o. 5 1. 8 I 0. 3 8 Helsinki M 0. 3 2.8 5.8 I 9. 5 I 12. 4 14.4 I 3. 8 F 0 . 04 0,4 1.0 1. 9 I 2. 9 5.4 1. 1 9 London M 0 . 5 2. 6 3. 8 5.6 I 6 . 1 8. 3 3. 2 F 0 . 03 0. 6 0.8 0. 8 2 . 5 3. 7 1. 0 10 Ni jmegen M 0 . 3 2.4 3. 7 i.6 9. 1 11. 8 2.8 F o. 1 0 . 5 o. 3 0.9 2.0 4.4 0 . 7 11 Tampere M 0 . 2 2.4 4 . 4 7 ,4 9.2 15 . 9 3.2 F o.o o.o o. 7 0. 7 I I. 9 4. 3 o. 7 12 Warsaw M o. 3 1. 7 2 . 8 4 . 6 5.4 7.4 2.0 F 0 . 03 0.2 0 . 9 1. 3 1. 8 3. 0 0. 7 13 Lublin M 0 . 2 1. 7 2. 3 4.0 4. 1 6 .6 1.5 F 0.01 0. 1 0.8 o. 1 0.9 I. 6 0. 3 M 0.2 1. 5 2.2 2 . 1 3. 6 4 . 4 1. 3 14 Innobruck F 0 . 04 0.0 0.4 0 . 7 o. 7 2.0 0 . 4 15 Kaunao M 0.2 I. 5 2 . 1 4 . 3 2. 9 7 . l I. 3 F I 0,0 0 . 2 o. 3 0 .6 I 1.0 I 2 . l 0 . 3 17 Boden M I 0.2 2. 6 3. 3 6.8 I 9. 3 I 9. 3 3. 5 F o.o o.o 2.4 0 . 8 I 4 . 1 2. 7 I. 1 0.2 I. 4 I I I 1.0 18 Sofia M o. 7 2.2 2 . 7 I 4. 6 I F 0 . 01 0 . 1 : 0.0 0. 1 0 . 7 I 0. 9 i 0. 1 M o. 3 2.5 I 3.9 5. 3 I 7. 2 1 10 . 0 I 2.9 30 Perth F 0 . 04 0.5 o. 7 1. 6 i 2. 7 3 . 7 I 0.9 M 0.2 I. 2 3. I 3. 5 I 3. 7 7 , 7 1. 9 31 Tel Aviv F 0.03 0.0 0. 7 1. 6 I 2. 1 4 . 3 o. 7 50 Berlin M 0.2 0.9 1.5 1.8 3. 4 4 . 5 1. 2 F o.o 0.0 0.2 1. l 2 . 0 2.7 0. 7 51 Erfurt M 0. l 1. 1 1.2 1.9 3. 3 4.4 1. l F 0 . 03 0. l 0.5 0.2 0.7 0.7 0 . 3 52 Puewalk M 0.2 I. 5 4.6 0 . 0 3. 6 9 . 8 1. 9 F 0 . 0 0.0 o.o 1. 1 o. 7 2.5 0 . 5 1 Includin11 "defini te AMI", " poaaible AMI", and "inau!ficient data" but excluding "AMI none". 64 Broadly speaking, the high incidence area forms a crescent around the north and west of Europe, in Scandinavia and the British Isles. Ex- tending inwards from this high incidence area through the centre of Europe is a medium incidence zone, which includes the Netherlands, the Federal Republic of Germany, Czechoslovakia, Poland, and Hungary. In a semi- circle around this is a low incidence zone, which includes the German Democratic Republic, the USSR, Romania, Bulgaria, and Austria. Of the non-European areas included in the study, the Australian centre shares the medium to high incidence of the European centres, while Israel has a relatively low incidence. Comparison with national mortality statistics In the case of 14 centres, the countries in which they are situated send to the World Health Organization mortality statistic s based on death certification. These statistics are broken down by age and sex, but it is not possible at present to break them down geographically beyond national boundaries. Comparison with the r egi ster population, which was mainly in urban centres, is therefore not strictly precise but nevertheless it might be expected that the experience in a centre would reflect the experience of disease in that country as a whole. Fig. 13 shows the relation between the attack rate of acute myocardial infarction computed from the register data compared with the death rate from catego ry 410 of the International Classification of Diseases (8th rev ision) in the country in question. It can be seen that there is a strong correlation between the two (correlation coefficient O. 818; T = 8. 56; Pless than O. 01). The actual correlation line corresponds to a 40% death rate, which is close to that observed in the register data. For the purposes of this figure only one age/sex range is shown, but correlations are similar in other groups. This study has added a further, convincing demonstration that the observed differences in the incidence of myocardial infarction really do exist among the communities of Europe. These differences in incidence are not minor; for example, the incidence of myocardial infarction in males living in the Finnish centres is five times that of the centre in Bulgaria. They raise questions of major significance that have a bearing not only on such practical considerations as the planning of health services but also on hypotheses concerning the etiology of this important condition. Incidence of "definite" cases The figures presented so far have referred to the combined group of "definite" and "possible" myocardial infarction. The former cases were more precisely defined by reason of the greater degree of clinical information available and therefore represent a higher proportion of the cases in some centres than others. For comparative purposes between centres, the combined "definite" and "possible" therefore provide the most accurate comparison of incidence. As shown in fig. 14, however, for males aged 50-54 the attack rate for "definite" myocardial infarction in the different centres correlates very closely with the rate for combined "definite" and "possible" infarction. It can be seen that the frequency is virtually of the same order as when all positive cases are considered. 65 O' O' ~ CORRELATION BETWEEN TH E A TTACK RATE OF AMI COMPUTED FROM THE REGISTERS AND THE DEATH RATE FROM CATEGORY 410 OF THE !CD (8th REVISION ) AS GIVEN Attack ra te per 1000 20 I 5 J O 5 X-.i...- .. -.~ .. x 1,.....,.,.x 0 0 IN TH E NATIONAL VITAL S TATISTICS: AGE-GROUP 55-64 YEARS I I 0 McJ~ .... k; oMale s X Fema les '"f •• ~ ..... ·"'·>--'~""' ,. ... ~ o Bo~h ... D-.r. ;.., • o Le ... do.-,. ePr•1'tC •W•f".., • L~\a,l i ... .,....,,.1 olltidcllo<n !~,. ~obut, Ol"in>bn.clit. r,,11. Xiwc- &.! -t·· ~ t>.ai .... XN.;-,-~ lC , .. ,.,,.,t )( ,..., .. lCr..,11. .. 1..r, llr"'-tbe,9 2 3 4 5 6 7 8 9 Dea th rate JO per JOOll 0' -.J Fig. 14 Attack rate: Definite AMI only, Males, 50-54 COMPARISON OF ATTACK RATES FOR DEFINITE AMI ONLY AND DEFINITE + POSSIBLE AMI IN MEN AGED 50- 541 15 +-------+--------11--------+------------ 10 I I "· 30. I I '" / 5 5 1 For actual numbers , see next page 17 • 10 I 5 Average ratio observed in males 45-54 (74% Definite AMI) Attack rate : Definite + possible AMI, Males, 50-54 Fig. 14 (contd) Males Population Attack Definite + Centre Definite 50-54 in 1000 rate possible 1 68 14. 34 4.7 5. 5 2 19 3. 92 4.8 7. 5 3 18 6. 36 2.8 3. 1 4 42 11. 21 3.7 6. 1 6 26 3.00 8. 7 1 o. 9 7 15 5. 31 2.8 4.4 8 127 11. 59 11. 0 14. 5 9 43 5. 43 7. 9 8.0 10 33 5.26 6.3 9. 6 11 32 3.24 9. 9 13.3 12 44 11. 11 4.0 5.9 . 13 16 3.90 4. 1 5. 5 14 15 4.33 3. 5 4 .7 15 23 4.66 4.9 6.3 17 11 1. 33 8. 3 9. 0 18 21 12. 86 1. 6 2.3 30 98 14. 05 7.0 7.6 31 17 5. 39 3.2 5.8 50 14 ,. 6.91 2.0 3.3 68 Attempts to measure and to make international comparisons of the incidence of myocardial infarction in various countries have previously been complicated by disagreement on precise diagnostic criteria. In this respect, this study is unique. Bearing this in mind, table 19 attempts to compare some of the major incidence studies from the literature. It can be seen that in the age-group 50-59 the present study presents one of the lowest incidence rates amongst those quoted. This may be related to the strict diagnostic criteria a dopted. Age and sex of patients Table 20 shows age/ sex breakdowns of the patients by centre. The cases c lassified as "not myocardial infarction" are excluded from this table. Eleven percent of infarction cases occurred in patients under 45 years of age, 28 % in the 45-54 year group, and 61 % in the 55-·64 year group. The total positive registrations are depicted graphically in fig . 15. The male : female ratio was 100 : 37 for all the registrations and 100 : 30 for patients with a positive diagnosis. This is because registration of patients who did not have myocardial infarction was relatively more fre- quent for females than for males : 41 % of the females registered received another diagnosis in contrast to 26% of the males. The percentage distribution of age of the patients is shown in fig. 16, with Kaunas, Lublin, and Sofia registering the greatest proportion of cases below 45 years. The comparative incidence rates in males and females at the different age ranges are depicted graphically in fig. 17. Although there i s a tendency for the two rates to show a parallel increase, there are still considerable differences between centres. For example, at ages 60-64 Innsbruck (No. 14) and Sofia (No. 18) both have the same low incidence rate for females, while Tel Aviv (No. 31) and Tampere (No. 11) both have the same high rate. In each of these pairs of centres, however, the incidence rate for males in the second centre (Sofia and Tampere) is over twice that in the first centre (Innsbruck and Tel Aviv). Diagnostic categories At 28 days the registered cases were studied by the register staff and placed into one of four diagnostic categories, based on clinical data and investigations. These categories were: Definite infarction Possible infarction Not myocardial infarction Fatal cases with insufficient information. The operating protocol (Annex I) describes how most patients could be allotted to a diagnostic category on the basis of history, ECG, enzyme tests and, if appropriate, autopsy findings. The extent to which this was possible varied from one centre to another (table 21). For example, the history could be obtained from 98 % of the patients registered 69 Table 19 C OMPARISON OF ANNUAL MALE INCIDENCE RATES OF MYOCARDIAL INFARCTION AND SUDDE N DEATH IN PRESENT STUDY AND IN NINE OTHER STUDIES Study Oxfo r d 1 Pres ent study 2 Albury- Wodonga Stratford- on -Avon 3 Albany, New York 4 British doctors 5 Oslo6 Framingha m, M a ssac huss e t s 7 HIP, New York 8 Beckenham 9 Inc id e nc e rate per 1000 by age - gro up 50-59 years 4.4 1.4-9.5 (age-group 50-54) 6. 9 7.0 7.0 7 . 7 7. 7 8.5 {age-g roup 45 -6 2) l O. I (age-g roup 4 5-54) 10.6 60-69 years 8 .3 11. 5 16 . 0 13. 2 (a ge-gr oup 60-64) 14. 0 (age-group 55 -64) 14. 0 1 Kinlen, L. (1969) A community study of acute myocardial infarction and sudden death, Thesis, Oxford University 2 Stephens, W.B. (1 9 70 ) Myocardial infarction - inc id e n ce in Albury- Wodonga, Med. J. A u st. , l_, 446-452 3 McWhinney, I.R. (1968) Incid ence of ischaemic heart disease in a country town group practice , Lancet, ~. 342-345 4 Doyle, J.T . , Heslin, A,S . , Hilleboe, H . E. &Formel, P.F. (195 9) Early diagnosis of ischaemic heart diseas e , New Engl, J, Med., 261, 1096 5 Morris , J.N., H eady, J.A. &Barley, R.G. (1952)Coronaryheart disease in medical prac titioners, Brit, med, J., .l, 503-520 6 Westlund , K. (1965) Further observat i ons on the incidence of myo - cardial infarction in Oslo, J, Oslo Cy Hosp., ll, 201-231 7 Dawber, T.R. & Kannel, W.B . (1 961) Susceptibility to coronary heart disease, Mod, Cone, cardiov, Dis., 30, 671-676 . 8 Shapiro, S., Weinblatt, E. , Frank, C. W. & Sager, R . V. (1969) Incidence of coronary heart disease in a population insured for medical care (HIP): myocardial infarction, angina pe ctoris, and possible myocardial infarction, Amer, J, publ, Hlth, .2..2., suppl. 2, 1- 101 9 Fry, J . ( 1964) Coronary heart disease in general practice: natural history over twelve years (1950-1961), Proc. roy, Soc, M e d., 57, 39-42 70 -.J ...... l'•ble ZO NUMBER OF PATIENTS BY AGE AND SEX, EXCLUDING THOSE DIAGNOSED AS "AMI NONE" ! Ase in year ■ Sex I z 3 4 6 7 8 9 10 II 12 I 3 14 15 17 18 30 31 M 10 16 13 34 14 31 31 21 29 7 43 15 II 3 I I 15 22 7 Under 40 F 2 0 I 9 I z 7 I 7 0 5 2 2 0 0 I 3 I M+F IZ 16 14 43 15 33 38 22 36 7 48 17 13 31 I 16 25 8 M 14 ZS 19 72 IZ 35 73 3q 54 26 9Z 31 17 42 3 16 53 16 40-44 F 3 z 8 14 4 2 6 10 8 0 14 4 0 4 0 I II 2 M+F 17 27 27 86 16 37 79 49 62 26 106 35 I 7 46 3 I 7 64 18 M 53 47 33 104 45 62 124 52 86 34 134 33 27 41 4 38 98 33 45-49 F 5 6 14 27 14 7 29 I 3 7 5 44 10 4 6 3 I 17 6 M+F 58 53 47 131 59 69 153 65 93 39 178 43 31 47 7 39 11 5 39 M 81 59 40 126 65 47 168 76 129 54 11 0 36 34 55 12 30 115 37 50-54 F 14 II II 39 21 6 40 10 19 II 40 2 10 II 4 3 37 15 M+F 95 70 51 165 86 53 208 86 148 65 150 38 44 66 16 33 152 52 M 118 130 86 228 81 93 253 109 167 72 176 48 50 5 1 15 47 173 51 55-59 F 31 22 19 61 25 14 76 34 32 17 86 12 12 19 8 12 66 26 M+F 149 152 105 289 106 107 329 143 199 89 262 60 62 70 23 59 239 77 M 119 149 87 270 81 140 287 I 36 189 96 231 58 74 97 19 55 212 79 60-64 F 44 52 42 131 35 48 I 56 48 70 43 124 25 27 33 3 7 76 22 M+F 163 201 129 401 116 188 443 184 259 139 355 83 101 130 22 62 288 10 1 M 395 426 278 834 298 408 936 4 33 654 289 786 221 213 317 54 201 673 223 Total F 99 93 95 281 100 79 314 116 14 3 76 31 3 55 55 73 18 25 210 72 M+F 494 519 373 I 115 398 487 I 250 549 797 365 I 099 276 268 390 72 226 883 295 1 Data a ■ at 18 . Z. 75 50 51 52 Total 5 3 z 36 I 0 I 0 45 5 4 2 406 8 10 z 659 2 I 0 96 10 II 2 755 10 7 4 I 069 3 4 0 225 13 II 4 I 294 10 9 2 I 295 8 I I 3 14 18 10 3 I 609 32 19 4 2 003 14 10 I 59 7 46 29 5 2 600 41 32 14 2 466 34 8 6 I 034 75 40 20 3 500 106 Bo 28 7 853 61 25 8 2 31 1 167 105 36 10 164 -.J N Fig. 1 5 2500 NUMBER OF PATIENTS (DEFINITE + POSSIBLE AMI) BY AGE AND SEX Total 9692 (Males = 7853, Females = 2311, Sex Ratio = 3. 4 : 1) Male 2000 1500 1000 500 60 55 50 45 40 < 40 Ate 0 64 59 Female 500 1000 1500 Fig. 16 P E RCENTAGE DISTRIBUTION OF AGE OF P A TIENTS , EXCLUDING THOSE DIAGNOSED AS " AMI NONE " Gothenburg Prague Buchare st Budapest Dublin Heidelberg Helsinki Lon don Ni jmege n Tampere Warsaw Lublin Innsbruck Kaunas Boden Sofia Perth Tel Aviv Berlin All centres combined Under 4 5 4 5 - 54 7 3 55-64 62.8 68 . 0 62. 8 61. 9 55 . 7 60 .4 61. 6 58.9 59.0 62.4 56. 1 51. 8 61. 1 52. l 62. 5 52.9 59 . 6 61. 1 69. 1 60. 1 -.J ,j::. ~ C O M PARISON OF INCIDE NCE R ATES I N MALES AND FEMA L ES AT VARIOUS A G ES IN DIFFERENT CENTRES • .. .; 3 . 0 2.8 2 . 4 2 . 0 1. 8 E 1.4 .. t.. I. 0 0.8 0 . 4 50-54 years e. ~- ~ .. ... ~- ·~· J I ... l • ,. ,,. ... ' ... I ... .. ~-.)• I l,-1 1• I 1,,. 2 3 4 5 6 7 8 9 I 0 M a les 40-44 years 1.0 ---.---~-~------ • .. '. g 0.5 I I ,. • I ,.! .. t.. .. . ,. lo ,. •s • .J1. s,t. 1. 1Je ,. 11 • .,.,,... I 11 •• 11 2 3 Males • !! .. ,.. .. t.. 6 5 4 3 2. 6 0- 6 4 ye a rs 11• ,. lO • ~- ♦• •l• ,. 'l • ,. •S• I 1• J• 5o• 13• "\• ... I I 2.345678 10 ' . ... ... 12. 14 16 Males Table 21 Centre 1 2 3 4 6 7 8 9 10 11 12 13 14 15 17 18 30 31 50 Total AVAILABILlTY OF DATA ON THE CRITERIA FOR DEFINITIVE DIAGNOSIS OF AMI Number of Percentage of patients for whom data Number deaths are available of before patients l st revie w history ECG enz yme autopsy of pain test (% of deaths 576 157 97.9 97.8 97. 7 70. 1 1 194 221 92. 9 86. 7 81. 8 71. 5 833 147 93.4 84.9 79.2 61. 2 1 994 479 91. 3 82.0 75 . 8 74. 5 529 129 96.2 82.8 79.0 48.8 523 167 90. 1 78. 6 74 .0 22.8 1 340 522 80. 7 69. 3 65 .6 82.2 625 21 6 85.6 73 . 9 67 .5 75.0 748 231 91. 0 76.5 72. 7 34.6 431 145 91. 9 85.8 75.9 90. 3 1 889 363 89.3 87,6 80. 9 49.6 421 76 90. 7 89. 3 62 .5 48.7 174 78 64. 9 65. 5 63 . . 2 60. 3 325 115 81. 2 75.4 52.6 92.2 94 23 91. 5 80.9 74.5 43.5 280 75 82. 9 82.5 26. l 49. 3 987 310 90.0 76.2 72. 8 50. 6 364 71 96. 7 89.0 84.6 4.2 434 117 78.3 76.5 69.4 96.6 13 761 3 642 88.5 80.8 73.5 64.4 75 in Gothenburg, but from only 65% in Innsbruck. There was an even wider range in the proportion of fatal cases submitted to autopsy , from almost none in Tel Aviv to virtually all in Berlin. As can be seen from the decision-tree in fig. 7, additional evidence was needed in some cases to distinguish between "possible myocardial in- farction" and "not infarction". In many cases, this clinical evidence was already available as part of the record form and evidence of ischaemic heart disease could, for example, be found in the past history of a previous myocardial infarction or ischaemic heart disease either clinically or at autopsy. It was possible, therefore, in nearly all cases to verify the diagnosis by means of a computerized programme based on information in the record forms. The breakdown of the total series into diagnostic categories can be seen in fig. 18 and it is a tribute to the classification system used that the number of cases in the "unknown" category was very small. The proportion of cases allotted to the different categories by the different centres engaged in this collaborative study varied considerably . The greatest amount of variation occurred in the proportion allotted to the "not infarction" category. These comprised cases that were notified to the register as raising a suspicion of myocardial infarction but for which another diagnosis was subsequently established . In se veral centres this category comprised over half the registrations, while in others it was less than lOo/o, and in the remainder somewhere between these two extremes (table 22). These differences can be explained partly by the diffe.rent screening methods adopted in the various centres and partly by differences in the £xtent to which clinical findings were supplemented by laboratory inve sti- gations. As was mentioned in Chapter 2 (fig. 8) some registers screened all notifications before the case was registered, even though the protocol stipulated clearly that all cases raising suspicion should be included in the registration scheme. Fortunately, it would appear that this screening process did not have much influence on the total number of cases of actual myocardial infarction that were detected. Although the proportion of "definite" cases was higher in the centres that screened notifications (3. 2 : 1 compared with 2. 0 : 1), these were also the centres placing more emphasis on laboratory and hospital investigations, which would tend to transfer cases from the "possible" to the "definite" category. The other variable is the source of notification, which depended on the system of medical care. Some centres received numerous notifications from community-based doctors seeing patients without the benefit of complex technological work-up; they consequently received more doubtful cases than those relying heavily on hospital-based notifications. 76 Fig . 18 DIAGNOSTIC CATEGORIES Not infarct 29 % Possible 2 l o/'o Unknown < l '1o 77 Definite 50% -.J CX) Table 22 AMI Definite Possible None Insufficient data Unknown Total Number of patients I 70 14 17 0 0 100 592 2 3 27 26 17 18 57 56 0 0 0 0 100 100 1194 851 DEFl1'1 flVE DI,\G1'0StS ESl ,\ 11!.ISIIF:D IN .\ LL P ,\ TIENTS 11' EAC H C F:NTR,: (1n pt"rccnt.1gc s) 4 6 7 8 9 10 II 12 1 l 14 I 5 17 18 28 5) 7) 65 68 ! 67 65 41 45 75 61 52 56 26 22 19 27 16 I 18 19 1 7 2 1 17 29 l4 22 46 25 7 8 16 I I 5 16 42 )4 7 10 2) 22 0 0 0 0 0 0 0 0 0 I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100 100 100 100 100 100 100 100 100 100 100 100 100 207 ◄ 529 524 I 352 65) 915 4 32 1894 42 1 288 4 31 94 288 I )0 31 50 5 1 52 Tota.I 72 44 32 86 48 50 17 31 26 1 3 27 21 II 24 42 I 25 29 0 0 0 0 0 0 0 0 0 0 0 0 100 100 100 100 100 100 989 389 289 106 48 14 373 The main effect of screening notifications, therefore, was on the proportion and type of case that ultimately fell into the category "not in- farction". In those centres that registered all notifications, these were the cases that had raised suspicion of myocardial infarction at the very earliest stage of the attack. In the centres that screened notifications, myocardial infarction was still suspected when the patient was seen by register staff but the case was later found not to fulfil the diagnostic cri- teria. The ratio of "definite" to "possible" ranged from 5 : 1 in Gothen- burg to 1 : 1 in Budapest, as can be seen from table 23. The breakdown of registered cases between "definite", "possible", and ''not infarction" also varied in relation to the age and sex of the patient {table 24). This information is given separately for each centre in Annex II {table 58) . Registered cases diagnosed as 11not infarction" Myocardial infarction as defined for the purposes of this study is a fairly well circumscribed condition with a dramatic onset and clear sequelae. The notifications requested from general practitioners and health workers were for any case where myocardial infarction or even a "heart attack" was suspected. Where centres screened notifications, this was usually done for hospital notifications. Thus, although the study invited false alarms it did so in the way that any community project designed to tackle this disease would. For example, if general practitioners were invited to contact an emergency transport service for suspected myocardial infarction, the resultant cases selected could be expected to be similar to those that were notified to the registers in this study. The suspects who did not have confirmed myocardial infarction suf- fered from other heart diseases in over half of the cases, The diagnoses ultimately established in the "not infarction" group are summarized in table 25 . and a more detailed breakdown is given in Annex II, tables 59 & 60. This list can be expected to be re pre sentati ve of cases t h at would be drawn into any community-based case-finding programme for myocardial infarc- tion. This should influence the design of a system as it clearly makes sense to plan the type of facility to cater for most of the cases that will be attracted to it. Delays occurring before reaching medical care A large amount of the effort put into this registration study was de- voted to the timing of events in the early stages immediately following the acute onset of symptoms. When the study was designed, the events con- sidered to be most important in that period of time were: {a) the delay before medical services were informed that an event had occurred; (b) the time at which a medical practitioner actually entered the patient's presence and examined him; (c) the time at which an antiarrhythmic prophylactic or therapeutic treatment was given; and, finally {d) the time at which the patient actually entered the hospital area, When the study was first designed research was in progress to determine whether it was 79 00 0 T.obl e 23 AM I Definite Poaaible None lnauffi c ienl data Unknown Tota.I Number o f pat ients DE F INITIVE DIAGNOSES IN ALL P,\TJENTS. F.XCJ. UDl"IG rIIOSE DIAGNOSED AS "AMI NONE " , IN EA C H CENT R E (in pe rc ent ,tJ;?es) l 2 3 4 6 7 8 9 10 11 I Z I 3 14 15 17 18 30 31 50 84 61 59 52 70 79 71 81 I 78 77 71 68 8 1 68 6 8 7 I 8 1 58 55 16 39 41 48 30 21 29 19 I 22 2 3 29 l l 18 32 32 28 19 4 I 45 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 i 0 0 0 l 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100 100 JOO 100 100 100 JOO 100 100 100 100 100 100 100 100 JOO JOO JOO JOO 494 519 373 111 5 398 487 I 250 549 797 365 1099 2 76 268 390 72 226 88 3 29 5 I 67 51 52 To tal 8 7 64 71 l 3 36 29 0 0 0 0 0 0 0 0 0 100 JOO 100 105 36 10 164 Table 24 AMI Definite Possible None Table 25 RELATION OF DIAGNOSTIC CATEGORY TO AGE AND SEX OF PATIENT Males Females Under 45 45-54 55-64 Under 45 45-54 49% 54% 54% 2 7 % 33% 16% 19% 24% 16% 18% 34% 2 7 % 22% 57% 49% DIAGNOSIS ESTABl.JSHED IN REGISTERED PATIENTS WHO DID NOT HA VE AMI Ischaemic heart diseases 31 % Other heart diseases 13% Angina 11 % Mental and nervous system 11 % Musculo- skeletal 7 % Abdominal conditions 6% Pulmonary disease 4% Sundry 10% No cause found 7% TOTAL 100% 8 1 55-64 43% 22% 25% beneficial in suspected heart attacks to administer antiarrhythmic treat- ment at the earliest opportunity. No definite conclusions were reached, however, and as the study progressed it was found that su·ch treatment was rarely given. Detailed analysis of this particular time interval, therefore, has not been pursued. The time s expressed in the figures and tables represent the median times of cases where the time interval was known exactly. These cannot be used as a complete measure of the state of affairs without some quali- fication, but they provide reliable comparp.tive statistics. Medians are used rather than averages as the distribution of time intervals is skewed, with a tail towards long delays, and the median provides a more suitable description of the distribution. Table 26 gives a median interval of time elapsed between the onset of the attack and the various events. The three main intervals - the patient delay, the doctor delay, and the delay before reaching hospital - are shown in the histogram in fig. 19. As can be seen the proportion of the delay for which the patient a_nd the doctor was each responsible varies considerably, partly as a result of local conditions and the system for obtaining medical care. For example, the doctor de- lay is very short in Lublin, Tampere, Gothenburg , and Boden. This is partly because patients go direct to hospital rather than call the doctor to their home. However, the effect of these habits on the total delay was variable; for example, of two centres where domiciliary visits were com- mon, Lublin had one of the· shortest total delays before the patient was examined and Boden one of the longest. The diffe r ences in total delay between one centre and another a r e quite marked. In Nijmegen and Heidelberg half of the patients were ex- amined within 60 minutes of the onset of the acute symptoms; on the other hand, in Boden and Berlin the median delay was over three times this figure. In fig. 20 the delays are shown in the form of clockface s superimposed on a map of Europe. The size of the segments into which each clockface is divided is proportional to the three delay periods, taking the median times, that is , the times needed for half the patients to complete each stage. More detailed breakdowns of the time elapsed between onset and call to doctor, and between call to doctor and first medical examination, are given in tables 27 and 28 . It should be borne in mind that the tables show- ing the delay before call to doctor and first examination include all cases of myocardial infarction, both those rece iving treatment and the sudden deaths. In the figures for the delay in reaching hospital (table 29), how- ever, the percentages refer only to those patients who actually reached hospital. 82 ex, l,.) Table 26 MEDIAN TIME (MINUTES) ELAPSED SINCE ONSET OF ATTACK, EXCLUDING PATIENTS DIAGNOSED AS "AMI NONE" Interval between I z 3 4 6 7 8 9 10 II IZ 13 14 I 5 17 18 30 31 50 51 Onset & call to doctor 140 120 90 40 60 30 7 5 90 30 85 40 60 60 75 210 60 90 60 115 135 Onset & first med. exam. 150 165 165 90 120 60 90 120 60 90 85 b5 90 100 210 90 130 90 180 240 Onset & anti-arrhythmic TMT 480 > 1000 >1000 390 430 300 30 719 420 I RO 45 115 115 65 220 150 ' 1000 - 450 Onset & arrival in hospital 150 510 ' 1000 260 225 330 120 180 lb 5 9 5 23 5 H O 150 270 240 240 230 210 390 480 Call to doctor & med. exam. 0 15 30 30 zo 10 0 I 5 15 0 15 10 10 10 0 0 15 15 30 30 Med . exam. & hosp. arrival 0 90 180 70 60 100 0 30 45 0 75 30 5 60 0 60 70 60 90 105 Ons et At dea th > 1000 7 5 540 30 •1000 1 55 275 120 95 170 730 415 ' 1000 90 260 >1000 > 1000 ' 1000 > 1000 > 1000 Table 27 TIME ELAPSED BETWEEN ONSET AND CALL TO DOCTOR/ HOSPITAL, E>..CLUDl1'G PAT IENTS DIAGNOSED AS "AMI NONE" (1n p c r c<'n ta g.--. ::.) Time e lapsed I 2 3 4 b 7 M 9 10 11 I 2 13 14 I 5 17 18 30 31 50 51 Under 30 min 12 31 25 39 27 44 27 20 43 27 lM 30 31 28 19 24 24 29 23 16 30 - S'J min 9 10 1-1 I 5 16 12 16 19 13 13 I 5 19 15 15 13 17 I 5 16 II 15 60-81J min 12 0 R 9 10 4 9 II 7 10 9 9 12 10 4 13 9 12 9 12 90-11"1 min 10 2 3 5 6 3 0 0 -I -I -I 4 4 0 4 J 6 l 7 l 2 hour s 13 7 -I " 8 b 10 10 5 9 7 ' 3 6 6 8 9 7 6 10 3 hours 8 -I 2 4 5 3 -I J 4 s 4 0 -I 5 7 4 6 6 5 7 4 hour s 6 J -I 2 4 J -I J J -I J J 2 5 II 3 4 3 3 5 5 hours 2 J 2 2 2 l J 4 2 l 3 J 2 4 0 3 3 I I I 6 hour:, 2 2 2 I 2 l 2 2 2 2 l -I 2 l 4 3 3 l z 3 7 hou rs J 2 3 0 I 2 2 2 2 2 I 0 3 2 (, I 2 I z 0 8 hour s z 1 2 I 2 2 I 2 2 2 I 2 4 2 4 I I 3 2 I "I hours I I 2 I I I I I I I I l I I 2 I 2 2 2 4 10 hours J 2 I I I I I I I I I 0 I 2 0 I I I I 2 11 hburs I I I I 2 I I 2 I I I 0 0 I 2 2 I I I I 12-17 hours 6 7 6 4 5 4 4 5 J ; J -I 5 J b I 4 4 7 4 18- 23hours 1 4 3 2 3 I 2 2 I 2 2 3 3 I 4 2 3 3 2 2 1 day 4 5 R 4 3 4 3 5 3 4 3 3 2 3 7 5 3 5 7 8 2 days 3 3 4 2 I 0 I 2 I 2 2 I 2 2 6 I 2 1 2 2 3 days + 2 5 5 3 I 4 2 2 2 J 2 1 3 3 4 4 3 1 7 2 Total 100 100 100 100 100 100 I U0 100 100 100 100 100 100 100 100 100 100 100 100 100 No. with info rmation 420 469 318 1057 336 429 10 49 485 7 53 324 987 215 172 304 54 143 668 255 100 91 No . without information 72 19 25 37 51 41 I ol 56 41 89 71 51 39 86 4 83 107 28 53 9 52 Total 30 60 70 100 0 285 zoo 210 30 15 70 45 585 360 52 Total 44 31 12 14 8 9 0 5 4 8 8 4 0 3 0 z 4 z 4 z 4 2 0 I 0 1 4 I 4 4 0 2 4 4 0 2 0 3 100 100 2 5 8654 10 1083 Fig. 19 MEDl AN TIME ELAPSED SINCE ONSET OF ATTACK, EXCLUDING C ASES DIAGNOSED AS "AMI NONE " Onset Onse t - ~ Call Dr - m•,;,: Med. exam. O call Dr med. exam ····· - Hospital ! 100 200 300 400 500 min. Gothi>nburg Pr;igue 13ucharest 13uda pe st Dub lin Heidelberg Helsinki London 0! ijmegen Tampere W a rsaw Lublin Innsbr uck Kaunas Boden So f ia Perth Te l Av i v Ber li n .. :::::•::::::::;:::::::~::::::::::::::: Total 100 200 300 400 500 min . f Onset 84 WEDGE DIAGRAMS SHOW ING FOR EACH CENTRE THE TIME THA T E LAPSED FROM THE ONS ET OF THE ATTACK TO THE CALL TO THE DOCTOR, FIRST MEDIC A L EXAM INATION, AND ARRIV AL IN HOSPITAL The size of each wedge is propor tiona l to the time taken fo r half the patients to demand or obtain the St!,rvic e (for t h e th ird category, half the pa ti ents ar r iving in hospital ). \ 12 h. - - ( LO~ ~ -v- , \ . ONSEl· CALL 10 OOt lOA ONSlHIRSl MEDICAL EIAMINAIION ':::::;::::::J OHSl l·AIRVAL HOSl'll AL 85 00 0--- .Table 2. 8 Time e lap sed Under 30 m in JO. 59 min 60-89 min 9().119 min l hours 3 hour s 4 hour s S hours 6 hours 7 hours 8 hours 9 hours 10 hours 11 hours 12.-17 hours 18- 2.3 hou r s I da.y 2. days 3 day, t Tot al No, with 1n!o rmation No. wi th out 1nformation I 98 0 0 I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100 419 74 2 3 60 32 19 46 9 18 4 3 ; 2 I I I I I I I I I 0 0 0 I 0 0 0 0 0 I 0 0 0 I 0 0 I 0 0 0 0 0 I 0 0 0 0 100 100 471 32 l 23 14 TIME ELAPSED BETWEEN CALL TO DOCTOR / HOSPITAL AN D FIRST MEDI CA L EX ,\~1 1'1/\ TION EXCLUDING PATIENTS DIAGNOSED AS " A M I NONE" ( in per ... eutagt:s ) 4 6 7 8 9 10 II 12 13 14 I 5 I 7 18 JO 49 56 73 8 1 58 7! I 9l I 6 4 9l 6 4 8 4 82 80 I (, I 27 20 II 10 19 II , 4 2 l 4 I 5 9 0 8 I !O 14 9 5 3 10 4 I 6 I I 9 I l 2 " 4 4 2 2 3 I 2 I 2 0 2 I 0 4 I 5 4 6 3 I I 3 I I 3 I 3 I 9 I I I 2 2 I } I I 0 0 I I I 2 I I I I 2 I 0 I 0 0 0 0 I 0 0 0 i 0 0 I I 0 I 0 0 0 I 0 0 I i 0 0 I I 0 0 I 0 0 0 I I 0 0 0 I I 0 0 0 0 I 0 0 0 i 0 i 0 0 ! 0 0 ! I i 0 0 0 0 0 I 0 0 0 0 0 0 0 0 I 0 2 0 0 0 I 0 I 0 I 0 0 0 0 0 I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 I 0 0 0 I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 I I 0 0 0 0 0 0 0 I 0 0 I 0 0 0 I I I 0 0 I 0 0 0 0 0 0 0 I 0 I I 0 0 0 0 0 0 0 0 2 I 0 0 0 0 0 0 I 0 0 0 0 I 0 0 0 I 0 0 0 0 I I 0 0 0 0 0 I 0 l 0 0 100 100 100 100 100 100 100 100 100 100 100 100 100 100 I 1091 376 44 6 12 6 , >lO 1 7H l5l 9Jl 235 I 76 350 56 H2 ( i i' 5 20 20 29 IOL Z.h 16 II 47 29 11 40 l 84 ,,, }I 50 51 52 Tota l 57 44 49 40 67 28 25 18 24 17 6 II 7 16 7 3 6 3 4 3 3 6 8 4 3 0 5 7 12 I I 0 I 0 I 0 2 3 0 0 0 0 I 0 0 0 0 2 0 0 0 0 0 I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100 100 100 100 100 247 102 89 25 8 932 l4 48 16 9 735 a:, --.J Table 29 Time e lapaed Under 30 min 30-59 min 60-89 min 90-119 min 2 hours 3 hour• 4 hour• 5 hour• 6 hour• 7 hour• 8 hour• 9 hour 1 10 hours 11 hour• 12-17 hours 18-23 hour• l day 2 day11 ] days + Total N o . with info rmat1on No , without information I II 9 12 10 13 8 6 3 l 3 l 2 2 l 6 I 4 3 3 JOO 419 73 2 3 4 3 2 7 2 0 3 7 6 7 7 6 6 7 6 15 6 4 9 4 4 5 4 2 4 5 2 4 2 l 2 2 3 l 2 3 l 2 l I I I I 10 8 7 6 6 3 JI 18 8 5 9 4 13 19 11 JOO 100 100 365 191 756 18 18 70 TIME ELAPSED BETWEEN ONSET AND ARRIVAL IN HOSPITAL: HOSPITALIZED PATIENTS ONLY, EXCJ,.UDING THOSE DIAGNOSED AS "AMI NONE " {in percentages ) 6 7 8 9 10 II 12 13 14 l 5 17 18 9 9 16 12 5 24 6 8 8 7 10 5 8 7 14 14 10 I 3 5 14 11 2 10 5 I 8 7 II 8 I 3 II 7 14 12 9 8 11 6 5 7 6 I 10 5 9 8 II 8 6 7 13 9 II 10 I I 3 10 13 13 9 11 8 15 8 8 6 7 7 4 10 7 8 12 8 6 6 4 6 4 6 4 6 5 2 4 10 2 7 3 3 I 5 4 2 4 4 I 5 2 3 4 2 2 I 3 3 2 4 I 6 4 l 2 2 2 2 2 2 3 3 3 l 0 I 0 l I l 3 3 3 2 3 3 3 4 3 2 I I l l l 2 I 2 0 4 l 0 I I I l I l I 3 I 0 I 2 I I l 2 l I I 2 I l 0 I 7 5 5 6 I 7 5 7 6 7 9 4 6 5 4 3 4 l l 3 3 4 3 8 4 7 10 4 6 4 4 6 3 4 6 4 8 3 5 l 4 2 l 4 3 4 2 10 5 3 17 4 5 4 4 9 I 5 9 4 13 JOO 100 100 100 100 100 100 100 JOO 100 100 100 304 351 991 433 600 322 880 199 169 247 52 131 42 36 89 59 36 35 59 56 42 143 l 60 30 JI 50 51 52 T o tal 4 3 l 2 13 9 5 11 5 5 4 8 6 9 4 5 4 9 9 10 4 9 8 8 14 12 8 8 I 3 12 12 7 6 8 l 3 8 7 5 10 5 4 5 4 4 6 3 1 3 4 3 l 4 2 0 3 3 2 4 0 0 2 2 I 3 5 0 2 3 l 2 I 4 2 I l I I 0 I l l l 0 4 I 5 7 9 8 -I 7 4 3 4 5 0 3 7 7 7 12 4 6 3 2 3 7 4 3 7 7 14 14 8 8 100 100 JOO 100 100 100 591 244 96 8 6 24 7 451 62 33 23 14 5 975 Fe a tures associated with various delays It must not be assumed that the delays in hospita lizat i on are related to the "efficiency" of the health servi ces in the differe nt centre s . They are closely related, however, to the system of manage m e n t of the acute attack in e ach city. For example, in Gothenbur g most p a ti e nts go straight t o hospital so that th e delay in seeking and reaching me d ic a l c a r e is much the same as that for admiss ion to hospital. In Buchare s t, on the other hand, most patients are treat e d at home initially and a r e a dmitte d t o hos p i- tal only when necessary o ver the following weeks; thi s a ffe c ts the ho spital death r a te {see page 123 ). Another v ariable to be cons i d e r e d is the fact that some centres have special mobile teams that s e t up e quipment i n the patient ' s home. The return to hospital may therefor e b e t aken a t lei sure, as the victim of the atta ck is now under full emergency c are. M ost such centres analysed their s y stem separately, but this could no t b e done fo r all centres. It is up to each c e ntre to d e cide if the desir e d s t a t e of a ffai rs is in accordance wi th the actual one shown by the se studie s. I n at le as t one {Prague), the discovery of a long delay before hosp i t a l i zat ion, in spi t e of reasonably quick action on the part of the patient, r e sulte d in m odification of the admission proce dure and reorganization of the ambulance s e r vice . Slightly more male s c alled the doctor within one hour tha n females {table 30) but in only a few centre s was this d iffer e n ce si gn ificant. When all c e ntres are c om b ine d t h e difference i s si gnifi c ant a t the 5% le vel. Table 3 1 show s th e breakdo wn of the delay b e for e calling fo r medical care b y the definitive d iagnos i s and b y the pres e n c e or absence of previous his- tory of myocardial infarction. In a majority of c entres {this information is given in detail for each centre in Annex II, table 6 1) th e delay in calling the doctor is shorter in patients diagnosed as havin g had a m yocardial in- farction than in those with a negative diagnosis. The re is only a ve r y slight tendency for patients with a previous history of m y o cardial inf arction to contact the doctor earlier than those without histo r y . When one conside rs the group of patients a dm itt e d t o the coronary care unit of hospitals and contrasts them with patients who wer e t reated in the wards only, it can be seen that the time elaps e d {table 32 ) was less betwe e n the onset and admission to hospital in thos e who were treat ed in coronary care units. {This information is given i n m ore detai l f o r each centre in Annex II, table 62.) 88 Table 30 PERCENTAGE OF PATIENTS WHO CALLED DOCTOR/ HOSPITAL WITHIN 1 HOUR OF O NSET OF ATTACK, BY SEX EXCLUDIN G PATIEN TS DIAGNOSED AS "AMI NONE" Male Fem a le Significance Centre Number with "/o calling Number with % calling of sex information doctor wi thin information doctor wi thin difference 1 hour 1 hour 1 335 20.9 73 20. 5 NS 2 386 44.8 84 25.0 :,: :,~ :,~ 3 235 38 . 7 84 44.0 NS 4 756 54.0 256 54. 7 NS 6 253 42. 7 83 45 .8 NS 7 361 57. 6 67 49 . 3 NS 8 766 46. 1 271 36 . 2 :::::, 9 369 38 . 2 10 3 36 . 9 NS 10 497 56 . 1 110 54. 5 NS 11 258 38 . 8 66 45.5 NS 12 691 55. 1 293 47.8 ::: 13 178 50. 6 37 43 .2 NS 14 59 40. 7 19 42. 1 NS 15 185 43.8 45 44.4 NS 17 40 30 . 0 14 35. 7 NS 18 132 41. 7 8 37 .5 NS 30 505 39. 6 162 34 . 6 NS 31 176 44.3 60 43 . 3 NS ' 50 155 34.8 58 37 . 9 NS Total 6 337 45. 9 1 893 42.6 ::( 1 NS = not s ignific ant; ,:, , ,:":' , a nd ,:":":' = s ignificant a t the 5"/o, 1 "/o, and 0. 1 % probabi lity leve l, respectively. 89 1 Table 31 TIME ELAPSED BETWEEN ONSET AND CALL TO DOCTOR, BY DIAGNOSIS AND PAST HISTORY OF MYOCARDIAL INFARCTION AMI none AMI without AMI with Time elapsed history of MI history of MI Number % Number % Number % Under 30 min 825 23.7 1687 29.3 776 33.2 30-59 min 507 14.5 822 14. 3 335 14.4 60-119 min 502 14.4 804 14.0 308 13. 6 2-23 hours 1266 36.3 1919 33.4 754 32. 3 1 day + 387 11. 1 522 9. 1 151 6. 5 Total 3487 100.0 5754 100.0 2334 100.0 No information 596 704 393 Table 32 TIME ELAPSED BETWEEN ONSET AND ARRIVAL IN HOSPITAL: COMPARISON BETWEEN PATIENTS TREATED IN HOSPITAL WARD ONLY AND THOSE IN CORONARY CARE UNITS Intervals Ward only + CCU - ward < 30 min 7 % 5% 30-59 min 6% 8% 60-119 min 15% 18 o/o 2-3 hours 19% 22 o/o 4-23 hours 32 o/o 32 o/o + 1 day 21 o/o 15% Total 100 o/o 100 o/o Median 250 min 210 min No. with information 3480 3030 No. without information 329 166 90 Time distribution of deaths The time delays occurring in the early stages of this condition becom e especially significant when the pattern and timing of mortality are taken into consideration. As can be seen from table 33, a third of all the deaths occurred in the first 30 minutes following the onset of acute symptoms. This information is given for each sex in Annex II, table 63. The precise figure varied from one centre to another, but in some centres the number of cases in which the exact time of death was missing was greater than in others. It seems likely that this information was more likely to be missing in the case of sudden death. Thus, in the centres Sofia, Innsbruck, and Berlin - the centres with the lowest proportion of deaths occurring within the first 30 minutes - the proportion of cases without exa ct time informa tion was the highest. In the centres that had the most complete time informa- tion, the proportion of patients dying within the first 30 minutes was about 40% to 45% . Other reasons may be considered for these variations. For example, sudden deaths may have been missed in the registration in some centres. Even assuming that all the deaths with the exact time missing had occurred within 30 minutes, the proportion would not have reached 30% in Dublin (6) , Warsaw (12) , Lublin (13), and Sofia (18) . Although some sudden deaths may have been missed in these centres, the mode of death might really vary among the centres. It would seem, however, that any such differences between the centres in the pattern of early mortality is submerged in the mass of missing information. This is obviously a difficult area in which to collect accurate data and the extent and nature of the difficulty must vary with different medical care systems. The difficulty of obtaining accurate information c a n be understood from fig. 21. In the case of early deaths, the proportion of patients dying before the benefit of medical examination is much highe r than for deaths after 24 hours. This ratio varied considerably from one centre to another (table 34) , with the percentage of deaths before medical examination in the case of deaths occurring within the first 24 hours ranging from 88 % down to 51 % . Relation of early mortality to delays It is possible to present these two sets of information - the delays occurring before a patient called for and received help, and the time dis- tribution of deaths - on a single graph . Such a graph is shown in fig. 22 and this information is repeated in more detail for each centre in Annex II, fig. 36. The scale along the bottom of the graph is a simple arithmetic scale which starts at zero time (time of onset of symptoms) and continues on for the first 24 hours. The scale on the left of the graph refers to the percentage of those patients alive at 24 hours who called for medical care and received it at various times, whereas the scale on the right of the graph starts at the top and r e fers to the percentage of pa tients of the whole group who died before a nd after medi c al examination. 91 A B th s u ... Tim~ <-l.1pi.~d I l 3 4 I U11dt r 10 1n1n I l l 4l l 4 47 JO-"-?m 1n I 6 ll 7 I &0-R9 l lllll I I l 4 4 ''0-119 mm I 0 I 0 l l hours l I 4 l 3 hour s I I I 3 4 hours I I 0 I 3 5 hour s 0 l l I 6 hour s I 0 I I 7 hours I 0 0 0 8 hours l 0 I 0 9 hou r s I 0 I 0 JO hour s 4 0 I 0 11 hou r ~ 0 I I 0 ll-1 7 hou rs 10 I 4 I J 8-23 hou r s 7 3 0 I I day 5 4 7 l l days I l I l 3 days ♦ 39 Jl 3 5 ll T o tal 100 100 100 JOO N o. w ith 10for m.it1on 188 lO J 136 490 No . without info rmation I 9 l ll JO TIME ELAPSED BETWEEN ONSET AND DEATH. EXCLUDING PA TIENTS DIAGNOSED AS ''AMI NONE " (in pe r c ent~ge•) 6 7 8 9 JO II I l 13 14 " I 7 I 8 JO 19 J7 37 40 41 33 l O 16 5 H 41 3 l 4 7 6 4 J 6 ; 9 II 0 II 7 I 6 4 J l 4 l 4 l 7 l 4 0 I 3 J ! l l I I l J 6 0 I 0 4 l I 4 l 4 l 4 l 3 l '> 0 4 l I I l I 3 0 3 I l I 0 0 l l I I I I l I I 0 I 3 0 I J 0 I 0 I 0 I ! I 0 l 0 3 l I l I 0 i 0 I I I I 3 4 3 3 6 I 0 ' 0 I 0 I 0 I 0 4 I 0 I I I I 0 0 0 I I 0 I 0 0 0 0 3 I I I I I I I I I I 0 0 I 0 u ! I I I 0 I I I 0 I 0 I I 4 5 l 0 6 0 I 0 I i I I I I I I 0 0 0 J I I I 4 J I 4 l 4 l 5 4 I II ·• l 7 I 5 4 ! I l I ' 3 4 4 I 0 9 ! I 4 '> 4 I l '> I I 4 J 5 2 3 J 7 l l J l I ·• 3 4 I 4 I 3 l I 5 I 38 JO JJ l9 I ! 5 I ; o I 15 JO i 54 l \ JI 43 39 J 00 I 00 100 I 00 IOU 100 JOO 100 JOO 100 100 JOO 100 14 5 168 S05 l09 l 10 I I 16 J36 70 57 IH l9 69 Jl0 14 II 79 so 10 !'> 4 3 JO !K lb I I 9 60 JI so I 51 5l Total lo 18 II I I 7 Jl 8 0 0 0 6 J 3 6 0 J I 0 0 0 z 5 0 I I 0 3 I 0 0 0 l 0 0 0 0 I 0 J 0 I 7 I I 3 6 0 I 0 0 0 0 I 0 J 0 0 I I 0 0 I 7 I 0 3 0 0 J 0 J 6 0 I 0 8 II I 7 4 4 10 0 0 l 5 8 I 6 I 7 4 I 0 0 I 7 l 4 l 4 3 H 0 ll 100 JOO I 00 100 100 76 40 18 6 3561 9 40 5 5 487 '° l.,.) B. Mah•s Time elapsed I Under 30 min 25 30-59 min I 60-89 min l 90-119 min 0 2 hours J 3 hours 2 4 hours l 5 houra 0 6 hours 0 7 hour• 2 8 hours 2 9 hours I 10 hours 4 11 hours 0 12-17 hours 9 18-23 hours 5 1 day 4 2 days I 3 days t 40 Total 100 No. with information 106 No. without information II C. Ft'malt'a Time f"laps('d I Under 30 mm 9 30-59 min 0 60-89 min 0 90-119min 0 2 hours 0 3 hours 0 4 hours J 5 hours 0 6 hours 3 7 hours 0 8 hours J 9 hours J 10 hours 6 11 hour• 0 1Z-17hour• I 3 18-23 hour a 13 I d.,y 9 2 dc1ys 0 J days t JS Total 100 No. with information 32 No. without information 8 d,lt:-i n,11 .lv.ulablf' 2 3 4 42 26 46 6 12 8 2 4 3 I 0 2 I 3 2 2 I 3 l 2 3 2 3 I 0 l I l 0 I 0 l 0 l 2 I 0 2 0 I 0 0 l 4 I 3 0 I 5 7 2 I I I 31 33 23 100 100 100 175 110 361 I 16 10 l J 4 42 12 49 8 12 5 4 8 5 0 0 I 0 8 3 0 0 2 0 0 2 0 0 I 0 0 I 0 0 0 0 0 I 0 0 0 0 0 0 0 4 I 0 4 2 0 0 I 0 8 2 I 2 0 2 35 46 22 100 JOO 100 26 26 129 I 5 0 6 7 8 9 10 II 20 J7 38 36 42 38 7 6 4 J 5 8 5 4 2 5 2 5 J I 2 2 0 3 2 4 3 4 3 4 I I 2 I 2 0 3 l I 2 2 J 3 0 I I I 0 I l I I 0 0 0 0 I I I 0 2 0 0 I I 0 2 0 l I I I 2 l 0 I 0 0 I 0 0 I I 0 5 4 3 4 6 2 6 4 2 2 I 3 5 6 3 4 5 5 2 3 3 2 I 2 32 l8 32 29 l5 26 100 100 100 100 100 100 111 I J7 411 161 l 1 7 I 02 6 9 65 J7 8 22 6 7 8 9 10 II 15 35 35 5l 38 I 8 6 6 I 4 8 J J 0 2 0 l J J 3 2 0 4 0 I 0 3 ! I 6 0 J 3 0 I 2 8 0 I 0 0 2 0 0 0 I J 0 0 0 0 0 I 0 J 2 0 0 6 0 0 0 0 0 0 0 0 I 0 0 4 0 0 J I 0 2 2 0 0 I 0 0 4 0 0 J 0 I 0 0 J 0 0 4 ' 0 0 J 0 6 4 2 2 12 0 J 5 0 8 0 6 0 2 0 2 9 59 35 36 27 25 41 100 100 100 100 100 100 34 JI 94 48 53 l4 8 l I 4 13 l J ll ll 14 I 5 17 18 JO JI 50 51 52 Total 23 19 7 38 50 2 25 27 30 I 5 17 33 9 9 0 10 5 2 6 9 0 0 0 6 4 7 2 4 0 2 2 2 0 8 0 3 3 4 0 4 0 5 2 2 0 0 0 2 2 4 0 5 0 5 2 7 0 8 0 3 I 2 2 2 0 0 2 2 0 0 0 2 0 2 0 2 5 0 0 0 0 0 0 l I 2 0 3 0 3 2 0 0 0 17 I I 2 0 J 5 7 I 2 0 0 0 I 2 0 5 I 0 2 I 0 0 0 0 I 2 0 0 0 0 3 l 0 0 0 0 I 2 0 0 2 0 0 l 0 0 0 I 7 I l 6 7 2 0 7 0 0 5 0 0 I I 0 0 0 5 2 0 0 5 8 0 I 4 4 12 3 0 8 4 0 10 15 I 7 4 3 4 5 I 0 7 2 2 I 0 0 0 2 l 4 5 I 0 2 6 5 5 8 17 4 4 4 5 I 0 l 5 0 0 0 17 2 J l JO 51 21 30 4l 38 4l 35 38 0 JI 100 IQO 100 100 100 100 100 100 100 100 100 100 247 54 43 I 11 lO 59 l50 55 lO I J 6 2775 33 8 l4 l 1 I 16 4l 7 lb 2 J 368 I 2 ll 14 I 5 11 18 JO JI 50 51 5l Total ll 6 I 0 I 6 ll 10 l 1 l4 5 0 � · 28 8 19 0 ll II 0 J 5 0 0 .. 5 I 6 I 0 0 0 0 J 5 5 0 . J I IJ 0 4 0 0 4 0 0 0 l l 0 7 4 0 0 I 0 0 lO 2 I 7 0 0 0 0 0 0 0 0 0 . 2 I I 0 0 0 0 0 I 0 0 0 I I 0 0 0 0 0 I 0 5 0 I 0 6 I 4 4 0 0 I 0 5 20 . 2 0 0 0 4 0 0 0 0 0 0 . 0 I 0 0 0 0 0 0 0 5 0 . I 0 0 0 0 0 0 0 5 0 0 . I I 0 0 4 0 0 0 0 0 0 . I l 0 0 0 0 0 I 0 0 0 ' I 8 6 1 8 II 0 6 0 5 0 4 2 6 0 0 0 lO 0 10 10 0 * J 8 0 7 8 II 10 9 5 10 0 . 5 I 6 0 0 II 10 J 5 0 0 . 3 43 JI 64 36 JJ 50 44 43 50 60 . 37 100 100 100 100 JOO 100 100 100 100 100 . 100 89 16 14 25 9 10 70 21 20 5 0 786 IO l 4 5 0 J 18 l 14 J 2 119 I I I . -..0 >I>- Fig. 21 NUMBER OF DEATHS ACCORDING TO MEDICAL EXAMINATION AND TIME ELAPSED SINCE ONSET OF ATTACK FOR ALL CENTR ES COMBINED, EXCLUDING PATIENTS DIAGNOSED AS "AMI NONE" Time elapsed between onset o f attack and death Less than 30 min 30 min to less than 60 min 60 min to less than 2 hou rs 2 hours to less than 4 hours 4 hours to less than 24 hours E8a Death before 1st medical examination O Death after 1st medical examination 0 JOO 200 300 400 500 600 700 800 900 1000 I I 00 J 200 471 - 68 ffl1 90 D: 100 ~ 275 24 hours or longe § I I 83 I 1300 cases Table 34 PROPORTION OF DEATHS BEFORE FIRST MEDICAL EXAMINATION Deaths within 4 weeks Deaths within 24 hours Centre % of deaths % of deaths Number before fir st Number before first med. exam. med. exam. 1 152 76 130 88 2 225 64 176 80 3 146 69 116 84 4 474 60 391 72 6 132 53 102 69 7 169 49 134 62 8 528 59 412 75 9 216 63 184 73 10 229 61 194 70 11 146 47 110 61 12 356 47 256 64 13 76 39 59 51 14 75 89 64 98 15 119 6 1 107 67 17 23 74 20 85 18 77 39 56 52 30 315 61 218 83 31 72 42 48 63 50 116 62 98 72 All centres 3 646 58 2 875 73 95 Fig. 22 RELATION BETWEEN EARLY MORTALITY AND DELAYS (ALL CENTRES COMBINED) l V > .... ...... ro rJl ... r:: V .... ... rJl ro '"' l'.l.,..c: '+-<-st' ON V ._. ~ ro ... r:: V u '"' V 0.. 100 90 80 70 60 50 40 30 20 10 0 1 2 4 8 0 10 20 rn .... 30 ~ 24 hrs . ... .... ro l'.l. '+-< 'O 0 V V • .-. b.O 'O ro o .... ...c: ~ ~ u '"' V 0.. Time elapsed since onset call to doctor first medical exam.--- hospitalization ~ death death after med. exam. 1 This figure summarizes the results from all centres (cf. fig. 36, Annex II). 96 It is clear that the lines from the bottom of the graph referring to the delay s will ultimately meet the lines from the top referring to deaths, be- cause by definition the patients had to be alive in order to c omplete one of these time intervals. Therefore, if the graph were continued to the right it would show surviving pati e nts to have calle d the do c to r and the remainder t o h ave died. The most important segment of the graph, th e refore, is the space be twe e n rising mortalit y coming down from th e top of th e graph and the slowly increasing number of persons who called for medical care. If a verti cal line is drawn at a n y po int on the graph, then the length of the line betwee n these two curves r e pres ents people who were st i ll alive but had ye t to call for medical assistance or to receive i t. It can be seen that the length of such a line is initially most rapidly affec ted by the number of deaths but continues to be affec ted in this way at least up to 24 hours. If medical intervention is as sume d t o be beneficial - and th e re is considerable clinical evi denc e that such is the case - then an inc r e ase in the speed at wh ich patients call for medical ca r e will result 1n the two lines converging more rapidly a nd h opefully meeting a t a higher point when the overall 1nortality has been less . The same type of diagram can be us e d to sho w all this info rmation in d ifferent subgroups of p atients. For example , fig. 23 shows the situation as it d iffers for males and fem a l e s at various age gro ups. It can be se e n that for both sexes the death rate is more rapid in the higher age groups and that the rate of calling for m e dical as sistanc e is correspondingly slower. How e ve r, this trend wi th age does not a pply to females below the age of 45 where the death rate i s quite h igh and in this case there is also a greater delay between first m e d ica l examination and hospitalization. Witnessing of deaths outside hospital In the c as e of d eath from myocardial infarction occurring outs i d e hos- pi t al, it is obvious that there is little the patient can do if he i s entirely alone at the time of death. It is therefo re a particularly important p ie c e of i nformation whether patients who die out of hospital do so in the absence of another p e rson. On the other h and, if another person is around, partic- ularly one associated with the p a tient, th a t p e rson m ay we ll be in a position to t ake some sort of action. Sixty percent of the deaths r eco rded in myocardi al infa rction cases in this s tudy oc c urred outside hospital, and 65% of all de a ths that occurre d outsi de hospital were actually witnessed by a nothe r p e rson . These figures are given in Annex II, tables 64 and 65. De a th o cc ur rin g when a person is entirely alone, even outs i d e hospital, is ther e for e unusua l. It h as been sugges t e d that a patient with ischaemic heart disease may be best a dvised to contact a colleague, friend, or r elative as soon as he experiences any symptoms that seem to him to be unusual. This obviates the hatural re - luctan ce of a p e rson to consult a doctor over apparently trivial changes in symptoms and the friend or r elative is possibly more likely to view the new symptoms objective ly. 97 --0 00 Fig. 23 PROPORTION OF PATIENTS IN RELATION TO EVENTS DURING 24 HOUH.S EL A PSED SINCE ONSET OF ATTACK, BY AGE AND SEX FOR ALL CENTRES COMnINED Call to Dr 1st med. exam. Death Hospitalization IOOo/c 90 I 0 90 80 20 80 70 30 70 60 60 Males 50 50 40 40 30 30 20 20 10 l 0 0 0 I 2 4 8 24 hrs l 2 4 Time e la psed since onset - call Dr --- JOO % 90 80 70 60 I st med . exam. - hospi ta lization I 0 20 30 8 {88 death % 0 100 % l 0 90 zo 80 30 70 60 50 40 30 20 l 0 0 24 hr s I 2 □ <le a th after me<l . exam. I 0 20 30 90 80 70 60 Age 55-64 4 8 Females 50 50 40 40 30 20 l: !. . 8 2 4 3 liY I I I 20 • 24 hrs 4 2 4 Ii rs 30 20 l 0 0 • j Z 4 b 0 10 20 30 24 hrs l 0 20 30 l.J Ii r ~ As two-thirds of the patients who were to experience myocardial in- farction already had a history of heart disease (table 41), efforts at training in fi rs t aid and prophylactic measures should therefore be possible. They could also be directed towards some person other than the subject at risk but closely associated with him, such as the spouse. The discovery that many of the deaths that occurred were witnessed should provide an impetus to further de velopments in this area. Time distribution of myocardial infarction Fig. 24 shows the distribution of onset of attack over the days of the week. In only one centre was there significant deviation from the uniform distr ibution at the 5 o/o probability level. As there were 19 centres, this result could therefore be expected to occur by chance. When the figures from all centres are combined a statistically signif- icant, though small, difference in the distribution from the uniform appears. The main feature of this i s a slightly higher incidence on Mondays and Saturdays compared with the other days of the week. Fig. 25 shows the distribution of time of onset of the attack throughout the day. The diagram is in the form of a 24-hour clock and the curve cuts each of the radii at a distance from the centre of the clockface proportional to the number of attacks occurring at that time (these times are shown in detail for each centre in Annex II, fig. 37). When the results from all the centres are pooled it can be seen that there is an increased incidence of attacks in the mid-morning and in the late afternoon. The fewest attacks occur in the late evening and in the small hours of the night (3 a . m. to 5 a. m. ). Interpretation of these findings is slightly complicated by the fact that in 12% of cases the time of onset was unknown. Furthermore, the cases with unknown onset are more likely to have occurred dur i ng the night than during the day. It is of interest in this context that the distributions for the two centres in Finland should be considerably more symmetrical than the rest. Onset during the night was more frequent than average in Dublin, Tampere, Helsinki, Nijmegen, Prague, Bucharest, Berlin, London, and Perth, where the most frequent occurrence was during the daytime of Monday to Wednesday and during the night of Saturday and Sunday (table 35). The occu rrence was predominantly during the daytime, particularly on Monday to Friday, in Warsaw, Budapest, Sofia, Heidelberg, Gothenburg, Innsbruck, Lublin, Tel Aviv, and Boden. Centres in the same country behave alike in this respect. 99 Fig. 24 FREQUENCY DISTRIBUTION OF THE DAY OF THE WEE K OF ONSET OF ATTACK, EXCLUDING PATIENTS DIAGJ-:OSED AS "AMI NONE" M T W Th F S Su M T W Th F S Su 20 ° I Gothenburg (409) NS 12 Warsaw (1004) NS 10 o _____________ _ ::~~-_.l_3_L_u+[1ITb_l_in-+-(2_4_6_.)_N_S-+----+-- * = deviation from uniform distribution significant at 5% level NS = deviation not significant 100 Fig. 25 FREQUENCY DISTRIBUTION OF TIME OF ONSET OF ATTACK 22 \ 23 \ 0 101 1 I 2 Table 35 NUMBER OF CASES BY DAY OF WEEK AND TIME OF DA Y1 o/o Centre Mon Tues Wed Thur Fri Sat Sun Total day- time 6 Dublin Day 28 29 19 18 25 24 23 166 49. 1 Night 21 19 23 26 20 33 30 172 1 1 Tampere Day 21 22 25 15 22 25 31 161 49.6 Night 16 31 33 21 23 25 15 164 8 Helsinki Day 101 95 62 65 70 69 66 528 49.9 Night 79 68 75 85 63 88 73 531 10 Nijmegen Day 36 33 58 42 47 45 44 305 49.9 Night 41 42 41 38 43 55 46 306 2 Prague Day 39 39 29 26 36 37 30 236 50.0 Night 36 42 29 33 23 30 43 236 3 Bucharest Day 21 24 18 24 25 32 23 167 50.4 Night 26 22 21 18 25 22 30 164 50 Berlin ) Day 22 14 18 15 21 9 14 113 51 Erfurt ) 51. 4 52 Pasewalk) Night 9 16 16 19 10 22 15 107 9 London Day 43 42 39 33 37 34 21 249 52.4 Night 29 31 27 34 22 42 41 226 30 Perth Day 56 52 56 43 54 71 56 388 52. 8 Night 39 44 48 40 55 62 59 347 15 Kaunas Day 23 21 20 20 17 1 7 30 148 54.8 Night 22 16 10 18 16 21 19 122 12 Warsaw Day 95 83 82 86 98 76 68 588 58.6 Night 59 55 70 58 57 51 65 415 4 Budapest Day 103 85 88 91 90 77 65 599 58. 1 Night 47 64 71 60 53 67 59 421 18 Sofia Day 13 9 1 5 JO 11 20 11 89 59.3 Night 5 16 5 4 10 11 10 61 7 Heidelberg Day 42 42 34 36 30 35 36 255 59.5 Night 18 33 20 22 30 27 24 174 1 Gothenburg Day 45 30 38 40 34 32 25 244 59.6 Night 27 19 15 22 25 31 26 165 14 Innsbruck Day JO 8 7 7 5 8 7 52 60.5 Night 6 4 5 4 5 7 3 34 13 Lublin Day 19 20 29 21 24 22 16 151 61. 4 Night 14 11 14 18 10 13 15 95 31 Tel Aviv Day 21 27 21 26 26 24 19 164 64.3 Night 17 15 9 7 9 21 13 91 17 Boden Day 12 7 5 9 5 6 2 46 67.7 Night 3 4 1 3 2 2 7 22 1 Day = 0600 - 1759; night = 1800 - 0559 102 Fig. 26 shows the frequency distribution of time of onset according to the day of the week. In this graph data from Tel Aviv for $unday to Thursday, and for Friday and Saturday were pooled with those from the other centres for Monday to Friday , and for Saturday and Sunday, respec- tively. It can be seen that on the weekends the increased frequency mid- morning is less obvious and instead there is a tendency for late afternoon and early evening incidence to be somewhat higher. Seasonal variation Fig. 27 shows the seasonal variations in the occurrence of attacks of acute myocardial infarction, Twenty-eight days were taken as the unit time period and an incidence index was computed by taking the average per 28-day period in each centre as one hundred. In Gothenburg, Sofia, Tel Aviv, Berlin and a few other centres a downward trend in incidence was seen, while in Lublin a slight upward trend was noted. When the seasonal pattern was drawn for all centres combined (except Perth) a tendency was observed for the incidence to be higher than average from February to June and lower from July to October. In P ,erth (in the southern hemisphere) the state of affairs is exactly the opposite. Although these figures should not be considered as conclusive, as the observations do not extend for a long enough period of time, it is interesting to consider the significance of demonstrating a seasonal variation in the incidence of myocardial infarction. For some reason it seems to be higher in spring and lower in autumn in both hemispheres. 1 Any hypothesis that attempts to explain these findings must take into consideration physiological and behavioural features of man, together with the climatic and social en- vironment, An analysis of the incidence of myocardial infarction on a day-to-day basis was made to determine the relationship to meteorological data, each centre taking 6-hourly readings of temperature, pressure, a.I+d humidity. The distribution of the daily incidence rates was essentially Poissonian, and apart from an overall seasonal drift in the means 1 there was no evi- dence of a connexion with the weather variables. Similarly, no correlation was found between incidence and sudden changes in these variables, although information on the actual passage of fronts was not available. 1 The highest incidence figures were recorded in the period 12 February to 3 June (average incidence 17. 4 cases/day) and the lowest in the period 2 July to 21 October (13. 4 cases/day). The figµres for each centre are detailed in Annex II , table 66. 103 ~ FREQUENCY DISTRIBUTION OF TIME (2 4-HOUR CLOCK) OF I ONSET OF ATTACK ACCORDING TO THF. DAY OF THE WE EK FOR ALL CENTRES COMBINE D, EXCLUDING PATIENTS DIAGNOSED AS "AMI NONE" 23 O J 21 2 \ \ I / / 13 I 2 11 13 12 11 12 11 For ce ntr e 31 (Tel Aviv) data for Sunday-Thursday . Frida y a nd Saturday were pooled with those from the other cen tres for Mond ay- Friday. Sa turd ay a nd Sunday, r es pec t ively . 104 140 130 120 110 Fig. 27 SEASONAL VARIATION IN THE INCIDENCE, EXCLUDING P ATIE NTS DIAGNOSED AS "AMI NONE" JOO= ave ra ge incidence per 28 -day pe r iod 197 0 197 1 1972 2 3 4 5 6 7 8 'J 10 11 12 13 1 2 3 4 5 b 7 8 'J 10 11 12 13 2 3 4 5 b I Gothen burg J I 00 +-..--,.........,---.---,.-,--,-..,.....-r--.,......--,.--+--,--.--,--..,.....-r-+-n",,..--,--,--.--,--+-.-,--r-..--,:--, 90 80 70 60 140 l 30 120 110 100 90 80 70 60 140 130 120 110 100 90 80 70 60 140 130 120 110 100 90 80 70 60 140 130 120 110 100 90 80 70 60 I 2 Prague 4 Buda pest 105 Fig. 27 (contd ) 1970 1971 1972 1 2 3 4 5 6 7 8 9 JO 11 12 13 I 2 3 4 5 6 7 8 9 JO 11 12 13 1 2 3 4 5 6 7 Heidelberg 140 1 30 120 110 100 90 80 70 60 8 Helsinki 140 130 120 110 JOO 90 80 70 60 9 London 140 130 120 110 100 90 I 80 70 60 10 Nijmegen 140 1 30 120 110 100 90 80 70 60 140 11 Tampere 130 120 110 100 90 80 70 60 106 ~ (contd ) 1970 1971 1972 2 '3 4 5 6 7 8 9 10 II 12 13 I 2 3 4 5 6 7 8 9 1011 12 13 I 2 3 4 5 6 140 12Warsaw I 30 120 110 100 90 80 70 60 13 Lublin 140 130 120 110 100 90 80 70 60 14 lnnsbruck 140 I 30 120 110 100 90 80 70 60 I 5 Kaunas 140 1 30 120 110 100 90 80 70 60 17 Boden 140 130 120 I I 0 100 90 80 70 60 107 140 130 120 I JO JOO 90 80 70 60 140 1 30 120 l l 0 100 90 80 70 60 140 130 120 110 100 90 80 70 60 140 130 120 110 100 90 80 70 60 140 130 120 110 100 90 80 70 60 F i g . 27 (contd} 1970 1971 1972 I 2 3 4 5 6 7 8 9 JO 11 2 13 I 2 3 4 5 6 ' 7 8 9 0 11 12 13 1 2 3 4 5 6 I 8 Sofia 30 Perth 31 Tel Aviv 50 Berlin All centres except Perth Place of onset The place of onset in patients with myocardial infarction can be seen from table 36. In this table the centres are placed in order 9f the propor- tion of patients who suffered an infarction at work and it can be seen that this was highest in Sofia and lowest in Nijmegen. However, the range is fairly small and the average number of myocardial infarctions occurring at work is llo/'o. This overall figure is of somewhat dubious value as it includes females, many of whom work at home. In addition, it includes infarcts that occur during the night when it could be expected that few people wouid be working. Table 37 therefore describes the situation at onset separately for males and females and divides the time of onset of attack into d ay-time and night-time. This table shows that in the men under 55 years of age over a quarter were at work when their infarction occurred during the day-time. This information is given in detail for each centre in Annex II, table 67. When the weekends are excluded from the calculations (Saturdfi-Y and Sunday in Europe, Friday and Saturday in Israel) the proportion of infarcts occur- ring in men under 55 years of age at work during the working day is 33'1/'o (table 38). Myocardial infarction does not occur at work as frequently as might be expected from the time spent by men at their place of work. Allowing for unemployment and a few hours spent during the day in other places, over half of the middle-aged men experiencing myocardial inflrction were absent from their work during the day at the time of the acute attack. The reasons for this are no doubt partly related to the ill health that these pa- tients had already experienced and partly to the premonitory 1 symptoms which occur in the few days prior to the onset of acute sympto:rns (see fig. 22). Transport The mode of transport to hospital is shown in table 39. As can be seen, this varied slightly depending on the time of day, with private trans - port less used at night. This information is given in more detail for each centre in Annex II, table 68. Prediction of myocardial infarction It can be seen from the results presented so far that a substantial number of coronary deaths occur under circumstances that make treatment by a doctor impossible. The patients are suddenly stricken with severe symptoms usually occurring outside a medical treatment areal. The speed with which some medical emergency treatment is needed is emphasized by the fact that, while the bulk of the deaths that follow the onset of myocardial infarction occur within a very short time, in the state of affai!rs pertaining at the time of the register study there were major delays in c~lling for and receiving medical assistance. 109 Table 36 PLACE OF ONSET OF ATTACK, ALL PATIENTS Centre Work Home Hospital Other Unknown No. of o/o o/o o/o o/o o/o patients Sofia 17 66 2 13 2 226 Tel Aviv 16 69 1 11 4 295 Boden 15 63 4 17 1 72 Warsaw 15 64 5 15 2 1 099 London 14 63 4 17 2 549 Lublin 14 66 2 13 4 276 Perth 13 67 3 13 4 883 Dublin 12 63 5 14 7 398 Gothenburg 11 61 2 18 9 494 Heidelberg 11 62 6 19 2 487 Budapest 11 76 4 8 2 1 115 Kaunas 11 68 4 17 1 390 Tampere 9 64 5 21 1 365 Innsbruck 10 46 3 9 32 268 Berlin ) Erfurt ) 9 58 3 11 19 311 Pasewalk) Prague 8 65 2 20 5 519 Bucharest 8 65 2 20 5 373 Helsinki 8 60 6 21 5 1 250 Nijmegen 7 75 4 13 1 797 Total 11 66 4 15 4 10 167 110 Table 37 PERCENTAGE OF PATIENTS FALLING ILL AT THE PLACE OF WORK BY TIME OF ONSET OF ATTACK AND AGE Time of onset of attack 1 Sex Age Total Day-time Night-time % % % Under 45 27.9 5.4 17.3 45-54 29.0 4.2 17. 5 Male 55-64 18. 2 2.6 11. 3 Total 22.6 3.5 14.0 I Under 45 14. 1 4.4 1 O. 6 45-54 15. 8 2.3 9.8 Female 55-64 5.0 1. 1 3.2 I Total 8 .3 1.6 5. 3 1 D . ay-time = 0600 - 17 59; night-time = 1800 - 0559 111 ..... ..... N Table 38 Age <45 .. 45-54 ~ .; l 55-64 Total < 45 . 4S-S4 ~ .; E ~ 55-64 "' Total Note• : PERCENTAGE OF PATIENTS FALLING ILL AT THE PLACE OF WORK DURING DAY-TIME (0600 - 1759 HOURS) ON WEEKDAYS , BY AGE AND SEX, EXCLUDING PATIENTS DIAGNOSED AS "AMI NONE" I 2 3 4 6 7 8 9 10 11 12 13 14 15 17 18 30 31 (83. 3) 28.6 (37. 5) 26.8 ( o. 0) 18. 7 26.9 35. 0 15. 4 60.0 29.8 43.5 (33. 3) 36.8 (33. 3) (44 . 4) 52. 0 43 . 7 28.3 25. 0 35. 3 34. 6 46.3 34.0 28.7 42. 5 19. 2 40.7 36 . 6 29. 2 (3 7. 5) 41. 7 50,0 30.0 45. 9 42.9 26 . 0 16 .8 10. 5 13 . 3 20. 5 19. 2 19 . 9 22.6 21. 7 24. 5 26 . 5 22 . 4 43 . 7 13 . 3 25.0 23 .8 32. 7 23 . I 29. I 19.9 18. 3 20. I 3 I . 4 23 . 6 23. 5 29.4 20 . I 33. 7 30 . 2 29 . 2 40 . 7 26 . I 34 . 5 30 . 0 39 . 3 34 . 4 ( o . 0) ( o. 0) (50. 0) 8.3 ( o. 0) • ( o . 0) (20 . 0) ( 0. 0) • 30.0 ( 0.0) ( 0 . 0) (100. 0) • ( 0 .0) ( o . 0) ( o. 0) (25 . 0) (66. 7) (12. 5) 26. 5 20 .0 (16. 7) 21. 4 (33. 3) ( o . 0) (20 . 0) 25 . 0 ( 0 . 0) ( 0 . 0) ( o . 0) ( 0 . 0) ( 0. 0) 14. 3 ( 0 . 0) 6. 7 12. 5 o. 0 3 . 8 5.0 ( 4 . 8) 6 . 3 10. 0 0 . 0 0 . 0 11. 9 0 . 0 ( o . 0) ( 0.0 ) ( 0. 0) ( o. 0) 4.3 0 . 0 I 0. 3 17. 9 13.3 10. 5 9. I 7. 4 9. 8 14. 6 0.0 5. 3 16 . 7 0.0 0 . 0 7 . 7 ( o. 0) ( 0. 0) 6. 2 0 . 0 NQ,_ with onaet at place of work durin& day-time Percentage No. with on■ et at aff J>lacea orl weekday• during day -time X 100 Percentages in brackets are baaed on a denominator of le•• than 10. The symbol • indicates that there were no patients in the age/aex gro up. 50 Total 15.4 32.3 28.6 34. 9 35 . 9 21. 7 30.3 27.0 ( 0. 0) 14. 5 10.0 19. 5 0.0 5. 7 4.2 9 . 7 Table 39 MODE OF TRANSPORT TO HOS PIT AL {if exact time of hospitalization known) Arrival during Arrival during day-time night-time Ambulance 65% 74% Private car 13% 11 % I Taxi 9% 7% Other 7% 2% Onset in hospital 4% 5% Unknown 2% 1 % Number of patients 5009 2966 It is important therefore, to determine whether the onset of acute symptoms is the first symptom of ischaemic heart disease that is experi- enced. As can be seen from table 40 and fig. 28, two-thirds of the males and four-fifths of the females were already suffering from sorri-e form of cardiovascular disease by the time they experienced acute myocardial infarction. 1 This information is given in detail for each centre in Annex II, table 69. • In table 41 the frequencies of "other cardiovascular diseases" are shown in absolute figures rather than as percentages. This is because, according to the design of the study, interviewers asked patients about "other cardiovascular diseases" in general without any specific restrictions being given, so that the proportions affected are not very reliable. The table suffers from a weakness inherent in the International Classification of Diseases, namely, the imprecise clinical classification of 9onditions not causing death, with no clear discrimination between symptbms and diseases. The existence of previous disease, although it permits a gen- eral predi ction of increased risk of myocardial infarction, does not help in predicting the point in time when an acute attack will occur. 1 This information applies to patients who survived the attack for 4 weeks. In the case of earlier death, the proportion of unkn~wn informa- tion was greater, and reliable statistics were therefore hard to obtain. 113 Table 40 PREVIOUS HISTORY OF PATIENTS WITH DEFINITIVE DIAGNOSIS OF AMI, AI.JVE AT FIRST REVIEW Males Females Myocardial infarction (all) 25 o/o 2 3 o/o 42 o/o a Angina 52 o/o Cerebrovascular accident (all) 5 % 6% 12 o/o a Intermittent claudication 9% Diabetes (all) 9 % 15o/oa Hypertension 25 o/o 50o/ob Other CVD 10 o/o 18o/oa Any of above 66% 82o/oa a difference between males and females significant at 5o/o probability level b difference between males and females significant at 1 % probability level Table 41 FREQUENCY OF OTHER CARDIOVASCULAR DISEASES Symptomatic heart disease (congestive heart failure, pulmonary oedema, arrhythmia) Chronic ischaemic heart disease Other disorders of circulation Diseases of arteries Chronic rheumatic diseases Other 114 559 256 154 104 86 149 Fig . 28 FREQUENCY OF PREVIOUS MEDICAL HISTORY (CONFJRMED A ND UNCONFIRMED ) ACCORDING TO AGE AND SEX, F O R ALL CEN TRE S COMBINE D } AMI d e finite, AMI } AMI pos sible , or in suffic ie nt none da t a '7o (11 /0 My oca rdia l infa r ct ion Diabetes me ll itus 40 40 30 ~ 30 20 20 .. - l 0 l 0 ~ 0 0 20 3 40 5 60 70 Age 20 30 40 50 60 70 .\;:,· (11 ·~ /0 .. ~ .. ., .. , ' ., ., ., 40 .. 40 ., .. .. , Y , ,' ., , ., 30 , 30 , , ,, ,, ,, , , , 20 , LO , I 0 An g ina pector i s o f effort more than l 0 A rteria l h y pe r tensi on 2 8 days 0 0 20 30 4 ~o 60 70 A ge 20 30 40 50 60 70 ,\ ~t' % % 40 Cerebrova scula r accident 40 Other cardiovascula r disease 30 30 , 20 20 , ~ I 0 l 0 O 20 ~ 0 - 30 4 5 70 Age 20 30 ➔ 50 6 70 Age Any of the seven ., , 40 Intermittent claudicat ion 40 disea ses , ,, _,, .. 30 ., .. 30 20 20 10 ~~ I 0 0 --- -- -- ---- -- 0 20 30 40 50 60 70 Age 20 30 40 50 60 70 Age 11 5 Particular attention was paid in this study, therefore, to the e v ents immediately preceding the onset of acute symptoms, and patients were asked about any unusual symptoms that they had experienced in the 4 weeks prior to the acute attack. If the patient could not be interviewed, this information was sought either from the family doctor or from relatives and acquaintances. The protocol specified certain symptoms about which in- formation should be obtained (see Annex I , page 146), but space was left on the forms for any other symptoms that might have been volunteered by the patient. It was possible to obtain information on 8954 patients and impossible on 596 patients. Table 42 shows the frequency of symptoms in the 28 days preceding onset in patients who were subsequently shown to have myocardial infarction, as well as in those reported to the register but in whom the diagnosis was not confirmed. The third column in this table concerns those with confirmed myocardial infarction who were alive at the first re- view, a special group picked out because most of these patients were inter- viewed and the information is fairly complete. 1 They provide, therefore, a standard group with which to compare others in the literature. Table 42 FREQUENCY OF SYMPTOMS IN THE 28 DAYS PRECEDING ONSET OF ACUTE ATTACK Confirmed d i agnosis Symptom Suspicion First attack not confirmed All cases only New angina 14% 17 % 9 % Exacerbation of angina 22% 18% 19 % Discomfort in chest 28% 28% 36% Heaviness in arms 13 % 12 % 12 % Unusual tiredness 16% 16 % 20 % Unusual bre athle s sne s s 14% 13 % 15 % Palpitations 5% 5% 10 % Any of above 56% 55% 57 % Total 100% 100 % 100 % 1 This group is almost identical with patients discharged alive from hospital or in the non-acute period 3-4 weeks after the onset of myocardial infarction. In the case of patie nts who die d before the end of the 28-day period, the figures were very similar, but much less confidence can b e placed in them because of the large proportion of mis sing information. I I 6 It can be seen from the table that over half the patients, both with and without confirmed myocardial infarction, experienced p~odromal symp- toms. In the bulk of cases this was chest pain, either angina conforming to the diagnostic criteria, or non-diagnostic chest pain. However, unfor- tunately for the prediction of myocardial infarction, these s,imptoms were almost as common in the group of patients who were registered but in whom the diagnosis of myocardial infarction was not confirmed. The range in the various centres was fairly wide (see Annex II, table 70); I for example, in the third group (patients who were alive at the first review) the propor- tion having any antecedent symptoms ranged amongst the various centres from 38% to 91 %. It is hard to say how much of this variat~on is the result of differences in the technique of interview and the level of suspicion adopted in the various centres, and how much is due to real variations in the natural history of myocardial infarction in different communities. The time relationship of these symptoms to the onset of acute symp- toms is particularly interesting. As shown in fig. 29, the symptoms were particularly common from about five days prior to infarctiod and increased in frequency the closer to the acute symptoms. The numbers recorded in this figure are the numbers of first episodes of the symptom occurring per day in the 4-week period prior to infarction. Many patients consulted their doctor for these symptoms in the few weeks prior to the acute episode. Information was not collected on this question for all patients but only for those with a fatal episode. For example, of all patients who succumbed to a fatal myocardial infarction within 24 hours of onset, 31 % were known to have consulted their doctor within the previous two weeks. This pro- portion varied a little from one centre to another (Annex II, table 71). Clinical state at first examination Table 43 compares the clinical state at the first examibation of acute myocardial infarction patients, patients without myocardial infarction, and those with definite acute myocardial infarction who were alive at the time of the first review. Nineteen per cent of acute myocardial infarction patients were dead before the medical examination, 1 while only 2 % were dead among those without myocardial infarction. The reco:r;-ding of clinical state seems somewhat heterogeneous among the centres, but on the whole the frequency of circulatory failure among survivors was greater in acute myocardial infarction patients than in those without myocardial infarction. Among the acute myocardial infarction group, 58 % had no circulatory failure; this represents 73% of those alive at the first examination. 1 This proportion refers to cases where a "medical examination" took place, and differs from the figures in table 34 where al[ cases (for example those sent straight to the morgue) are included. 11 7 Fig. 29 TIME RELATIONSHIP BETWEEN ANTECEDENT SYMPTOMS ("PRODROMATA") AND ONSET OF ACUTE SYMPTOMS ("MYOCARDIAL INFARCTION") IN 8954 PATIENTS Persons per day with onset of the 300 250 200 1 50 100 50 O 27 , ,,,- ~ 21 14 7 I ,. 512 I I I ' I ,! ,: I I ' I I I I ' onset Days before onset - Discomfort in chest Angina pectoris exacerbation Unusual tiredness • 118 ----Angina pectoris first attack ......... unusual breathlessness ---Heaviness in arms ..... ..... '° ~ A. Excluding puient■ diapo■ed a• 11AMI none 11 Clinical ■tate I 2 3 No circul. f&ilure 77 60 58 Cong. heart failure 3 14 9 Shock 0 2 2 Cong. heart f. • ■hock 0 0 3 Cardiac arreat 3 0 2 Death before exam . 8 20 21 Unknown 9 3 6 Total 100 100 100 Number of patient■ 494 519 373 B. Patient■ dia1nosed a■ 11AMI none" Clinical atate I 2 3 No circul. failure 59 83 91 Cong . heart failure 4 II 5 Shock 0 0 0 Cong. heart f. • ■hock I 0 I Cardiac arreat 0 0 0 Death before exam . 0 4 2 Unknown 36 I I Total 100 100 100 Number of patient. 98 675 478 C. Definite AMI, alive at 1 at review C lini cal atate I 2 3 No ci rcul. failure 95 84 8 5 Cong. heart failure 3 15 13 Shock 0 l 2 Cong. hea rt f. Ir: ■hock 0 0 0 Cardiac arreat 2 0 0 Death before exam. 0 0 0 Unknown 0 0 0 Total 100 100 100 Number of patient■ 337 248 144 4 6 44 63 22 12 2 4 4 2 I 3 u 16 4 I 100 100 115 398 4 6 1l 78 25 18 0 I I 2 0 0 2 2 I I 100 100 959 131 4 6 68 81 26 13 3 3 3 l 0 2 0 0 0 0 JOO 100 385 205 CUNICAL STATE AT FIRST MEDICAL EXAMINATION (in percentage a) 7 8 9 10 II 12 13 14 15 57 53 59 68 55 67 75 46 56 15 9 8 6 12 7 5 12 13 3 3 2 3 2 3 0 10 2 6 2 2 2 2 I 3 2 0 3 2 2 I 10 I 2 3 0 14 u 25 16 18 12 9 25 23 I 6 2 3 2 8 6 2 6 100 100 100 100 100 100 100 100 100 487 ~2 50 549 797 365 1099 276 268 390 1 8 9 10 II 12 13 14 15 46 65 74 I 83 7Z 91 83 60 88 19 20 18 7 24 6 9 5 10 0 2 I i 2 0 I 0 15 0 5 0 I I 0 0 I 0 0 3 I 0 0 3 0 2 0 0 22 8 4 1 0 I 2 10 0 5 5 2 0 I I 3 10 2 100 100 100 100 100 100 100 100 100 37 102 104 138 67 795 145 20 41 1 8 9 10 II 12 13 14 15 11 81 87 89 80 89 91 66 80 15 10 9 7 14 8 7 17 16 2 3 2 3 2 2 0 9 2 4 I l 0 0 0 l 2 0 0 2 0 I 4 0 0 2 0 0 0 0 0 0 0 0 0 0 0 4 I 0 0 I l 3 0 100 100 100 100 100 100 100 100 100 323 597 264 522 176 582 151 149 202 17 18 30 31 50 51 52 Total 67 57 56 65 28 79 33 58 6 11 1Z 18 29 3 39 11 0 9 4 3 2 5 0 3 I I 2 I 2 0 3 2 3 I 0 0 0 0 0 2 22 12 22 4 35 I 19 19 I 8 4 8 4 12 6 5 100 100 100 100 100 100 100 100 7Z 226 883 295 167 185 36 10 164 17 18 30 31 50 51 52 Total 82 81 80 81 26 100 42 79 14 6 15 15 19 0 33 13 0 2 I I 0 0 0 I 0 0 I I 0 0 0 I 0 0 0 0 0 0 0 0 5 2 0 0 5 0 8 2 0 10 3 2 50 0 17 4 100 100 100 100 JOO 100 100 100 22 62 106 9 4 122 I 12 4 209 17 18 30 31 50 5 1 52 Total 90 78 11 73 44 95 41 82 7 8 15 22 53 0 59 13 0 1 5 l 2 5 0 3 0 0 l l 0 0 0 l 2 0 0 0 0 0 0 I 0 I 0 0 0 0 0 0 0 6 2 2 2 0 0 I 100 100 100 100 100 100 100 100 41 114 521 138 64 66 17 5 246 Among the "not myocardial infarction" group, 7 9 % had no circulatory failure; this represents 82 % of those alive at first examination (79/(1-0. 04)), which happens to be the same proportion as in survivors of definite acute myocardial infarction examined four weeks later at the first review. The clinical state is compared by age and sex groups in fig. 30. Patients in the age-group 55-64 years showed a higher proportion of clinical signs than the younger groups. No marked difference is seen between sexes. Smoking habits In addition to the well-known fact that cigarette smoking can increase the risk of ischaemic heart disease and myocardial infarction, it is also known that the risk varies from one community to another. It can be seen from table 44 that the proportion of patients who smoked heavily varied considerably in different centres. The percentage was higher in those patients who were subsequently confirmed as having definite myocardial infarction than it was in those who were registered but in whom the diag­ nosis was not confirmed. This is to be expected from the fact that ciga­ rette smoking is a risk factor of myocardial infarction so that, if all other things are equal, the fact that a person smokes statistically increases the likelihood that myocardial infarction has occurred. It is also of interest that the younger age-group smoked considerably more cigarettes than the older age-group. As can be seen in the case of males, 52 % of those under 45 smoked, compared with only 28% of those aged 55-64 years. Before any conclusions can be drawn from the heavier smoking observed in younger patients and from the finding that females with myocardial infarction smoked considerably less than males, compar­ ison must be made with figures for smoking habits in the whole community. The effect of "previous history" of myocardial infarction on smoking habits can be seen in table 45 (and for each centre in Annex II, table 72). Table 45 PERCENTAGE OF PATIENTS SMOKING 15 CIGARETTES OR MORE PER DAY (AGE STANDARDIZED) BY PREVIOUS HISTORY OF INFARCTION History Males Females Previous myocardial infarction 26. 2% 11. 7% No myocardial infarction 44. 7% 13. 8% It can be seen that in the case of males, those without previous myo­ cardial infarction smoke-cl considerably more than those with history. This is not due to aging of this group as the figures have been corrected for this factor. The exact cause, however, has still to be ascertained. 120 Fig. 30 CLINICAL STATE AT FIRST MEDICAL EXAMINATION, ACCORDING TO AGE AND SEX , FOR ALL CENTRES COMBINED, EXCLUDING PATIENTS DIAGNOSED AS "AMI NONE" Male < 45 Female < 45 Male 45-54 Female 45-54 Male 55-64 Female 55-64 All patients ~ ■ ~ ~ 0 10 Dead Cardiac arrest Congestive heart failure + shock Shock 20 30 40 50 m Congestive he art failure D No circulatory failure [I) Unknown 60 70 80 90 100 % ? I I 2 0 10 20 30 40 50 60 70 80 90 . 100 % 121 Table 44 PERCENTAGE OF PATIENTS SMOKING 15 CIGARETTES OR MORE PER DAY, BY AGE AND SEX1 Male Female Centre Under Unde r 45 45-54 55-64 Total 45 45-54 55-64 Total 6 57 53 40 47 (13) 28 17 21 13 62 50 33 46 (11) (14) ( 7) ( 9) 15 45 58 38 46 (33) ( 0) ( 2) ( 5) 12 58 50 34 44 26 26 8 15 4 59 44 33 40 24 12 9 12 9 49 41 33 38 (54) 50 24 33 30 56 40 31 37 53 30 16 23 8 40 47 30 37 (19) 25 7 12 2 54 47 26 37 (1 7) 15 ( 4) 8 11 48 44 28 36 ( 0) ( 5) ( 5) ( 5) 10 40 43 30 35 (33) (2 5) ( 6) 13 18 54 41 21 34 ( 0) ( 0) ( 4) ( 3) 7 53 36 22 31 (40) (21) (11) 14 3 55 32 26 31 (11) ( 3) ( 3) 4 14 71 29 19 30 (33) ( 0) ( 7) ( 7) 1 42 30 16 22 (50) ( 18) ( 4) 9 31 45 21 14 20 ( 0) ( 13) ( 10) 10 17 ( 0) (30) ( 5) 14 * (14) ( 0) ( 5) 50 22 18 9 13 ( 0) (10) ( 2) ( 4) Total 51. 9 42.8 28.3 36. 3 23.6 18. 5 8. 2 12.3 ' 1 Percentages in brackets are based on a denominator less than 10. * = No patient registered in this age/sex group. 122 Follow-up One of the major difficulties of studying myocardial infarction from a hospital is that a selected group of patients is normally followed by the hospital only as far as the end of the treatment phase or as far as the visits to the outpatients department. The patients are returned to the community health services where difficulties of communicatipn mean that they are removed from the ambit of hospital-based clinicians. It was felt important, therefore, in the present stu dy to rectify this gap in the knowledge of the condition and to attempt to integrate information about all stages of myocardial infarction. After the pat ients left hospital, the follow-up phase lasted for one year from the initial onset of symptoms. Only patients with definite or possible myocardial infarction were followed up and the remainder of the registered patients, that is those without con- firmed infarction, were excluded from further study. After the initial review at 28 days (or at earlier discharge from hospital) a further follow- up was done at three months and the final follow-up occurred at one year. The time of the first review was arbitrarily set at 28 days in order to facilitate recording and to produce roughly comparable figures between centres where hospitalization was the rule and those where hbme treatment was more frequently practised. For all centres taken together, the pro- portion of those alive at first review who had been admitted to hospital was 90% ranging from 99% in some centres down to 38% in Bucharest. 1 The policy regarding the us·e of coronary care units also varied, with some centres treating nearly all hospitalized patients in a coronary care unit and others virtually none. This information is contained in table 46, which shows the percentage of patients hospitalized in the different centres up to the time of the first review. This table includes only patients with definite or possible diagnoses who were alive at first review in order to give a realistic picture of the differing policies adopted. Because the study was not designed to analyse the results of different treatment policies, one cannot expect to draw any conclusions from these figures at this stage. However, the different policies adopted provide ethical justification for further controlled studies in this direction. 1 Hospitalization policy explains most of these differences (see p . 88) 123 .... N ~ Table 46 PERCENTAGE OF PATIENTS ALIVE AT FIRST REVIEW WHO HAD BEEN HOSPITALIZED IN CORONARY CARE UNIT AND HOSPITAL WARD FOLLOW ING THE INITIAL EXAMINATION Centres Hospitalized in 1 2 3 4 6 7 8 9 10 11 12 13 14 15 17 18 30 31 50 CCU only 2 12 2 5 28 0.3 0.4 2 2 1 1 15 0 3 0 6 1 0 1 Ward only 57 41 19 91 23 55 77 58 9 21 83 7 78 53 56 50 29 97 58 Both CCU and ward 40 27 17 2 43 42 20 35 88 77 14 54 15 43 39 40 67 2 17 All hospitalizations 99 79 38 98 94 98 98 94 99 99 97 75 94 99 96 96 97 99 75 All centres 4 56 30 90 Complications occurring Because of the differences in the degree of hospitalization it is not possible to draw any definite conclusions from the different rates of com­ plications observed in the first four weeks in different centres (these rates are given in Annex II, table 73). For example, it might be expected that hospitalization, with its more intensive supervision and better record keeping, would produce a spurious increase in the frequency of complica­ tions observed. Fig. 31 and table 47 therefore show the combined exper­ ience of all the centres in the complications observed in the first 28 days following myocardial infarction. It can be seen that the frequency of com­ plications was greater in the older age-group and that there was little dif­ ference between males and females. The most frequent complication ob­ served was congestive cardiac failure and in about two-thirds of all patients at least one of the seven types of complication occurred. A study was made also of the complications occurring in the first eight weeks or so following discharge from hospital. Figs 32 and 33 and table 48 show the frequency of complications in all centres combined in the interval between the first and second reviews, that is, between one and three months following the onset of acute symptoms, and between the second and third reviews (3-12 months). It can be seen that the moist frequent complication observed is angina pectoris. Both angina and congestive cardiac failure are significantly more frequent complications in women than in men. The increased frequency of angina pectoris seen in the post-hospital phase compared to that in the first 28 days is probably related to the nec­ essity for activity before this condition can be diagnosed. It is a clinical fact of major significance that half the patients discharged e'fperience angina in the next couple of months. Not only is this important from a therapeutic point of view but it also has a bearing on the advice that a per­ son needs to be given in order to prevent needless anxiety and fear that the attack may be recurring. In fact, reinfarction was a particularly rare occurrence in the year following the acute episode, only 5% occurred within the first three months and 6% within the first twelve months. The prediction of the development of these complications is signifi­ cantly related to the previous history of the patient before the onset of his acute symptoms. The actual nature of this history does not seem to be as important as the presence of any pre-existing cardiovascular disease. Table 49 shows that if any of the four conditions myocardial infarction, diabetes, hypertension, or angina without myocardial infarction was present, then the complication rate was increased. This information is given separately for each centre in Annex II, table 74. 125 Fig . 3 I FREQUENCY OF COMP LICATI ONS BY AGE AND SEX IN THE INTERVAL f\F.T WEE N INITIAL EXA MIN ATION AN O 1st REVIEW . DATA FOR ALL CENTRES COMBI NED, EXCLUDING P ATIENTS DIAGNOSED AS "AMI NONE" M F % 50 50 C ongestive ca rdiac failure Re-in fa r c tion 40 4 0 , 30 / 30 20 20 I (J 10 0 u 20 30 40 SU &U iO Age 2U 30 40 50 60 70 ,\~,· <T" 50 50 . Shoc k Angina pe c toris of effort 4 0 40 30 30 -- ---- 20 2 0 ~ I 0 ~ 10 0 0 2 0 30 40 50 60 70 Age 20 30 40 50 60 70 Age % 'Z 50 Thrombo-embolism 50 Death 40 40 30 30 2 0 20 ~ 10 10 0 ----- u 20 30 40 50 60 70 Age 20 30 40 50 60 70 Age 50 50 Ca rdiac arrest Any of the seven types of complication 40 40 30 30 ~ 20 20 10 ~ 10 0 0 r I I 20 30 40 50 60 70 Age 20 30 40 50 60 70 Age 126 Table 47 FREQUENCY OF COMPLICATIONS BETWEEN INITIAL EXAMINATION AND FIRST REVIEW Complication All patients Hospitalized only o/o ' % Congestive heart failure 32 3 3 Angina pectoris 22 21 Shock 10 10 Cardiac arrest 3 10 Re-infarction 3 3 Thromboembolism 3 3 Died before 1st examination 21 6 Died after 1st examination 15 15 Any of above 65 56 I Total 100 100 127 Ii&_E FREQUENCY OF COMPLICA TIONS BY AGE AND SEX IN THE INTERVAL BETWEEN 1st AND 2nd REVIEWS (FOR PATIENTS ALIVE AT 1st REVIEW). DATA FOR ALL CENTRES COMBINED, EXCLUDING PATIENTS DIAGNOSED AS "AMI NONE" M F 50 50 Congestive card iac failure Re-infarcti on 4 0 40 30 30 20 ~ 20 10 I 0 0 0 ----- 0 30 40 50 60 70 Age 20 30 40 50 60 70 Age 50 % 50 Shoc k Angina pectori, of effort 40 40 -------~ ~ 30 30 ~ 20 20 10 10 0 ... - - - -.. 0 (J 30 4 0 0 60 70 Age 20 30 40 50 60 70 Age 50 o/o 50 0 Th rombo - emboli em Deeath 40 40 30 30 20 20 10 10 0 0 0 30 40 50 60 70 Age 20 30 40 50 60 70 Age 50 % 50 % Cardiac arrest Any of the, ■ eeven type• of 40 40 complication 30 30 -- - 20 ,,. 20 ~ 10 10 ,, 0 -------- O A~e lo 510 1b Aie 0 3 0 0 60 3b 4b 6 10 128 Fig . 33 FREQUE NCY OF COMPLICATIONS BE AGE AND SEX IN THE INTERVAL . BETWEEN 2nd AND 3rd REVIEWS (FOR PATIE NTS ALIVE AT 2nd REVIEW). DATA FOR ALL CENTRES COMBINED, EXCLUDING PATIENTS DIAGNOSED AS " AMI NONE" M - - - F 50 50 C ongestive ca rdiac failure Re-infarction 40 40 , 30 , 30 ~ , - 20 - 2 0 10 10 • --:,ii ..... 0 0 20 30 40 50 60 70 Age 20 30 40 50 60 70 Age 50 50 Shoc k Angina pect oris of effort 40 40 ,,, .. -____ ,, 30 30 ~ 20 20 10 10 0 0 20 30 40 50 60 70 Age 20 30 40 50 601 70 Age 50 % 50 Thrombo-embolism Death 40 4 0 30 30 20 20 10 10 ~ 0 0 --- I 20 30 4 0 50 60 70 Age 20 30 4 0 50 60 70 Age 50 50 Cardiac arrest Any of the seven types of 40 4 0 c omplication 30 30 --- ~ , 20 2 0 .,,_ 10 10 0 70 A~e To 410 I 6b -fo Age 0 3 4 50 60 36 50 129 Table 48 FREQUENCY OF COMPLICATIONS BETWEEN FIRST AND THIRD REVIEW Percentage of patients alive 1 at beginning of review period Con1plication Between Between 1st and 2nd review 2nd and 3rd review (3 months) (12 months) Congestive heart failure 22 22 Angina pectoris 50 54 Shock 1 1 Cardiac arrest Nil <l Re -infarction 5 6 Thromboembolism 1 1 Death 3 6 Any of above 59 62 Total 100 100 (= 6 507 cases) (= 6 021 cases) 1 i.e., at 1 month and at 3 months Table 49 FREQUENCY OF COMPLICATIONS ACCORDING TO PREVIOUS MEDICAL HISTORY Frequency of complications History Onset to first review First to second review Myocardial infarction 73 % 40 % Diabetes 70 % 37 % Hypertension 67 % 38 % Angina without myo- % % cardial infarction 64 43 Any of the four 68 % 39 % None 58 % 27 % 130 The complications descr ibed so far are those that were specifically searched for and defined precisely at working meetings of the registers. However, space was left on the form so that any other complications ob- served in the course of following up the patient could be recorded, and attention drawn to them, for the benefit of possible future studies. Thes e other complications are recorded in table 50. As in the previous section of the form dealing with "other past history", the group of conditions in- cluded here mixes together symptoms and diagnoses. HoweJer, it is of interest that in addition to symptoms d irectly referable to the heart, a number of patients experienced the first signs of latent diabetes and hyper- tension following their heart attack. The observation of pericarditis is of interest, since increasing attention is now focused on post-myocardial infarction syndromes. Table 50 NUMBER OF PATIENTS WITH "OTHER" COMPLICATIONS Number of patients affected Complication Initial exam. 1st-2nd 2nd-3rd to first review review review ICD category 427 Symptomatic heart disease 246 115 47 250 Diabetes 121 30 19 400-404 Hypertension 60 36 37 465-490, 511 Chest infection 60 18 10 420, 423 Pericarditis 44 2 1 300, 305 Neurogenic 17 22 24 443 Claudication 1 12 13 Other Other 280 274 304 One year survival rates The most serious complication following myocardial infarction is death of the patient. When the various phases of the disease are considered, the most significant from the point of view of survival remains the imme- diate period following the onset of symptoms. In those first few hours, before the medical services can be properly mobilized, a large proportion of the deaths that will occur ih the first year has already taken place. 131 By the first half-hour, one third (34%) of all the deaths that will occur in that first year have taken place, and by the time two-and-a-half hours have elapsed half of the year's mortality has occurred. The bulk of this mortality occurs before any therapeutic intervention is possible and, in 58% of cases, before the patient is even examined by a doctor. Thus, from a community point of view, the advances that may be made in hospital treatment of the acute attack are diminished in signifi- cance by the fact that many patients do not survive sufficiently long enough to receive such treatment. The deaths thereafter can be divided approximately in half - those occurring in the treatment phase and those in the first year after discharge. The de sign of the study was for two reviews following discharge from treatment, at three months and at one year. It can be seen that 90% of patients who were to die in the first year (40% of the total) did so by three months. By the time of the third review all 40 % of the original patients had died. The number of deaths fell off in an exponential manner, inversely proportional to the time from the onset of acute symptoms. The impor- tance of the immediate post-attack period cannot therefore be over- estimated. The major efforts of public health planners must be directed at this early phase in order to extend the recent therapeutic developments to those in most need. The one-year survival rates varied a little in the various centres and are shown in detail for each centre in Annex II, tables 75 and 76. So many factors are involved in producing differences between case fatality rates in the different centres that there would be little profit in discussing them here (see page 91). Features associated w ith fatality Survival rates were different for different groups of patients. The association between the previous medical history and the case fatality rate can be seen from table 51. This table excludes cases where information on the history was missing (largely due to early death) and therefore pro- vides higher survival rates than if the whole group was taken. It can be seen that the highest case fatality rates were associated with a history of previous myocardial infarction or of "other cardiovascular disease" • (usually congestive cardiac failure). For males without any previous medical history (the "unexpected" coronary) the one-year case fatality rate is 25%. Where there is a significant difference (P< 0. 05) between males and females, this is shown separately in the tables. It can be seen that a history of angina, hypertension, or "other cardiovascular diseases" had more serious implications for men than for women. For example, the average fatality in all cases where hypertension was known to be ab- sent was 35%; its presence raised the risk of dying by 6. 4% in males but by only 1. 9% in females. 132 ..... (>) (>) Table 51 Fatality rates per 100 cases (a) in patients with various medical histories (b) in patients without these histories ASSOCIATION BETWEEN FATALITY RATES PER 100 CASES AT ONE YEAR* AND PREVIOUS MEDICAL HISTORY Medical hi story Angina O the r Previous Hyp e rte nsion ca rdi ovascula r (general) myocardial pectoris Intermittent diseases claudication infarction M F M F M F M F 43.0 38. 5 48. 3 43 . 7 36. 3 42.0 38.0 44. 3 59. 2 46. 2 24. 5 31. 2 33. 2 30. 0 36. 5 35. 6 36. I 35. 7 33. 1 34. 2 Diabetes Pr e monitory symptoms 45. 6 33. 5 36. 7 37.9 * The mean for the whol e series is 40. 4 , which is higher than the average of the cases included in th is table as it includes patients with un- known history, most of whom di e d. Unfortunately, from the data collected it is not possible to determine whether patients who died outside hospital were being electively treated at home or were in the process of being transferred to hospital. However, for purposes of comparison between this series and others, table 52 shows the fatality rates of all cases reaching hospital and of those who did not. It is clear that the inclusion of the figures from the community produces a considerably bleaker picture of the prognosis of this condition than would appear from any hospital series. Table 52 FATAI.JTY RATES PER 100 CASES FOR PATIENTS REACHING HOSPITAL COMPARED TO RATES FOR THOSE WHO DID NOT Rates for all cases Rates for cases not Age-group reaching hospital reaching hospital (dead or alive) or home -treated M F < 45 21. 6 88.6 45-54 23.4 97.6 78.7 55-64 36.2 94.0 Total numbers 8536 1887 The association with obesity (ponderal index) is shown in table 53. At all ages, the obese subjects had a statistically significant though small increase in the risk of dying as compared with those of average build. In younger patients and older women, those patients who were thinner than average had slightly increased fatality rates, although no allowance has been made for a possible association with chronic illness. Table 53 FATAI.JTY RATES PER 100 CASES FOR PATIENTS OF DIFFERENT DEGREES OF OBESITY AND DIFFERENT AGES Fatality rates per 100 cases Age-group Obese Average weight Thin M F < 45 29.3 25.3 27.3 45-54 31. 3 27.0 23.4 55-64 44.7 42.0 35.4 38. 7 134 The effect of smoking history on survival is also of interest {table 54). When the whole group is taken, the fatality rate of non-smokers is greater than that of the smokers. However, this trend is ~ot observed at all age-groups. It may therefore represent a spurious feature of the data. It must be remembered that information on smoking habits was usually obtained by interview of the patient and may have been unreliable; in fatal cases, where the information was obtained from a friend or rela- tive, the statement that the patient was a non-smoker was more likely to be correct . Table 54 FATALITY RATES PER 100 CASES FOR PATIENTS OF DIFFERENT SMOKING HABITS AND DIFFERENT AGES Fatality rates per 100 cases Age-group 1 Non-smoker Ex-smoker Light smoker Heavy smoker M F < 45 30. 8 26.6 26.7 26.0 45-54 26.0 28. 3 26.3 29.0 55-64 44.9 39.5 39.0 40. 7 41. 8 All ages 37.7 35. 3 35.2 34.2 I 1 1-14 cigarettes per day 2 15 or more cigarettes per day Return to activity 2 The main purpose of the reviews in this study was to determine the degree of disturbance to the patient's life as a result of an attack of myo - cardial infarction. Assessment was done at three months and again at one year. It was imagined that by three months, if the patient had sur- vived the acute attack, there should have been sufficient time for convales- cence and a return to at least partial work. At one year, it was hoped that the attack would be a thing of the past and that the ultimate stable state of the patient could be determined. The extent to which this return to activity occurred is shown in fig. 34, and this information is shown in detail for each centre in table 55 and Annex II, table 77. The figures are very similar for "definite" and "i:1ossible" cases, provided they survived beyond the first review {the 11 Jossible" cases had a much higher initial fatality rate). 135 Fig. 34 CONDITION OF PATIENTS AT REVIEWS Second re view (3 months) I I I I ~ ,0 t r 9 f? 2% 27% 42 % 24% 4% I ~hird review (1 year) I P------1 A l ! q ~ 1 % 13 % 38% 40 % 6 % ft----1 Bedridden 8 Convalescent f Modified activity f Full activity ~ ~ Dead 136 Table 55 COMPARISON OF RETURN TO NORMAL ACTIVITY IN CENTRES WITH VARYING DEGREES OF REHABILITATION PROGRAMMES Percentage of patients Percentage of patients returni:rig to Centre undergoing normal activity in: systematic rehabilitation (1st-2nd review) 3 months 1 year 15 57 20 68 18 48 21 56 17 48 8 I 28 30 36 41 53 11 35 29 66 12 31 27 39 14 29 16 40 7 27 12 36 3 15 47 55 2 14 6 28 13 13 18 19 8 5 16 29 31 5 44 55 6 2 44 61 1 2 24 43 4 1 11 28 9 0 25 43 10 0 14 23 Total 17 23 40 137 The picture presented is dismal indeed. By three months, as ex- pected, about one quarter of those who survived the acute episode had returned to normal activity and nearly half had some modified activity (these terms are defined on page 155). However, by one year, only 40 % of the survivors had returned to full activity. The prospects, therefore, even for the survivors were not as good as could be hoped and it seems that if a person does not get back to full activity by three months, his ultimate chances of doing so are slender. One approach to this problem has been to develop an active rehabili- tation programme for patients after acute myocardial infarction and in some communities this has been implemented to a greater extent than in others. The figures show the state of affairs in 1971 when the study was performed; it must be borne in mind that since then the situation may have changed considerably, partly in consequence of the early analysis of these results. Table 55 shows the degree of return to activity in the different centres, depending on whether there was an aggressive rehabilitation prog- ramme or not. There is no relationship between the extent of rehabilita- tion and return to work at three months, and at one year. The early analysis of these figures led to a more intensive examination of the effects of rehabilitation1 and as a result many programmes were considerably modified and extended. This illustrates one of the benefits that can be expected from inter-centre comparisons. 1 See "Evaluation of comprehensive rehabilitative and preventive programmes for patients after acute myocardial infarction", Report on two working groups, Prague 1971 and Moscow 1972, WHO Documents EURO 8206(8), Copenhagen 1973 138 ANNEX I OPERA TING PROTOCOL INITIAL RECORD (Form Jl. 1 } Identification and registration (Card 1 ) 1 4-9 10-11 1 2- 1 6 17-31 32-36 37 38-44 45 Date of initial interview or examination of documints (This is the date on which the initial record form is filled in, which should be done as soon as practicable after noti­ fication.} Code number of registry (See list of collaborating centres, page 1) Registration number (Sequence number generated by each centre} Name ) Used for identification Present address } of individuals only, not Telephone number } placed on computer Permanent address (if different}} file. Identification number (Optional identifying number used by each centre if desired, e.g., to link with other records.} Registration number of previous entry in register, if any (Applies to patients being registered twice durflg the year.) Sex Date of birth Source of admission to register (General practitioner, hospital admission, hospital dis­ charge record, ECG record, death certificate, autopsy record, social insurance record, medicolegal authority, other (to be specified).) 1 The Initial Record is punched on four 80-column punch cards for computer processing, the card number being entered in column 80. The numbers given against ear.h item correspond to those on the record form and to columns on the computer punch cards. 1 39 \ Annex I ...... 1 WHO PILOT STUDY ON ACUTE MYOCARDIAL INFARCTION REGISTER Initial Record Form Study J 1.1 4-9 Dat_e of ~ rnmonth 19n--, 10-11 Centrernl2·16 RegiJUatlon I I I I I I Regutrati0n LJ_J LJ_J code numbu ~--~-'-~--~-.__. __ __._ Name: (and maiden name)- ··············· -- • •••• ••••••••••• ••• •••••••• •••••••••• ••••• •• •••••••••• ···--····· · ·· •••••• Present address: ...... . ....................................... . . . . .. ... - -- .. Tel . no . - -- - ---- - - -- - · ····· -- - - · · - Permanent address: (if different) 17·31 Identification num bu (If applicable): I 32·36 Previous registration numbu (If app licable): I I I I I I I I I I I I I I I I I I I I [I] month feat Ma1eO1 Fema1eO2 OJ 1 I 3~ Sex: 38-4-4 Date of birth I 45 Source 0f admiui on tu Register: Hospita l discharge record O 3 Autopsy record O 6 General practitioner O 1 ECG record O 4 Social I.ruurance record O 7 Hospital admission O 2 Death certificate D 5 Medico· legal authority Other (specify): •••• - -- --· - -- - ••••••• - - •• - --- - - - - - ••••• O s Os 46 State of patient: Alive O 1 Dead □ 2 47-79 Local optlona (e g . occupation) Early stages o f the present attack 17 Place of ofllel: Date and time of: 18·27 oo,et 28·37 call to doctor /hospital 38·47 flnl medical examlnallon 48·57 ,ran of mttt·anhydimlc trc&tmenl 58-67 arrival In booplUI 68 Transport to h01plUI Date Date Dale Due Dae Work O 1 Home O 2 [I] rn urn DJ DJuDJ DJ CDuDJ DJ DJuDJ DJ DJuDJ Ambulance O 1 80 [!J Hospital O 3 Other 04 Time Time Time Time boun mlnuta DJITJ DJ rn DJITJ DJITJ DJITJ Prtvue car 02 Tut O 3 Other (specify) .......•..•••.• 04 89·79 Local opd- (•- I· 4ala W time of ow, al coronary care) 140 I I I page 2 Symp t o ms ln the 28 days preceding o nset yes 17-1 9 Angina pectoris, fresh occurrence: 01 2u-22 Angina pectoris, exace.rbatlon of pre-existing condition: 01 23-25 Discomfort in the chest: 01 26-28 Heaviness in arm(s): 01 29-31 Unusual t!tedness: 01 32-34 Unusual breath lessness: 01 35-37 Palpltatlon.s (incl. arrhythmias) for f!trt tlme: 01 38-40 Othe.r (specify) 41-43 Other (specify) no unknown 02 □ 9 □ 2 □ 9 □ 2 □ 02 □ 9 02 □ s 02 □ 02 □ 9 r-, I I (leave blank) L_J ,- -, l_ _ J (leave blank) r-., Annex I If yes, interval from onset of symptom to attack rn days rn day. rn da)'I rn days 44-46 Other (srecify) --- ---- - ------------------------------------- - - ~- _: (leave blank) []Jda)'I []Jda)'I rnda)'I []Jda)'I rn day. rnda)'I Previou s medical hist o ry 47 Myocardial Infarction: Yes, confirmed D l No □ 3 Unknown O 9 I/ yes, 48-49 Number of confirmed episodes 5 0-55 Date of I UI epuode 56 Angina pectoris ,,f effort (In physician 's t'pin1 1in) more than 28 days befl1re l1nset of attack: Yes 01 No □ 2 Unknown □ 9 57 Cerebrovaacu!ar accident: Yes, confumed O l Yes, not conf!nnedO 2 No □ 3 Unknown Os 58 Intermittent claudlcat!on: Yes 0 No □ 2 Unknown Os 141 Annex I 59 Diabet .. me l lltus: Yc.s , confirmed 01 Yea, not confirmed 0 2 No 60 If yes1 Onset before age 4u 01 b ruet age 4 0 or later 61 Arterial hypenCJ11i on: Yea, confirmed 01 Yes , not confirmed 02 No 62 Other cardi ov11cul&r dlae.ue:: Yea 01 No 03 0 2 0 3 0 2 page 3 Unknown D 9 On.set unknown 0 9 Unknown D 9 Unknown D 9 JCD code 63 ·66 If yes, specify: .... _ . ........... __ ........ ...... . .......... __ ......... . . 67·7u 71 ·79 weal optluru Pers o nal deta i l s 17 SITl oklng habit: If smoke, at preaent: Body build at omet 1 Smokes D 1 Ex anolw: D 2 18 Clg11etteo per day 19 Pipe/cigar, Yes □ 1 Non smoker 1-4 5·14 0 2 15·24 0 3 25+ 0 4 :Jnknown 0 9 No 02 20•22 Body weight LI _._~_...JI le& 23-25 Height ,___.___....._ ..... I cm 142 80 G] Unknown 0 9 Unknown Os Annex I e 4 Clinical cunditi 11 n at first medical examinati o n 26 Clinical state: 27-29 Heart rate 3., Heart rhythm No circu latory failure D Shoc k □ 3 Cardiac arrest D 5 per min . Regular □ Extrasyst oles (at lea.rt 1 in 1 11} □ 2 Auial fibrillati on □ 3 Irregular, unspecified □ 4 Hospital ward Othct dnctN Congestive cardiac failure D 2 2 & 3 □ 4 Unknown D 9 31 ·32 Re,piratory rate min . Bl uod pressure: 33-35 Sy,tolic mm Hg 36·38 Diast.,llc mm Hg CCU 02 Patient □• Other (specify): ________ ____ __________ __ ____ _____ _ .... D 5 4 u-79 l.i)cal options Su 0 143 Annex I 46 State of patient when fir st notified (Alive or dead) (The remaining columns on Card 1 ( 47-79) are available for coding optional data, e.g., occupation) Early stages of the present attack (Card 2) For the purpose of this study, the patient's symptoms are considered under two headings: (a) the attack (b) symptoms occurring in the 28 days preceding the onset of the attack (premonitory symptoms). Myocardial infarction will usually be accompanied by characteristic chest pain or other acute symptoms. The patient or his relatives can usually recollect the time and place of onset of the symptoms vividly and will seek medical help at some time subsequently. He or she may have suffered milder, vaguer, more indefinite symptoms for which medical advice may or may not have been requested in the previous four weeks. These are described as premonitory or prodromal symptoms. The onset of acute symptoms may occur before, at the same time, or after the pa- thologic entity of myocardial infarction; however, the "onset of the attack" is estimated from the patient's symptoms and is used as a basis for meas- uring the time taken to seek and receive medical care. Occasionally, there is no clear distinction between premonitory symptoms and the acute attack, as for example in crescendo angina pectoris accompanying myo- cardial infarction. In these cases there has been no definite acute onset of symptoms; the date, time and place of onset are consequently not rele - vant and should be treated appropriately (Fig. 35). 17 18-68 18-27 Place of onset Dates and times (These dates and times should be recorded as accurately as possible from the patient or other sources.) Date and time when first symptom noticed (If there was no definite onset of the attack, either because there were no symptoms or because the symptoms became gradually worse over a period of days, the year and month should be entered, (see example (d) in Fig. 35).) 144 Annex I Fig . 35 ILLUSTRATION OF CODING TECHNIQU E ADOPTED FOR THIS ST UD Y. HISTORY OF THE MODE OF ONSET. severity of symptoms days No history of p remonitory symptoms obtained per iod of premonitory symptoms daye days j onset of attack l onset of attack l onset of attack +-----•• ... o~r~e-monito ry B¥:,_ro...,p..,t .. o.._m .... e_" ____ ... No definite onset of attack days 145 (a) (b) ( c) (d) Annex I 28-37 38-47 48-57 58-67 68 Date and time of call to doctor/hospital (If several calls are made, the first should be recorded. A call for an emergency ambulance does not qualify as a call to a doctor unless the ambulance is ordered through a doctor, or is manned by a doctor.) Date and time of first medical examination (This applies to the first doctor seeing the patient after the onset and his clinical findings should be recorded under "clinical condition at first medical examination" (Card 4, 26-39).) Date and time of start of anti-arrhythmic treatment (This refers to the administration of drugs such as ligno- caine, propranolol, procainamide, atropine for prophylaxis or therapy; not external cardiac massage. Treatment after admission to hospital is not recorded.) Date and time of arrival in hospital Type of transport to hospital The remaining columns on Card 2 (69-79) are available for coding optional data, e.g., time of arrival in coronary care area. Symroms in the 28 days preceding onset of present attack (Card 3, first parl The symptoms listed below will be coded as present "yes", absent "no" or "unknown" in the absence of information. In fatal cases, where the patient cannot be interviewed, an attempt should be made to find some- one who knew the patient and had seen him in the few days preceding death. If routine questioning of such a person does not reveal premonitory symp- toms, code them as absent. If the patient lived alone and no information is available from anyone else, these items should be coded as unknown. For each symptom present, the interval between its onset and the actual attack should be recorded in days. "Other" symptoms should be specified. If a symptom has been present for more than 28 days, it should not be re- corded in this section unless there has been progressive exacerbation. 17-19 20-22 Angina pectoris of effort, fresh occurrence (Chest pain at re st, even if of angina! distribution, should be coded under columns 23-25 below.) Angina pectoris of effort, exacerbation of pre-existing con- dition 146 23-25 26-28 29-31 32-34 35-37 38-40 41-43 44-46 Annex I Discomfort in the chest at rest Heaviness in the arm(s) Unusual tiredness Unusual breathlessness Palpitations for the first time (This Other(s) II II includes the recognition of preceding arrhythmias) ) 1 - general ill-feeling, dizziness, fellt weak ) 2 - pain in upper part of body ) 3 - cerebral episode ) 4 - collapse, syncope 1 ) 5 nervous symptoms and any neur logical disturbances 6 - gastrointestinal and other abdomtnal symptoms 7 - backache, musculo- skeletal pains 8 - other circulatory symptoms 9 - other Previous medical history ( Card 3, second part) This should be ascertained from the patient and/or hosfital or other medical records. The previous medical history may be con radicted by subsequent investigations and findings, e.g., post-mortem e idence of old myocardial infarction, but should not be altered on these grofnds. Sim- ilarly, new features of the history discovered after admissio should be recorded at review and not here. In fatal cases, the history should be sought from relatives, general practitioners, and/or other ledical records. If no friends, relatives, doctors, or records can be trac ed, hese items should be coded as unknown. 47 Myocardial infarction (If such an event has occurred in the past, con~irmation must be sought from the medical records, hel~ either in hospital or by the general practitioner. A coffirmed myo - cardial infarction should conform to the d iagnostic criteria laid down for "definite acute rny_oc ar.dial infardtion" ( see page 160). Where confirmation is not availablr1 owing to the lack of a record or inadequate investigation or documentation, but where the history is in keeping with the di1,gnosis, the box "yes, not confirmed" should be ticked. I_t_ several at- tacks of myocardial infarction - both "confirmFd" and "not confirmed" - have occurred, the box "yes, confirmed" should be ticke.d. ) I 147 Annex I 48-49 50-55 56 57 58 59 1 Number of "confirmed" attacks Date of most recent episode (Refers to the last "confirmed" attack. ) Angina pectoris of effortl considered by the physician to have been present before the 28-day period preceding onset of the acute attack (The physician referred to may be the registry doctor, the usual attending doctor, or the hospital doctor under whose care the patient has come. ) Cerebrovascular accident (When a history of such disease is obtained, confirmation must be sought from medical records held either in hos- pital or by the general practitioner. The neurological sequelae may also serve as confirmation of previous cerebrovascular accident, e.g., hemiparesis. Where confirmation is not available owing to lack of a record, in- adequate investigation or documentation, or absence of neurological sequelae, but where the history is in keeping with the diagnosis, the box "yes, not confirmed" should be ticked. ) Intermittent claudication {A history that satisfies the registry doctor or that, in the past, has satisfied the usual attending doctor or the hospi- tal doctor that intermittent claudication has been present, is sufficient for the positive diagnosis.) Diabetes mellitus (When a history of this disease is obtained, confirmation must be sought from medical records held either in hos- pital or by the general practitioner. If the history is sup- ported by current evidence, such as continuing insulin therapy or hyperglycaemia, it should be regarded as con- firmed. When the patient's history is unsupported, the box "yes, not confirmed" should be ticked.) See footnote on page 157 148 60 61 62-70 Annex I In a patient with diabetes me llitus, the age of the patient at the time of first diagnosis {under 40, 40 or over or unknown) Arterial hypertension {When a history of this disease is obtained, confirmation must be sought from medical records held either in hospi- tal or by the general practitioner. Where confirmation is not available and only the patient's statement indicates hypertension, the box "yes, not confirmed" should be ticked. If a definition of hypertension is required, the criteria re- commended in WHO Technical Report Series No. 1681 and No. 231 2 should be followed.) Other cardiovascular diseases {Coding should be according to the International Classifica- tion of Diseases, 8th revision3) The remaining columns on Card 3 (71-79) are available for coding optional data. Personal details (Card 4, first part) 17 Smoking habit (Should be ascertained from the best available source(s). A smoker is one who smokes at least one cigarette per day or the equivalent in pipe or cigar tobacco or who has smok- ed at that level until within three months of the acute epi- sode. An ex-smoker is one who smoked at least one cig- arette per day or the equivalent in pipe or cigar tobacco but ceased smoking at least three months before the acute episode. A non-smoker is one who has not at any time smoked tobacco at the levels indicated above.) 1 World Health Organization (1959) Hypertension and coronary heart disease: classification and criteria for epidemiological studies; First Re ort of the Ex ert Committee on Cardiovascular Diseases and H er- • tension, Geneva Wld Hlth Org. techn. Rep. Ser. , No. 1 8 2 World Health Organization (1962) Arterial hypertension and ischaemic heart disease: reventive as ects· Re ort of an Ex ert Com- mittee, Geneva Wld Hlth Org. techn. Rep. Ser., No. 231 3 Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, 8th revision, vol. 1, Geneva, World Health Organization, 1967. 149 Annex I 18 19 20-22 23-25 Average recent cigarette consumption should be recorded {If the patient makes his own cigarettes from tobacco, one gram of tobacco is equivalent to one cigarette.) Pipe and/ or cigar smoked Body w e ight {In most situations only an estimate of current body weight will be available .) Height {In most situations only an estimate of current height will be available.) Clinical condition at first medical examination {Card 4, second part) For the purposes of this section, the examination reported will be the first full medical examination for which data are available. It may be carried out by a general practitioner or the doctor admitting the patient to hospital. If the time of death precedes the first medical examination, leave this section {26-39) blank. 26 Clinical state (1) no circulatory failure {2) congestive cardiac failure! 1 Congestive cardiac failure. The failing heart does not maintain an adequate circulation for the needs of the body in spite of a satisfactory venous filling pres sure. Effort dyspnoea, orthopnoea, paroxysmal car - diac dyspnoea, pulmonary venous congestion and interstitial oedema, but normal jugular venous pressure are characteristic of left ventricular failure. Elevated systemic venous pressure, with retention of the elec- trolytes and water {enlargement of the liver, oedema of extremities, or even ascites), characterize right ventricular failure. The term "conges- tive heart failure" is used to indicate either pulmonary or systemic con- gestion or both. {Adapted from Wood, P. (1968) Diseases of the heart and circulation, 3rd ed., London) 150 27-29 30 31 -32 33-38 39 (3) shockl ( 4) shock and cardiac failure (5) cardia~ arrest2 (6) dead before examination (7) unknown Annex I (The appropriate category will be allocated on the basis of the examining doctor's report.) Heart rate Heart rhythm Respiratory rate Blood pres sure Source of information (This refers only to the clinical condition of the patient, not to the other information on the form. (1) hospital: reception area, casualty department or con- ventional ward; (2) coronary care unit: an area specifically designed for the continuous and intensive care and surveillance of a patient suspected of having an acute myocardial infarction, 1 Shock. In acute myocardial infarction shock is character i zed by a marked fall of arterial blood pressure (systolic usually below 85 mm Hg); cold, clammy, sweating skin; cyanosis; weak, thready pulse; oliguria; mental confusion; and sometimes coma. The signs correspond to acute circulatory failure w i th a very low cardiac output. Pulmonary congestion and elevated venous pressure when present indicate hear t fail i re. T h e term "cardiogenic shock" is also used for such a condition. ~Adapt ed from Wood, P. (1968) Diseases of the heart and circulation, 3rd ed., London ) 2 Cardiac arrest. This has occurred when the heart contraction has ceased but the patient is considered to be still living . In the presenc e of a clinical description, no ECG evidence of asystole or ventr icular fib - . rillation is necessary. If on examination by a doctor, despite absent pulse and blood pressure, attempts to resuscitate the patient are ini tiated or continued, the patient is to be considered in cardiac arrest. II£ the patient is pronounced already dead on the first examination, the apparent t ime of death as recorded in the death form will precede the time of first medical examination. In a patient where the attempted resuscitation has failed , the recorded time of death also precedes the first medical examination. 151 Annex I in orde r to prevent and treat its complications, especially arrhythmi~s;l . (3) general practitioner or equivalent doctor outside hos- pital; (4) examination of the patient by registry doctor; (5) other, e.g., mobile coronary care unit personnel (specify). ) The remaining columns on Card 4 (40-79) are available for coding optional data. REVIEW RECORD (Form Jl. 2) Information will be ascertained at intervals from the onset of symp- toms, as follows: (1) 28 days, or on earlier discharge from hospital; (2) three months; ( 3) one year after the onset of the acute attack. The information sought at each review will be similar, except where specifically stated. Identification of patient undergoing review 4-9 10-11 12-16 17 18-23 24 Date of registration ) ) Code number of registry) ) Registration number ) Name (and maiden name)) Present address ) Sequence number of review Date of review The numbering of these items is identical to that on the initial record form. State of patient at the time of review : alive or dead (If the patient cannot be traced this should be indicated. For such a patient the remainder of the review record form should be completed as far as possible, using the "unknown" category where appropriate. ) 1 World Health Organization Regional Office for Europe (1969), The or anization of coronar • care units, Report on a Preparatory Meet- ing, Copenhagen, 3 - February 19 9 document EURO 5020), p. l. 152 Annex I .,. ... 1 WHO PILOT STUDY ON ACUTE MYOCARDIAL INFARCTION REGISTER Review Record Form Study J 1.2 day month year 4·9 Date of rn rn 19rnl0· 11 Centre[IJ12·16 Registration ' Registration code number ._ _ _.__..____..___. _ _, Name: (and maiden name) Preoent address: Tel. no 17 Review: First 01 Second 02 day month year 1S-23 Date of review, ITJDJ 19DJ 24 State of patlem: 25 Slruation of patient: In hospital 01 Bed-ridden 01 Modified activity Os 26 Recovery status: 27 Number of h01pltall.utlon1 during the Inter,&!: Reason for each hoopltal!utlon: 28-31 32·35 36-39 40-43 44-47 48-50 Number of days In CCU 51-53 Number of days In baspltal ward 54 Doral led lwtory1 Not In hospital 02 Convalescent 02 Normal activi ty 04 □ days clays Anllable 0 55 Systematic rehablllwlon programme: Yes □ l No D 153 Third □ 3 Not traced O 9 Unknown 0 9 Unknown 09 lCD code I Not available D Unlmown 0 9 Annex I page 2 C o m pli c at i o ns i n the int erva 1: Yes No Unknown 56 Congestive cardi ac fallure: 01 02 09 57 Shock: 01 02 09 58 Throm~,-em bolism: D1 02 09 59 Cardiac arrest: D 1 02 0 9 6U Re - i nfarcti1m: 0 1 02 0 9 61 Angina pcct,l r i.s ,1 f eff11n: 01 02 09 !CD code 62-65 Other (srec,fy): ------- ------- ------- -- --- ------------------- ---- --- -- -- -- -- -----' ~~ Def t nitive diag n ,, sis (1 st re vi ew 11 11 l y ) Criteria f11r diagnosis: 66 History nf pain: Typica l 01 Atypica l 0 2 Nunc 04 No data □ 9 67 ECG changes: Definite 01 Equivocal 0 2 Other 0 3 None 04 ·No data 0 9 68 Scrum enzymes: Elevate.:! 01 Equivocal D2 Normal 04 No data 0 9 69 Autopsy diagn,>sis: Positive 01 Negative o. No data 0 9 70 Acute myocardi al infarcli 1111: Definite □ Po■lble 02 None 0 4 Insufficient data 0 9 71-74 If none, specify ,1ther diagn t1sis: !CD code ________________________________________________________________________________ ! _1 _I __._I_ 75-80 Local options 154 25 26 27 28-37 48-50 51-53 Annex I Situation of patient (If patient is discharged before 28 days from onset, the box "not in hospital" should be ticked.) Recovery status! Number of times admitted to hospita l in interva l under r e vie w Reason for e ach admission (Give the appropriate principal diagnosis or diagnoses in consecutive order, coded according to the Internati onal Classification of Diseases, 8th revision2.) Number of days in coronary care unit or othe r intensive c are area (Record a period of less than one day as 001) Numbe r of days in hospital ward exclusive of time in coronary care unit ( 48-50) (If the patient was still in hospital 28 days after onset, i.e., at first review, the figure 28 less the number of days be- tween onset and admission and the number of day s in the 1 Four categories are giv en on the form, de fin e d a s follows : Bedridden. Where the patient is mainly at rest. Convalescent. When the patient is out and about but not yet unde r - taking any regular a ctivity. Modified a ctivity. The standard of comparison is the amount of activity indulged in before the onset of the acute attack. This de scr iption will apply to those who have changed to sheltered or part-time employme n t , or to those who have, since the acute attack, retired or to those now un - employed. It applies also to previously retired persons or to those doing household work if their actual level of activity is less than before the attac k. Normal activity. The standard of compa r i son is the amount of activity indulged in before the onset of the acute attack. 2 Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, 8th revisi on, vol. 1, Gene va, World Health Organization, 1967. 155 Annex I 54 55 coronary care unit should be entered in this box. Any re - maining period in hospital should be recorded on the sub- sequent review record form, even though there is no re - admission to hospital in the interval. If myocardial infar- ction occurred when the patient was already in hospital, the number of days in the hospital ward subsequent to onset, and not to the original admission, should be recorded.) Detailed history (Record whether medical records held by the hospital or by the general practitioner are available.) Rehabilitation programme (If a systematic rehabilitation programme involving early mobilization with physical training of the patient, similar to that described in the WHO Programme for the Physical Rehabilitation of Patients with Acute Myocardial Infarction, 1 has been started or continued in the review interval, the box "yes 11 should be ticked. Clinical condition and complications in the interval Record if the following conditions are present at review, or have occurred in the interval (which is from the onset for the first review and from the preceding review subsequently): 56 Congestive cardiac failure 57 Shock 58 Thrombo-embolism2 59 Cardiac arrest 1 World Health Organization, Regional Office for Europe ( 1968) The development of a programme for the physical rehabilitation of patients with acute m ocardial infarction Re ort on a Workin Grou Freibur - im-Breisgau, 4 - 6 March 1968 (EURO 50 30 . 2 Thrombo-embolism. Held to comprise pulmonary embolism (or infarction) and embolism in the systemic circulation, e.g., cerebral , visceral, extremities. 156 60 61 62-65 Re -infarction I Angina pectoris of effort2 Other Annex I (Specify: give complications coded accorded to the Inter - national Classification of Diseases, 8th revision, Hyper - tension and diabetes mellitus discovered and confirmed after admission should be recorded i:n this section.) Definitive diagnosis This section will b~ completed only on the first review. The defin- itive diagnosis of the registered episode will be made on the basis of four criteria: history of the acute attack, electrocardiogram, serum enzyme levels, and post-mortem examination, 66 History of pain at onset of the present attack (Typical. When it is characterized by retrosternal pain with the following characteristics : (1) diffusion through the chest, anteriorly or generally, which may remain localized in the chest or radi~te to the shoulder, arms, jaws or abdomen on one or both sides; ( 2) resistance to nitroglycerine if taken during the attack; 1 Re-infarction. Must satisfy the criteria laid down for the diag- nosis of definite acute myocardial infarction (see p,160). In most in- stances this will involve readmission to the register and fresh documenta- tion, 2 Angina pectoris of effort. In this group are placed incj-ividuals with pain or discomfort localized in the upper or mid-sternal region and appearing during effort, especially on walking or starting to walk. The pain may remain localized in the chest, radiate within the chest, or radi- ate to the shoulders, arms or jaws, on one or both sides. It is crushing or constricting in character, occasionally numb or burning, and compels the patient to stop or slow down. After the cessation of effortJ or the use of sublingual nitroglycerine, the pain disappears in one or two minutes in most cases, but the interval may be longer or shorter in dura~ion. In cold surroundings, after eating, or when walking uphill or into the wind, pain is more easily produced. It may begin or remain locali:zled in any one of the above radiation sites. Pains which appear during emotional crises, especially anger, at the moment of lying down or during sexual intercourse, have the same significance as those occurring on effort. The diagnosis of angina of effort may be made on the above criteria even in the absence of electrocardiographic changes. (See : Wld H~th Org . . techn. Rep. Ser., 1962, No, 231, p. 1 7) 157 Annex I 67 ( 3) duration of more than 20 minutes; (4) usually severe and at times of agonizing intensity. Atypical. When it is characterized by symptoms such as dyspnoea, a sense of suffocation, "indigestion", syncope, general malaise, sweating or acute cardiac failure.) Electrocardiogram ( The ECG classification will be based on the reading of all records taken in the period following the acute attack and, if available, records taken immediately before. The defi- nitions of the categories "unequivocal ECG changes of acute myocardial infarction" and "equivocal ECG changes of acute myocardial infarction" are based on the annex to the fir st report of the WHO Expert Committee on Cardiovascular Diseases and Hypertension. 1) Definite ECG changes ( 1) development of a pathological Q wave, and/or (2) evolution of an injury current that lasts more than one day. The interpretation of at least two ECG records is therefore necessary for the establishment of this category. Note that the development of a pathological Q wave in this context does not require accompanying S-T-T changes to establish the "definite" category. Equivocal ECG changesl ( 1) evolution of an injury current that disappears within 24 hours : injury current present when only one graph is available; (2) a stationary injury current; (3) symmetrical inversion of the T wave; (4) bundle branch block with additional Q wave; ( 5) pathological Q wave in a single ECG record and in other circumstances where there is no evidence of devel- opment. Other ECG abnormalities ( 1) where morphological abnormalities exist that do not conform to the pattern as described under "definite" and ".equ.ivocaV' changes above; l Wld Hlth Org. techn. Rep. Ser., 1959, No. 168, p. 25 158 68 69 1 Annex I (2) abnormalities of rhythm in otherwise normal ECG records. Normal ECGl Serum enzymes (Owing to differing local laboratory circumstances, it will not be possible to standardize the serum enzyme tests nor the reagents and methods employed. It will be the re spon - sibility, therefore, of the local registry, in cooperation with their laboratories, to define: (1) the tests employed; (2) the local ranges of normal, equivocal and abnormal. The ideal contribution of serum enzyme levels to diagnosis is a series of recordings in which transient elev~ted levels can be observed, but the occurrence of an elevated or equiv- ocal level in a single estimation in the period after the acute episode will be accepted for appropriate coding.) Post-mortem examination ( The results of post-mortem examination, which are re - corded in the following section on data requi rements for death, provide the information for classification 1nto : Positive evidence of acute myocardial infarction The presence of a fresh myocardial infarction and/or re- cent occlusion of a coronary artery (from ante-mortem thrombus, haemorrhage into atheromatous plague or em- bolism), Note that this refers to the naked-eye appear- ance of the heart. Negative The absence of macroscopic evidence of fresh myocardial infarction or recent occlusion of the coronary artery. Signs of chronic ischaemic heart disease, namely old myocardial infarction (scar), occlusion, or severe sten- osis (greater than 50o/c, reduction of lumen) by mural atheroma do not qualify as positive criteria fot this study, A book of illustrations entitled Electrocardiographic criteria for use in the Ischaemic Heart Disease Registers Study, prepared py the Cardiovascular Diseases Unit, WHO, Geneva, is available as a separate annex to the Report of the Working Group on Ischaemic Heart Disease Registers, Copenhagen, 12 - -14 May 1969. 159 Annex I 70 although the pathologists may use them as evidence for the autopsy cause of death ( see death record form) and they should be recorded there.) Diagnostic categories (Allocation of a diagnostic category must follow strictly the definitions provided. The categories used for the diagnosis of "definite" and "possible" acute myocardial infarction are not necessarily those that would be us ed by a clinician, but rigid definitions are e ssential for the r egiste rs. The group of cases of "possible" acute myocardial infa rction will in- evitably include a number of cases of non-cardiac chest pain but it is considered worthwhile following up all these cases. Patients who are seen too late after the episode of chest pain for diagnostic dynamic ECG or enzyme changes to be pre - sent will fall into this category. (see also fig. 7) Definite acute myocardial infarction (a) ECG shows unequivocal serial changes, or (b) history, typical or atypical, together with ECG e quivocal and elevated enzyme s, or (c) typical history and elevated enzymes with ECG nega- tive not available, or ( d) fatal cases, whether sudden or not, with naked-eye appearance of fresh myocardial infarction and/ or recent coronary occlusion found at necropsy . Note: Category (1) must include all cases in which 1 has been entered in column 67, all cases in which 1 has been entered in column 69, all cases in which 1 has been entered in both 66 and 68, and all cases in which either 1 or 2 has been entered in column 66 with a 2 in column 67 and a 1 in column 68. Of course, some cases will fulfil more than the minimum requireme nts. Possible acute myocardial infarction (a) Living patients with typical pain, whose ECG and enzyme results do not place them in category ( 1) and in whom there is no good evidence for another diagnosis for the attack, or • (b) fatal cases whether sudden or not (not in category (1 )), where there is no good evidence for another cause of death, clinically or at autopsy: (i) with a history of pain, typical or atypical; or (ii) without a history of pain, but with evidence of chronic coronary occlusion, or stenosis, or old myo- cardial scarring at necropsy; or 160 Table 56 Annex I (iii) with clinical evidence of chronic ischaemic heart disease. No acute myocardial infarction (a) Living patients (not in category (1)): (i) equivocal ECG changes without a typical history or elevated enzymes; or (ii) where chest pain has been explained by another diagnosis. (b) Fatal cases, whether sudden or not, not in category ( 1) where another dianosis has been made (clinically or at autopsy). Fatal cases with insufficient data Cases with no autopsy, no history of pain, no previous history of chronic ischaemic heart disease and no other diagnosis. The foregoing are summarized in Table 56 SUMMARY OF DIAGNOSTIC CATEGORIES Definite Typical ECG £!._Equivocal ECG with definite enzymes .£!:. Typical history with definite enzymes .£!:. Positive post-mortem Possible Remaining surviving cases with typical history history of pain (typical or not) or Fatal cases with past history of chronic IHD or autopsy evidence of chronic IHD Not an Remaining living cases notified infarct Fatal cases where another diagnosis made Insufficient Remaining fatal cases notified information 71-74 Other diagnosis (If there is no acute myocardial infarction (70 equals 4), the other diagnosis is entered, coded in accordance with the International Classification of Diseases, 8th revision. 161 Annex I The remaining columns ( 7 5-80) are available for coding optional lo- cal data. DEATH RECORD (Form Jl. 3) 4-9 Date of registration ) Date and registration number ) should be the same as those on the 10 -11 Centre code ) initial record form. ) 12-16 Registration number ) Name (and maiden name)) Not coded Address ) Time and place of death A patient may not be declared legally dead until he has been examined by a doctor. For the purposes of the r egister, however, the apparent time of death should be recorded and the place where this occurred. The apparent time of death will therefore be established by eye-witnesses or other evidence. It is the earliest time at which the patient appeared mo- tionless, pulseless and unresponsive. As most coronary deaths occurring outside hospital are sudden, there is usually no doubt as to when apparent death occurred, if e ye-witnesses are available. 17-26 27 28 29 30 31-32 33 Date and time when patient apparently died (Not the time death was certified.) Place of apparent death (Certification of death may occur later in a different place, for example, if the body is removed to hospital.) In the case of death outside hospital (see above), state whether the death was witnessed or not. Consultation with doctor in two weeks preceding death (Specify reason for consultation. This information will not be punch coded. This is most relevant to cases of sudden death outside hospital, but should be completed in all cases.) Transfer to pathology department Give approximate interval from death to transfer, in hours Autopsy done or not 162 Annex I paite 3 WHO PILOT STUDY ON ACUTE MYOCARDIAL INFARCTION REGISTER Death Record Form Study J 1.3 day month yur 4-9 Date of rn rn rnl0-11 reglstratlon 19 Name: (and maiden name) - • - --- - - - -- - - - -- - -- --- - - - - - -- - -- - -- -- --- - -- - -- -- ---- -- - - - - -- - --- --- ------- --- --- ~ Address: day month yur hours m lnutea 17-26 Date and time of death: Date rnrn l9rn Tlme rnrn 27 Place of death Work □ l H ospltal Other (specify): 28 U death ouulde hospltal: Witne.ed 01 Not witna,ed D2 Unknown O 9 29 Consultation with doctor in p,ecedlng 2 weeks: Ya □ l Unknown O 9 I! yes, specify reason: _____________ ______ __________________ __ __________ _ 30 Transfer 10 pathology departmem: Ya D l Unknown Os 31-32 U ya, how soon after death: rn hours 33 A Ulvpsy perf,ffl'led: Ya, ln hospltal □ l No 03 !CD code 34-3i Certified cause of death (cllnlcal) I I I I 38-41 I I I I I I I 46 -49 Certified ~u,e of death (autopsy) I I 50-53 I I . . . I I 58-8 ◊ Local options 163 Annex I 34-57 Certified cause(s) of death When a death certificate is issued before or in the absence of a post-mortem examination, the certified cause(s) of death should be recorded in the section(s) marked "clinical". The condition directly leading to death is recorded under (a). If the immediate condition causing death is a complication or a consequence of an underlying condition, this underlying condition should be recorded next under (b). If this, in turn, arose from a further underlying condition, the latter should be recorded next, so that the underlying cause of death or the condition initiating the fatal sequence is record- ed last. When a death certificate is issued after the results of nec- ropsy a copy of the post-mortem report should be obtained. If the cause of death is given as other than "ischaemic heart disease" it should be recorded as coded in the International Classification of Diseases, 8th revision. In addition, and especially when "ischaemic heart disease" is given as the autopsy cause of death, the findings in the heart at autopsy should be recorded as follows (the 4th digit is a special code for use in this study): 4101 4102 410 3) or 4123) 4124 4125 recent acute myocardial infarction recent coronary occlusion (by thrombus, haemorrhage into a plague or embolism) chronic complete occlusion of an artery (two codes possible) old myocardial infarction or scar ( >0. 5 cm) coronary stenosis or stricture ( > 50o/o lumen) Code all items if pre sent, except that 412 5 need not be coded if 4103 or 4123 is present. Where the local or national practice is to record both clini- cal and autopsy causes of death on the death certificate sep- arately, both sections should be completed. Associated causes of death need not be recorded. 164 SUPPLEMENTARY TABLES AND FIGURES 165 ANNEX II ..... 0-- 0-- Table 57 Source !CENTRE = I Blank 1 GP 2 Hospital admission 3 Hospital discharge record 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Ott,er Total CENTRE = 2 Blank l GP 2 Ho s pital admission 3 Hospital discharge record 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Other Total CENTRE = 3 Blank l GP 2 Hospital admission 3 Hospital discharge record 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Other Total SOURCE OF DATA AND DIAGNOSIS AT INDIVIDUAL C E NT RES Diagnosi s Definite Possibl e None Insufficient data 13 3. 3 o/. 2 2 . 5% 3 3 . 01, 0 0. 0% I 0. 3 0 0 .0 0 0.0 0 0.0 345 86.9 36 -15. 0 bl 6 I. 6 0 0.0 I 0. 3 0 0.0 0 0.0 0 0 .0 0 o.o 0 0.0 0 0.0 0 o. 0 3b 'I. I -12 'i2 . 5 35 3 5. -I 0 0.0 0 0.0 0 0 . 0 0 0.0 0 0 . 0 0 0.0 0 0.0 0 0.0 0 0 . 0 0 0.0 0 0.0 0 0.0 0 0.0 I 0. 3 0 0. 0 0 0 . 0 0 0. 0 3'!7 100,0 XO 100.0 'l'I I 00 . 0 0 100.0 0 0.0 0 0.0 0 0 . 0 0 0.0 0 o.o 0 0.0 0 0 . 0 0 o.o 268 8-1. 5 n 4-1. 9 -121 62 . 6 0 0.0 4 l. 1 I 0. 5 5 o. 7 0 0.0 3 0.9 0 0 . 0 5 o. 7 0 o.o 8 2 . 5 48 23. 4 I 0. I 0 o. 0 4 1, 3 -I 2. 0 3 0 . 4 0 0. 0 4 I. 3 2 1.0 13 I. 'I 0 0 . 0 20 6. 3 5 1 2-1. 'I l2 -1. 8 0 o. 0 6 I. 'I 7 3. 4 I '!2 28.6 0 0.0 317 100.0 205 100 .0 672 l 00. 0 0 100.0 3 I. 4 0 o. 0 0 o.o 0 0.0 3'! I 7. 9 31 20. 3 21 'I 47 . 4 0 0 . 0 25 11. 5 6 3. 'I 14 3. 0 0 o. 0 7 3. 2 0 0 . 0 2 0.4 0 o.o I 5 6.9 6 3.9 I!! 3. 9 0 o.o 22 IO. l 40 26. l 3 0 . 6 0 0 . 0 0 o.o 0 0 . 0 0 o.o 0 0. 0 0 o.o 0 o. 0 0 o.o 0 o. o 38 17.4 0 o.o 14 3. 0 0 o.o 69 31. 7 70 45.8 192 41. b 0 o.o 218 100. 0 I 53 100.0 462 100,0 0 100.0 Blank 0 0. Oo/, 0 0. 0 0 0 .0 0 0.0 0 0.0 0 0.0 0 0. 0 0 0.0 0 o.o 0 0.0 0 100.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0. 0 0 o.o 0 0 . 0 0 o. 0 0 0. 0 0 100. 0 0 0 .0 0 o. 0 0 o.o 0 o. 0 0 0 . 0 0 o.o 0 o.o 0 0.0 0 o.o 0 o. 0 0 100. 0 Total 18 3. I o/, I 0 . 2 442 76. 7 I 0.2 0 0.0 113 19. 6 0 0.0 0 o.o 0 o.o l 0. 2 576 100.0 0 0.0 0 0.0 781 65. 4 10 0.8 8 0. 7 57 4.8 11 0.9 19 l. 6 103 8.6 205 l 7. 2 I 194 100.0 3 0.4 289 34.7 45 5. 4 9 l. I 39 4. 7 65 7. 8 0 0.0 0 0.0 52 6. 2 331 39. 7 833 100.0 ► ::i ::i (1) X ..... ..... ...... 0--- -J T a ble 57 (contd) So u r ce CENTRE = 4 Blank 1 G P 2 Hospital admission 3 Hospital discharge record 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insuranc e record 8 Medicolegal authority 9 Other Total CENTRE = 6 Blank I GP 2 Hospital admission 3 Hospital disch a rge record 4 ECG record 5 Death certificate b Autopsy record 7 Social insurance reco rd 8 Medicolegal authority \I Other Total CENTRE = 7 Blank I GP 2 Hospital admission 3 Hospit a l discharge record 4 ECG r ec ord 5 DeaU1 certificate 6 Autopsy record 7 Social insurance record 8 Medic olcgal authority \I Other Total Definite 6 I. I 'lo 107 !';I. I 203 36 . 3 JO 1. 8 0 0.0 2';1 5. 2 28 5.0 0 0.0 57 10. 2 11';1 21. 3 55'1 100.0 I 0.4 25 8. \I 168 60.0 8 2. \I I 0.4 18 6.4 2 0. 7 0 o. 0 I 0.4 56 20.0 280 100 . 0 2 0. 5 4 I. 0 322 84. 5 33 8 . 7 5 I. 3 \I 2. 4 5 1. 3 0 0.0 0 o.o I 0.3 381 100. 0 D iagnosis Possible None 7 1 . 4 fo I O. I '/o % 18 . ';I I 82 l '1. 6 Ill 21. 'I 276 2';1. 8 4 0. 8 28 3.0 0 0.0 0 o.o ';II I 7 . 'I 2 0.2 II 2. 2 I! 0. ';I 0 0.0 I 0 . I I!/! I 7. 3 11 I. 2 100 I \I. 7 -Ill! 45. I 5011 100. 0 '12 7 100.0 2 I. 7 I 0 . 1! 2\1 24. 6 1\1 14. ~ 46 l\l . 0 \10 bl!. 7 2 I. 7 I 0 . 8 I 0. 8 0 0 . 0 b 5. 1 0 0.0 0 0.0 0 0 . 0 0 0.0 0 0.0 0 0 . 0 0 0 . 0 32 27.1 20 1 5. 3 118 100. 0 131 100 , 0 1 1.0 0 0.0 I I. 0 0 o.o 17 I 6. 7 2-1 63. 2 3 2. \I 3 7. \I 0 0.0 0 o.o 80 78.4 II 28 . 'I 0 o. 0 0 0.0 0 o.o 0 0.0 0 0.0 0 o.o 0 0. 0 0 0.0 102 100 .0 38 100.0 Blank Insufficient data 0 o. 0 % 0 o. 01, 0 0.0 0 o. 0 0 0.0 0 o. 0 0 0 . 0 0 0.0 0 o.o 0 o.o 0 o.o 0 o. 0 0 0.0 0 0.0 0 o.o 0 0 . 0 0 0.0 0 0.0 0 0 . 0 0 0 . 0 0 100.0 0 100.0 0 o.o r) 0 . 0 0 0.0 0 0.0 0 o. 0 0 o. 0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0 . 0 0 0.0 0 0 . 0 0 o.o 0 0.0 0 0.0 0 o.o 0 o.o 0 0.0 0 100 . 0 0 100 .0 0 o. o 0 o. o 0 0 . 0 0 0.0 0 0.0 0 0 .0 0 0.0 0 o.o 0 o.o 0 0.0 2 I 00 . 0 0 o. o 0 o.o 0 0 . 0 0 o.o 0 0 . 0 0 0 . 0 0 o. 0 0 0 .0 0 0.0 2 100.0 0 100.0 Total 14 385 5';10 42 0 122 47 I 156 637 I \1\14 4 73 304 II 2 24 2 0 I 108 52\1 3 5 363 3'1 5 102 5 0 0 1 523 o. 71, I ';I. 3 2';1 . 6 2 . 1 0 . 0 6. I 2.4 0. 1 7. 8 3 I. 9 100.0 0.8 13. 8 57 . 5 2. I 0.4 4. 5 0.4 o. o 0.2 20.4 100.0 O.b 1. 0 69.4 7. 5 1.0 I ';I . 5 1.0 0.0 o.o 0 . 2 100.0 ► ::, ::, (1> )< ...... ...... ..... 0-- CX> Table 57 (contd) Source CENTRE = 8 Blank 1 GP 2 Hospital admission 3 Hospital discharge record 4 ECG record 5 De ath certificate I, Autopsy reco rd 7 Social insurance record 8 Medicolegal authority 9 Other Tetal CENTRE = 9 Blank I GP 2 Hospital admission 3 Hospital discharge record 4 ECG record 5 Death certificate I, Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Other Total CENTRE = 10 Blank I GP 2 Hospital admission 3 Hospital discharg e record 4 ECG record 5 Death certificate I, Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Other Total Definite 0 0 . Oo/, 2 o. 2 504 57. 5 54 6. 2 0 o.o 267 30 . 5 I O. I 48 5. 5 0 o.o 0 0.0 876 100.0 2 o. 5 38 9. 0 235 55.4 8 I. ':I 2 0. 5 61 14. 4 10 2.4 0 o.o 1,1, I 5. I, 2 o. 5 424 100. 0 0 0.0 32 6. 7 3':18 83.8 31 6. 5 0 0.0 7 I. 5 I, I. 3 0 0.0 0 0.0 I 0.2 475 100. 0 Diagnosis Possible None 0 O. O'!o 0 0. Oo/, I 0 .3 0 o.o 100 27. 7 67 65. 7 27 7. 5 15 14. 7 0 o.o 0 0.0 220 60. ':I 11 10.8 0 0.0 0 0.0 13 3. I, 9 l!.8 0 o.o 0 o.o 0 o.o 0 o.o 361 100. 0 102 100.0 0 o. 0 0 0.0 14 13. 3 21 21. 9 5':I 56. 2 61 63.5 0 o.o I 1.0 0 o.o I 1.0 26 24. 8 10 10.4 2 l.':1 0 o.o 0 o. 0 0 o.o 2 I. ':I I I. 0 2 I. ':I I I. 0 105 100.0 ':lb 100.0 0 o.o 0 0.0 46 2 7. 5 3 2. ':I 40 24.0 ':14 8':I. 5 4 2. 4 0 o.o 0 o.o 0 o.o 75 44. ':I 2 I. 9 I 0.6 I, 5. 7 0 o.o 0 0.0 0 0.0 0 0 .0 I O.b 0 o.o 167 100. 0 105 100.0 Blank Insufficient data 0 0. Oo/, 0 O. Oo/, 0 o. 0 0 o. 0 0 o.o 0 o.o 0 o.o 0 o.o 0 o.o 0 0.0 0 o.o 0 o.o 0 o.o 0 o.o I 100.0 0 o.o 0 o.o 0 0.0 0 o.o 0 o. 0 1 100. 0 0 100.0 0 o.o 0 o.o 0 0.0 0 o. 0 0 o. 0 0 o. 0 0 o. 0 0 o. 0 0 0. 0 0 o. 0 0 o.o 0 o. 0 0 o.o 0 o. 0 0 o. 0 0 o. 0 0 0.0 0 o. 0 0 o.o 0 o. 0 0 100.0 0 100.0 0 o.o 0 o.o 0 o.o 0 o.o 0 o. 0 0 0.0 0 o.o 0 o.o 0 o. 0 0 o. 0 I 100.0 0 o. 0 0 o.o 0 o. 0 0 o.o 0 o. 0 0 o.o 0 o.o 0 o.o 0 o. 0 1 100. 0 0 100. 0 Total 0 O. Oo/, 3 0.2 671 50. I 96 7 . 2 0 o.o 498 37. 2 I o. 1 71 5.3 0 o.o 0 o.o I 340 100.0 2 0.3 73 11. 7 355 56. 8 9 I. 4 3 o. 5 97 I 5. 5 12 1. 9 0 o.o 6':I 11.0 5 o. 8 625 100.0 0 o.o 81 10. 8 532 71. 1 35 4. 7 0 o.o 85 11. 4 13 I. 7 0 o.o 0 o.o 2 0.3 748 100.0 ► :::, :::, CD >< ...... ...... ..... 0-- '° Table 57 (contd) Source CENTRE = 11 Blank 1 GP 2 Hospital admission 3 Hospital discharge record 4 ECG record 5 Death certificate 6 Autopsy record 7 Soc ial insurance record 8 Medicol egal authority 9 Other Total CENTRE = 12 Blank I GP 2 Hospital admission 3 Hospital discharge record 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Other Total CENTRE = 13 Blank 1 GP 2 Hospital admis s ion 3 Hospital discharge record 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Other Total Definite 0 O. Oo/, 1 0.4 250 89.0 0 o. 0 7 2. 5 10 3.6 13 4.6 0 0 . 0 0 0.0 0 o. 0 281 100. 0 12 I. 5 14 I. 8 432 55. 5 7 0 . ';I 8 I. 0 25 3. 2 4 0 . 5 0 o. 0 40 5. I 236 30. 3 778 100.0 3 I. 6 7 3. 7 81 43. I 0 0.0 3 I. 6 3 I. 6 0 o.o 0 0.0 4 2. I 87 46.3 188 100.0 Diagnosis Possible None 0 O. Oo/, 0 0. 0% I I. 2 0 o.o 72 86.7 66 ';18. 5 0 0.0 0 o.o I I. 2 I I. 5 8 ';I. 6 0 0 . 0 I I. 2 0 0.0 0 0.0 0 o.u 0 0.0 0 0.0 0 o.o 0 o . o 83 100.0 b7 100.0 3 o. ';I 2 0 . 3 7 2. 2 15 I. ';I I 31 41. 5 534 67.3 I o. 3 2 0 . 3 I o. 3 0 0.0 ';13 29.4 6 0.11 0 o. 0 0 0 . 0 0 0 . 0 0 0 . 0 10 3. 2 2 U. l 70 22 . 2 Z33 2';1 . 3 31b 100.0 7';14 100 .u I I. I 3 2. I 7 H.O 11 7 . 6 32 3b.4 7 1 -1'.l. 0 0 0 . 0 0 0 . 0 0 0. 0 2 I. -l 17 I ';I. 3 0 o. 0 0 0. 0 0 0 . 0 0 o.o 0 0 . 0 I I. I 2 1.4 30 34. I 56 38 . 6 88 100.0 145 I 00. 0 Blank Insufficient data 0 O. Oo/o 0 0. Oo/, 0 o.o 0 o.o 0 0.0 I 100.0 0 o.o 0 o. 0 0 o. 0 0 0.0 0 o.o 0 o.o 0 0.0 0 0. 0 0 o. 0 0 0 . 0 0 o.o 0 o. 0 0 0.0 0 0.0 0 100.0 I I 00. 0 0 o. 0 0 0. 0 0 o.o 0 o . o 0 o.o 0 o.o 0 0.0 0 0.0 0 o.o 0 0 . 0 0 0.0 0 0 . 0 0 0.0 0 o . 0 0 0. 0 0 o. 0 I 100.0 0 o . 0 0 o. 0 0 o.o I 100. 0 0 100. 0 0 o.o 0 0.0 0 o.o 0 0 . 0 0 o.o 0 o.o 0 o.o 0 o.o 0 o.o 0 o . o 0 o. 0 0 o.o 0 0. 0 0 o. 0 0 o. 0 0 o.o 0 0.0 0 o.o 0 o. 0 0 0 . 0 0 100.0 0 I 00. 0 Total 0 0. Oo/, 2 o. 5 38';1 90.0 0 o.o 9 2. 1 18 4.2 14 3. 2 0 0 .0 0 o.o 0 o.o 432 100.0 17 0.9 36 I. 9 1097 58. 1 10 o. 5 ';I 0 . 5 124 6.6 4 0.2 0 0.0 53 2.8 53';1 28. 5 I 889 100.0 7 I. 7 25 5. 9 184 43 . 7 0 o.o 5 I. 2 20 4 . 8 0 0 . 0 0 o.o 7 I. 7 173 41. 1 421 100.0 ....... ....... ..... -..J 0 Table 57 (contd) Source CENTRE = 14 Blank 1 GP 2 Hospital admission 3 Hospital discharge record 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Other Total CENTRE = 15 Blank 1 GP 2 Hospital admission 3 Hospital discharge record 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Other Total CENTRE = 17 Blank I GP 2 Hospital admission 3 Hospital discharge record 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Other Total Definite 5 4. 3 o/. 0 o. 0 58 50.4 22 19. I 4 3. 5 0 o.o 3 2.6 0 0.0 23 20.0 0 0.0 115 100.0 0 0.0 2 I. 0 136 70. 5 5 2. 6 I o. 5 3 I. 6 26 13, 5 0 0.0 3 I. 6 17 8. 8 1':/3 100.0 0 0,0 0 o.o 38 77,6 3 6. I 2 4. I 5 IO. 2 0 o.o 0 o.o 0 0,0 I z.o 4':/ 100.0 Diagnosis Possible None I 2. 2% 0 0. Oo/, 0 0.0 0 o.o 10 22. 2 ':I 75. 0 4 8.':I I 8. 3 0 0.0 0 0.0 23 51. I 0 o.o 0 o.o 0 o. 0 0 0.0 0 0,0 7 15. 6 2 16. 7 0 o.o 0 0. 0 45 100,0 12 100.0 0 o.o 0 0.0 7 7. I I 2. ':I 21 21. 4 27 79. 4 1 I. 0 0 0,0 0 0.0 0 0,0 13 13. 3 0 o.o 3':I 3':I. I! 0 o.o 0 0. 0 0 0,0 ':I ':I. 2 0 0.0 8 8. 2 b I 7. 6 ':/8 100. 0 34 100. 0 0 o.o 0 o.o 0 o. 0 0 0,0 7 30. 4 20 ':/0. ':I 0 0,0 0 o. 0 2 8. 7 0 o. 0 14 60. ':I I 4. 5 0 o. 0 0 o.o 0 o.o I 4. 5 0 0,0 0 o.o 0 o.o 0 o.o 23 100.0 22 100. 0 Blank Insufficient data 0 0. Oo/, 0 o. 0% 0 o.o 0 o.o 0 o.o 0 o. 0 I 50.0 0 o.o 0 o.o 0 0.0 1 50. 0 0 o.o 0 0.0 0 o.o 0 o.o 0 0,0 0 o. 0 0 o.o 0 0.0 0 0.0 2 100.0 0 100.0 0 o.o 0 0,0 0 o.o 3 25,0 0 o.o 5 41. 7 0 o.o 1 8.3 0 o.o 0 o. 0 0 0,0 3 25.0 0 0.0 0 0.0 0 0.0 0 0,0 0 o.o 0 0.0 0 0,0 0 o. 0 0 100,0 12 100. 0 0 o.o 0 o.o 0 o.o 0 o.o 0 o. 0 0 0.0 0 o. 0 0 o.o 0 o.o 0 o.o 0 0.0 0 o.o 0 0. 0 0 o.o 0 o.o 0 o. 0 0 0,0 0 o.o 0 o. 0 0 0.0 0 100. 0 0 100. 0 Total 6 3. 4% 0 o.o 77 44.3 28 16. 1 4 2,3 24 13,8 3 I. 7 0 0.0 32 18,4 0 o.o 174 100.0 0 0,0 13 3.9 18':/ 56. 1 7 2. 1 I 0.3 19 5.6 65 I 9. 3 0 o.o 12 3.6 31 9.2 337 100.0 0 o.o 0 o.o 65 69, I 3 3. 2 4 4.3 20 21.3 0 o.o I 1. I 0 o.o I I. I ':14 100.0 ► ::, ::, Cl) >< ...... ...... .... -.J .... Table 57 (contd) Source CENTRE = 18 Blank 1 GP 2 Hospital admission 3 Hospital discharge record 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Other Total CENTRE = 30 Blank 1 GP 2 Hospital admission 3 Hospital discharg e rec ord 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Other Total CENTRE = 31 Blank 1 GP 2 Hospital admission 3 Hospital discharge r ec ord 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insurance r ecord 8 Medicolegal authority 9 Other Total Definite 12 7. 6 % 35 22.2 74 46.8 9 5. 7 4 2. 5 12 7. 6 2 I. 3 0 0 . 0 10 6.3 0 o. 0 158 100. 0 0 o.o 64 8.9 439 61. 3 45 6. 3 40 5. 6 12 I. 7 I 0. I I 0. I 114 15. C, 0 0.0 716 100. 0 5 3. I 0 o. o 142 88.2 2 I. 2 0 0.0 8 5.0 3 l. 'J 0 0.0 I 0.6 0 o.o 161 100.0 Diagnosis Possibl e None 5 7. 8 % 0 o. 0% 20 31. 2 11 I 9. 3 20 31. 2 25 43.9 7 10. 9 21 36.!! 0 o.o 0 0.0 10 15. 6 0 0 . 0 0 o. 0 0 o. 0 0 0 . 0 0 0.0 1 I. 6 0 o.o 1 I. b 0 0 . 0 64 100.0 57 100.0 0 0.0 0 o.o 14 !!. 4 l'J I!!. I 36 2 1. 7 73 6'1. 5 6 3 . 6 3 2 . " 2 I. 2 10 " · 5 100 60.2 0 o.o 0 0.0 0 0.0 I 0 . t, 0 o. 0 7 4 . 2 0 0 .0 0 0 . 0 0 o.o 166 100. 0 10 5 100. 0 4 3.6 0 o. o 0 o.o 0 0 . 0 78 69. 6 87 95 . 6 0 o. o 0 o.o 0 o.o 0 0.0 2'1 25. 9 3 3 . 3 0 0.0 0 o.o 0 o.o 0 0.0 0 o. o 0 0.0 I o. " I 1.1 112 100 . 0 'JI 100.0 Blank Insufficient data . 0 0 . 0 % 0 o. 0% 0 o.o 0 o.o 0 o.o 0 o.o 0 0.0 0 o.o 0 o.o 0 0.0 1 100.0 0 o.o 0 0 . 0 0 0 .0 0 0.0 0 o.o 0 o.o 0 0 . 0 0 0 . 0 0 0.0 1 100. 0 0 100.0 0 0 . 0 0 0.0 0 o. o 0 0 .0 0 0 . 0 0 0.0 0 0 . 0 0 o.o 0 o.o 0 o.o 0 o. 0 0 o.o 0 o. o 0 o.o 0 0 . 0 0 0.0 0 o. 0 0 o. 0 0 o.o 0 0.0 0 100.0 0 100.0 0 o.o 0 o. 0 0 o.o 0 o. 0 0 o.o 0 o.o 0 o.o 0 0 . 0 0 0 . 0 0 0 . 0 0 0.0 0 0 .0 0 o. o 0 o.o 0 o. o 0 o. 0 0 o.o 0 o.o 0 o. o 0 o.o 0 100. 0 0 100. 0 Total 17 6. 1 % 66 23.6 119 42. 5 37 13. 2 4 I. 4 23 8.2 2 0 . 7 0 o.o II 3. 9 I 0.4 280 100. 0 0 o.o "7 'I.!! 548 55.5 54 5 . 5 52 5.3 112 11. 3 I 0 . I 2 0 .2 121 12. 3 0 o.o '187 100.0 " 2. 5 0 o.o 307 84.3 2 0. 5 0 o.o 40 11. 0 3 0.8 0 o. o I o. 3 2 o. 5 364 100.0 ► ::, ::, (1) >< H H ...... -.J N Table 57 (contd) Source CENTRE = 50 Blank I GP 2 Hospital admission 3 Hospital discharge re c ord 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insur a nc e r ec ord 8 Medicolegal authority 9 Other Total CENTRE = Total Blank I GP 2 Hospital admission 3 Hospital discharge r ec ord 4 ECG record 5 Death certificate 6 Autopsy record 7 Social insurance record 8 Medicolegal authority 9 Other Total Definite 1 o. 5 "/, 66 33.0 102 51. 0 1 o. 5 3 l, 5 1 o. 5 22 11. 0 0 o. o 3 I, 5 I o. 5 200 100 , 0 6 5 l, 0 437 6. 5 422 0 62.4 2 50 3. 7 98 I. 4 536 7. 9 130 I . 9 53 o. 8 380 5. 6 597 8,8 6766 100. 0 Diagnosi s Po ss ibl e No nf' l 0 . 9 "lo 0 0 . 0 ~ ~ l 7 l 5. 5 19 l 5. 3 3 6 32. 7 100 1!0 ,b 0 0 . 0 0 0.0 1 o. 9 2 1. 6 0 0.0 0 0 . 0 29 26.4 l 0 . 8 0 0. 0 0 0 . 0 24 21. 8 I o. 1l 2 I.!! I 0. !! 11 0 100. 0 124 100 . 0 27 0.9 10 o. 2 2 ';11 10. 0 520 12. 7 950 32. 7 21 20 5 1. 9 60 2. l X2 2.0 14 o. 5 39 l. 0 935 32. 2 1!5 2. l 87 3.0 18 0.4 16 o. 6 24 0 .6 200 6. 9 65 I. 6 324 I I. 2 I 12 0 2 7.4 2904 100. 0 4083 100.0 B lank ln s uff ic i c nt d a t a 0 O. O"/, 0 0. O"/, 0 o.o 0 o. 0 0 o. 0 I 100. 0 0 0 .0 0 o.o 0 o. 0 0 o. 0 0 0.0 0 0.0 0 o.o 0 o. 0 0 o. 0 0 0. 0 0 0 . 0 0 o. o 0 0 . 0 0 0 . 0 0 100. 0 I 100 . 0 0 0 . 0 0 0 .0 0 o.o 3 21. 4 0 0.0 7 50 ,0 1 12. 5 1 7. I 0 0.0 0 o.o 5 62. 5 3 21. 4 0 o. 0 0 o. 0 1 12. 5 0 o.o l 12. 5 0 0.0 0 0.0 0 o. 0 8 100. 0 14 100. 0 Tota l 2 102 239 I 6 I 52 0 28 4 435 102 I 251 7 297 394 I 51 I 564 235 94 646 2 041 13 775 0. 5 "/, 23.4 54.9 0,2 I. 4 0.2 12. 0 0 . 0 6 .4 0 . 9 100 . 0 o. 7 9. I 53. 0 2.9 I. 1 11, 4 I. 7 0. 7 4. 7 14.8 100, 0 ► ::, ::, Cl) >< ...... ...... Annex II 173 .... -.J ,j:,,. Table 58 (I) Male under 45 IA.cute M. lnfar c ti on ~efinite IPo • ■ ible None nauUicie nt dat a Unknown T otal No . o f patients (2) Male 45-54 A.cut e M. Infar c t1 on Defin i te P oaa1ble None nauffic 1ent data Unknown Total iNo. of patient ■ (3) Male 55-64 ~cute M . lnfar c llon !Definite IPo aa ib le IN one Jn 1uffic1en t data !Unknown Total !No. of patie nt s I 79 7 14 0 0 100 28 I 74 9 16 0 0 100 160 I 6 8 15 17 0 0 100 287 2 3 22 36 II 12 67 52 0 0 0 0 100 100 128 66 2 J 27 35 15 15 59 50 0 0 0 0 100 100 256 145 2 3 35 36 23 22 42 42 0 0 0 0 100 100 481 300 DEFINITIVE DIAGNOSIS IN PATIENTS WITH SUSPE CTE D ACUTE MYOCARDIAL INFAR C TION (in percent ages) 4 6 7 8 9 10 II 12 13 14 15 17 18 25 55 82 65 66 6 2 68 40 42 77 64 40 6 4 21 7 8 27 15 16 15 15 16 17 23 40 4 54 38 8 8 19 lZ 18 H 42 7 13 20 31 0 0 I I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100 100 100 100 100 100 100 100 100 100 100 100 100 229 42 72 Ill 74 107 40 241 79 JO 84 5 45 4 6 7 8 9 10 II I 2 13 14 15 17 18 30 59 8 1 68 73 /,7 57 50 45 80 6 1 52 49 26 17 16 24 13 l b l4 15 17 II 29 7 25 44 24 4 8 15 I 6 19 35 38 8 9 41 25 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 100 100 100 100 100 100 100 100 100 100 100 100 100 30 79 6 16 0 0 100 89 JO 78 I 2 9 0 0 100 411 145 11 J JI 6 150 255 109 376 Ill 66 106 27 91 234 4 6 7 8 9 10 II I l I J 14 15 17 18 JO 34 5 3 ,,9 /, 7 66 70 74 4 9 51 73 58 49 1,0 69 29 28 ll 27 18 zo 16 18 ll 19 35 34 28 ll 37 19 8 5 15 II 10 33 26 6 7 17 II 8 0 0 0 0 0 0 0 0 0 l 0 0 I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100 100 100 100 100 100 100 100 100 100 100 100 100 100 790 zoo 254 571 289 398 187 60 4 144 132 159 41 115 420 31 50 51 38 25 79 34 21 14 28 54 7 0 0 0 0 0 0 100 100 100 32 28 14 J I 50 51 43 25 75 38 25 25 19 50 0 0 0 0 0 0 0 100 100 100 86 40 16 J I 50 51 49 32 96 2 9 35 4 22 34 0 0 0 0 I 0 0 100 100 100 166 110 51 52 67 0 33 0 0 100 6 52 6 7 33 0 0 0 100 6 52 56 16 28 0 0 100 25 > :::i :::i Cb >< ...... ...... Total 50 16 34 0 0 100 I 547 T o tal 55 19 27 0 0 100 3 219 Total 55 23 22 0 0 100 5 724 (4) Femole under 45 ~cute M. Infarction I 2 3 4 6 7 8 9 10 IDe!inite 83 4 6 16 13 40 56 69 70 W'o ■■ ible 0 4 12 15 50 40 25 15 5 ~one 17 93 82 69 38 20 19 15 25 ~n ■u{ficient data 0 0 0 0 0 0 0 0 0 lt.Jnknown 0 0 0 0 0 0 0 0 0 Total 100 100 100 100 100 100 100 100 100 No. of patient ■ 6 28 50 H 8 5 16 13 20 (5) Femole 45-54 Acute M. Infarction I 2 3 4 6 7 8 9 10 Defini te 57 13 7 13 48 79 SJ 53 54 Poe1ible 26 7 17 26 ll 14 30 19 16 ;None 17 80 76 61 40 7 17 28 JO -J ln ■ufficient data 0 0 0 0 0 0 0 0 0 \JI Unknown 0 0 0 0 0 0 0 0 0 Total 100 100 100 100 100 100 100 100 100 tNo. of patient ■ 23 87 106 170 58 14 83 32 37 (6) Female 55- 64 ~cute M. ln!arction I 2 3 4 6 7 8 9 10 Definite 6 8 20 14 24 49 70 63 69 6 4 Poa11ble 17 14 19 24 JO Z4 29 1 7 Z I IN one 15 66 67 sz Zl 6 8 14 14 ~n1uUic1ent data 0 0 0 0 0 0 0 0 I Unknown 0 0 0 0 0 0 0 0 0 Toto! 100 100 100 100 100 100 100 100 100 No. of patient, 88 219 184 400 76 66 HJ 95 118 11 12 13 14 15 17 0 21 11 33 33 33 0 10 56 33 33 33 100 69 33 33 33 33 0 0 0 0 0 0 0 0 0 0 0 0 100 100 100 100 100 100 I o I 9 3 6 3 II 12 13 14 15 17 55 29 32 80 67 100 18 I Z 23 13 28 0 27 58 45 7 6 0 0 0 0 0 0 0 0 0 0 0 0 0 100 100 100 100 100 100 ll ZOI 22 IS 18 7 11 12 13 14 15 17 59 JI 4 3 71 66 43 23 20 23 21 24 36 18 49 H 7 10 Z l 0 0 0 0 0 0 0 0 0 0 0 0 100 100 100 100 100 100 73 411 56 4l 58 14 30 31 50 51 63 22 0 100 11 11 33 0 26 6 7 67 0 0 0 0 0 0 0 0 0 100 100 100 100 19 9 6 2 18 30 31 50 50 64 44 18 0 16 ll 15 50 19 34 67 0 0 0 0 0 0 0 0 100 100 100 100 8 67 32 33 18 30 31 50 50 73 41 47 Zl 16 H 19 27 II ZS 33 0 0 0 0 0 0 0 0 100 100 100 100 26 160 6 4 72 52 Total 0 26 0 15 100 59 0 0 0 0 100 100 2 341 51 52 40 0 60 50 0 50 0 0 0 0 100 100 s l 51 52 BJ 14 17 86 0 0 0 0 0 0 100 100 18 7 Total 34 18 48 0 0 100 I 042 T otal 43 22 35 0 0 100 2 500 ► ::, ::, (1) :< ...... ...... .... ....:, 0-- Table 59 000 - 136 140-239 240-279 280-289 290-315 320-389 390-392 393-398 400-404 411 412 413 414 420-429 430-438 440-448 450-458 460-519 520- 577 580-629 630-678 680-709 710-738 740-759 780- 796 800-999 y DEFINITIVE DIAGNOSES IN PATIENTS WITH OUT INFARCTION, SHOWING BREAKDOWN BY SEX, FATAL CASES, ANO PATIENTS RE-REGISTERED LATER. DATA FOR ALL CENTRES COM BINED B y sex Patients Diagnosis All cases Fatal cases re- reg istered male female later Infecti ve and paras ,tic diseases 1% 1% l '7, 0.4 % - % Neoplasms I I 0 . 4 4 - Endoc r ine diseases I I I I - Diseases of blood and blood-forming organs 0. I 0. I - - - Mental disorders 9 8 9 0.4 5 Diseases of the nervous sys t em 2 2 2 I - Active rheumatic fever 0. I 0.2 0. I I - Chroni c rheumatic d i s eases 2 I 2 6 I Hypertensive dise ase 4 4 5 I 2 Other acute and sul>acute is c haemi c heart disease 7 7 6 2 10 Chronic i schaem ic heart disease 25 24 25 4 45 Angina pectoris 11 II 9 0.4 10 Asymptomatic i s chaemic heart di scase I I I - l Other forms of heart diseas e 9 9 8 21 5 Cerebrova scular disease I I I 12 0 .5 Diseases of arteries I I 2 8 0.5 Other d i seases of circulatory s ystem I I 2 8 I Diseases of the r espirato r y system 4 5 3 8 3 Diseases of the digesti ve system 5 5 5 3 3 Diseases of the genito -urinary system I 0.5 I I - Complications of pregnancy, childbirth and the pue rpe rium 0. I - O. I - - Diseases of the skin and subcut aneous tis sue 0 . I O. I - - - Diseases of the musculoskeletal system and connectiv e tissue 7 5 II 0.4 7 Congenital anomalies I I I l - Ill-defined conditions 7 9 5 17 4 Acc idents 0.3 I O. I I - Examination and investigation O. I O. l - - 0.5 All diagnoses . 100 100 100 100 100 Number of patients 4083 2554 1529 266 219 > ::s ::s ~ X H H ...... -J -J Table 60 NUMBER OF PATIENTS IN " AMI NONE " GROUP, ACCORDING TO DEFINITI VE DIAGNOSIS D1a.gno1 i s 1 2 J 4 6 7 8 9 10 11 12 1 J 14 15 000 - 136 Jnfe chve and pa.ra.ait ic diaease a I I s 20 J 6 s - 140-239 Neopla.1m• 2 2 12 4 1 240-279 Endoc rine diaea.aea I 2 1 22 1 1 1 1 10 2 - 280-289 Diaea. ae s o f blood and blood-form 1ng or ga.na 1 1 290 -3 15 Ment a l d 11ordera 1 97 78 54 7 1 1 4 I 2 57 29 1 320-389 Oi aea. aea o f the nervous syatem 2 1 J I 3 8 1 l 1 I 20 2 - 390-392 A ctive rheumati c feve r 1 1 1 I 1 1 393-398 Chr onic rheumati c d11ea.sea 1 10 2 20 ' 1 I I 8 1 l l 1 1 400-404 Hypertenaivc d.iaease l l J JS 62 5 I s J 28 s 1 411 Other a cute and aubacute ucha.em1c heart di1ea.1e - 49 5 14 13 2 38 11 S 10 - 412 Chrome ucha.emic heart dise a s e 6 81 44 J09 7 l6 9 10 7 317 6 9 1 6 413 Angina pectoria 23 51 82 58 8 8 lJ 12 14 25 54 4 4 23 414 A ■ ynlptoma.tic iachaem1c heart du e a.ae 20 4 - - J - 4 I - - - 420-429 Other form s of heart di1ea1e SI 28 JI 52 2J 6 l4 16 17 12 40 6 1 I 430 - 438 Cerebrova.acula.r di1ease 19 9 17 1 3 I I J - I 440-448 Oi1ea.ae1 of arteries I I 2 7 14 2 I s I 11 1 450 -45 8 Other duea.1e1 of c1 rcula.tory system - 12 JO J 2 2 - 1 4 1 I 460-519 Dueaaea of the reapir.itor y system I • J& IS S& IS 3 J 6 2 I 14 I 520-577 D11e a 1e• of the digestive ay1tem 1 46 IJ 68 II 1 1 8 s s 27 1 580-629 Di1ease1 of the gen1to-urinary system - l I J I - s 1 630- 6 78 Comph c ahon • of pr egnancy, c hildb irth and the pue rpc r ,um 2 - - - - - 680-709 Di 1ea1e1 of the ak in and subcuta.neou, tu1 ue 3 - - - - - - - 71 0-738 Di1ea1e1 of the mu1culo1keletal ayatem and conne c tive ti11ue I 9l I 20 JS 2 2 2 - 43 - - - 740-759 Congeniu.l anomahe1 I I 23 J - 1 . 780-796 lll-de£1ned cond i t ion ■ J 79 s 31 I 9 14 8 10 8 J 25 1 J J 800-999 ALLi.dcnU s 2 l I I I - y Ex.a.minat,on and inve 1t i gation - J - All dia gno1ea 99 672 462 927 I J 1 38 102 96 105 67 794 145 12 34 17 18 JO J 1 3 1 1 1 1 8 6 1 10 - - 2 - - 2 2 - 4 31 I 3 2 7 12 10 7 15 13 - - - - 8 3 12 10 - - - I - - - - 1 1 - 4 2 1 1 6 - - - - - - - 2 - - 1 2 24 21 12 - 2 - - - 22 57 105 91 so I - - - 2 1 3 7 1 8 - 7 4 s 1 - - - 20 1 124 All ce ntre a 45 23 43 3 350 64 5 67 177 281 1006 432 32 348 55 46 6 1 167 205 22 2 3 299 JO 300 14 3 4083 ► ::, ::, (1) >< H H Tabl e bl {I) "AMI none" ...... ..._.J C1J Time e l apsed Under 30 min 30- 59 min b0-89 min 90 -119 min 2 hours 3 hours 4 hours 5 hour a b hours 7 hours 8 hours 9 hours 1 0 hours l lhou rs 12-17 hours 18-23 ho u r s I day 2 days 3 day s t Total No . with information No . without information I 5 8 13 10 13 1 5 2 5 3 5 0 0 2 1 3 8 3 2 100 61 J& 2 18 13 I 0 4 8 b b 3 2 2 2 3 I I 5 4 5 2 4 100 556 18 TIME ELAPSED BET WEEN ONSET OF AT TACK AND CALL TO DOCTOR 111OSPITAL. BY DIAGNOSIS AND HISTORY OF MYOCARD IAL INF .\RCTION (in pe rc e ntages ) 3 4 b 1 8 y 10 II 12 I J I 4 I 5 17 18 30 3 1 13 lb 21 48 20 21 41 II I H 21 31 l4 0 12 18 20 II l b IY 3 H 8 IY I J i 15 19 IY II 0 2 4 y 24 1 12 1 17 I 5 s 5 I y 9 5 I J 8 25 14 I 0 10 2 5 2 0 J 1 4 b I 5 8 0 5 5 0 b I 5 b 13 0 14 15 b 8 8 8 IJ 8 15 1 I J 3 J 4 5 0 4 5 4 5 I 4 3 b 8 10 2 5 2 J 3 5 J I 0 8 I I 2 5 b 0 5 5 2 I I 0 2 3 0 1 I I 5 4 1 0 0 I 0 I 2 I 2 2 2 0 0 I 3 I 2 2 b b 3 5 5 I 0 4 2 2 0 I I o I 2 J 0 0 3 0 i 5 I I 2 2 l J I I I 2 J I I b 0 0 0 5 0 2 2 I 0 I I J I 2 I o 0 5 5 0 2 2 2 I 0 o I J 2 J I l u 5 0 I 0 2 2 2 I 3 I l I I I l I I 0 0 0 0 2 I b 5 5 I o I 1 l I ll l 5 0 3 10 I H b II y 2 2 0 " J l I " l 4 0 J 0 I 5 2 7 14 4 8 0 4 1 4 J l I 0 5 5 5 7 4 b 2 2 3 5 I I l I J I 4 0 0 5 I 0 J 3 y 4 I 7 J I I ! l I I 0 6 5 0 2 5 3 I I 00 100 1 no 1 Oo I oo I Ofl I 1 111, J rt11 I l Oil l Of) 100 100 100 100 I 00 100 4 32 SH l it) 2Y 14 n llH bl 77 0 Ill 16 38 20 42 87 89 IY 27 2J s lb I H y ; I! ll l 3 I 20 I y 5 (2) AMI without h u tory of Ml Unde r 30 min 7 30 28 I JS 25 41 lb l 18 4 1 I 2 4 I H I JI I 28 26 25 I 2 5 21 27 30- 59 min y I 0 14 I 6 18 II 16 17 IJ y IS 18 IS I J 5 17 I b 16 60- 89 min 12 b 1 I y I 0 5 y 10 7 ' 111 I ~ 5 II IU ; I IJ 10 13 90-119 min 10 2 4 4 5 J b 5 5 ; ' 4 b 1 3 4 7 3 2 hours 13 b 4 5 1 7 10 12 5 y 7 I 8 I 4 b J i 7 1 b 3 hours 8 4 2 J 5 I 4 4 l J & 4 H 4 b 8 b 5 9 4 hours b 3 3 2 J J 4 J 4 4 l 4 l 4 13 I 2 3 3 5 hours 2 4 2 2 2 2 4 5 l J I J 4 J J I 0 I 4 l I b hours l l I I 2 l I l l J l I 2 4 I l l J 4 J 2 7 hours 3 l 2 I I 2 2 2 2 4 I 0 4 2 0 2 2 I 8 hours I I 2 " I 2 I 2 2 J I I ! 5 2 5 I I I 3 9 ho u rs 2 I 2 I 2 I I I I 2 I I I I 3 0 3 2 10 hours 3 3 I I 0 2 2 I I I I 0 I 2 0 I 0 0 I 11 hours 0 2 I I 2 I I 2 I 2 0 0 0 2 3 I I I 12 - 17 ho urs 8 b 1 J 5 4 4 b 4 b J 4 4 4 8 2 5 3 18 -2 3 hours I 4 3 2 3 2 2 2 2 4 2 4 3 2 0 I 3 4 3 1 day 4 b 8 5 4 s 3 b J 4 2 3 I 3 I 0 4 4 5 2 days 3 5 4 2 2 0 I 2 I 2 2 I 2 2 5 I I I 3 days +- l 5 5 4 0 5 3 2 l 4 2 I 4 3 5 6 4 I Tota.I I 00 100 100 100 I 00 I 00 100 100 100 100 I 00 I 00 I 00 100 I 00 100 I 00 100 No. with informat ion 297 306 230 789 2 50 302 671 3UY 558 I Y7 716 160 123 2 38 4 0 104 44 1 144 No. wi thout information 13 14 II 2 l ZY 24 75 J2 2 4 23 40 27 I 5 49 4 51 58 y 50 51 IY 0 8 100 11 0 1 1 0 8 0 3 0 3 0 b 0 b 0 0 0 0 0 0 0 3 0 6 0 0 0 8 0 8 0 0 0 0 0 I 00 100 J& I 82 0 20 16 II 16 8 13 8 2 5 10 4 5 I 4 b I I I 3 4 I 3 0 I I I ! 3 5 I I 0 I 7 5 3 I 5 7 3 2 9 2 100 100 74 82 y 5 52 0 0 50 0 0 0 0 0 0 0 0 0 0 0 50 0 0 0 0 I 00 2 9 50 9 5 0 0 9 0 0 5 5 5 0 0 5 5 0 5 0 0 I 00 22 5 T o ta l 24 15 10 4 8 4 4 3 2 2 2 2 I I 5 3 5 3 4 I 00 3 56b 361 30 14 y 5 7 4 3 3 l 2 2 I I I 5 2 4 l 3 I 00 b 053 54 0 ► ::s ::s (I) >< H H ..... --J "' ( ,) AMI w i th hiatory of Ml Tim e e lapsed 1 l Under 30 min 15 34 30- 59 min 8 10 60-8~ min 14 5 90-119 min 9 3 Z. hours 14 b 3 hours 10 5 4 hours 5 J 5 hours l l 6 hours l 2 7 hou rs J 2 8 hours J 1 9 hour• 0 1 l O hours 1 I 11 hours J I l l- 17 hou rs J 1 0 18 -23 hours l 4 1 day 5 4 2 day 2 I 3 d ays + 1 5 Total 100 100 No. with informat ion 111 158 No. withou t inform ation 10 4 3 4 19 JR 14 14 8 10 1 5 5 9 I 1 4 8 l I 3 l 1 0 I 5 0 I J I I 4 0 I I 0 1 I 4 4 4 I I 10 4 4 1 5 l 100 100 79 lll 5 5 b 7 8 9 10 31 53 29 l4 49 ll 14 l b 21 l l 7 l II 11 b 7 5 5 8 3 II 4 : 11 I b b b I l 5 5 b 8 I l I 4 : J J 5 l 2 J 2 0 I 1 ! l ! 1 I 0 I 2 I 2 ! 2 2 I 0 2 i I J I 0 0 0 I 0 I I 0 1 I I I I I l 2 4 b 5 J l 1 0 I l l I I I l J 2 1 1 0 I 0 2 l I 1 l 1 00 100 100 I 00 100 83 ll4 Jbb 175 189 19 8 57 l l 14 11 l l 1 3 14 15 17 I 18 34 I 4l l5 35 l 9 0 ! 23 18 14 Z5 19 lb Jb ! lO II I u l I I 14 II 0 7 3 l I l 0 4 7 3 1 O 7 4 I l 9 I 14 I 17 l I 4 l ' 5 l 7 0 4 J 0 2 9 7 7 2 l ' l I 0 9 0 3 J 2 I l I 2 0 7 J I I 0 0 4 0 0 2 I I b l 0 I 0 u 0 I l 4 l 2 I 0 J I : I) I 0 I 0 0 ' 0 7 I 2 u I 0 0 I 0 0 J I l 4 7 0 0 0 I I I 0 ! 5 0 ' 14 0 3 4 2 5 l 0 7 1 I 0 2 0 2 7 0 1 l 0 0 l 0 I 0 I 100 I 00 100 I 00 100 I 100 I 100 l Z 5 lbO 5l 43 55 14 : JO 14 14 19 12 11 o I 17 30 3 1 50 l9 I 3 I l9 I lZ 1 5 8 7 10 1 3 I b I 4 ! 11 9 8 I 9 l I 8 I I 4 2 0 3 l I 0 2 3 0 l 2 0 l 4 i 4 0 l 0 2 I I 0 I I 1 I 4 J 4 8 I 4 0 l 7 1 3 2 1 0 2 I 0 0 I 1 oo 100 I 00 I I Z lb 1 oz Z4 JS 14 b 51 5Z 25 0 0 33 0 33 0 0 1 3 33 Z5 ' 0 0 I 0 0 I 0 0 I 0 0 I 0 0 I 0 0 0 13 0 0 0 0 0 1 3 0 1 3 0 0 0 0 0 I 00 100 8 J l l Tota l 33 15 9 4 9 5 4 l 2 I l i l 1 1 1 4 2 4 1 l 100 Z 4 50 Z9Z > 5 (1) >< H H -00 0 Table 62 A . Ho ■ pital ward o nly Time e laps e d Unde r 30 min 30 -59 min 60 -1 19 min 2 - J hour• 4 - 23 hour ■ 1 day + Total M edian time (m in) No. with inform ation No. wi thout inform ation TIME ELAPSED BETWEEN ONSET OF ATTACK AND ARRIVAL IN HOSPITAL - COMPARISON BETWEEN PATIENTS TREATED IN HOSPITAL WARD ONLY AND THOSE TR EATED IN CORONARY CARE UNI T (in per c entages) Centr es I 2 J 4 6 1 8 9 10 II I l I J 14 15 17 18 30 J 4 I 1 9 8 ll ; II 11 l l 5 14 4 1 5 12 6 9 2 0 4 4 l 9 11 8 4 0 6 J 5 6 3 ll 10 13 14 5 9 18 l J 17 10 16 0 25 11 5 10 17 22 14 1 24 25 14 19 18 ll 20 21 0 14 25 27 23 16 31 34 23 29 J] 21 29 J3 27 34 35 57 35 3l 32 zz 33 12 35 54 22 2 4 46 12 l I IJ I 16 20 29 16 21 26 27 25 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 180 7 JO >1000 250 310 ·1000 165 295 I 75 l 10 240 720 240 320 270 215 310 198 Ill 1l 610 56 16 4 61 I I 95 41 50 6 15 1 52 95 19 52 15 2 II 14 0 25 14 l I 62 17 I l 6 l8 8 I 7 ll 1 l8 24 B . CCU {wi th or without stay 1n h ospi ta l) Under 30 min 5 0 1 6 Ii I 9 6 9 J 14 4 I ~ I 18 4 1 0 3 30-59 min 11 I 0 I 10 l b 1 8 13 b 0 l 11 4 5 60 - 119 min 26 16 Il 15 IJ lb 16 ll l I 17 ll 18 lO 18 ll 15 Z -3 h ou r ■ 25 14 ll 25 ll I l I lO 20 lO 15 l1 ll I 18 ll 11 ll 30 4-23 hour • ZS 43 12 28 40 JO Z6 J J 36 27 Jl 28 H 36 42 26 3l l day + 9 26 4 3 25 12 I I 7 6 15 10 10 15 6 I 12 15 II 26 14 i Total 100 100 100 100 100 100 100 100 100 100 100 100 I 100 100 100 100 100 Median time {min) 150 480 > 1000 271 240 220 120 20 4 180 I JO 2 10 135 180 270 240 285 215 No. with informat ion 173 230 104 85 211 181 199 I 18 40 l 20 8 226 170 17 90 28 71 42 6 No . wi thout 3 J 4 0 IJ 8 9 4 12 10 8 29 J I I 21 lb information 31 50 J 4 8 4 19 8 19 17 ]] 43 18 25 100 100 240 360 208 I 36 ll 1 7 ll l 22 5 22 16 1 1 18 22 30 0 29 100 100 90 480 9 6 1 0 I Total 1 6 15 19 3l 21 100 250 3480 329 5 8 18 ll 3l 15 100 210 JO 30 166 ► ::s ::s (1) >< ...... ...... ...... (X) ...... Table 63 A. Male ■ Tim e elap•ed Under 30 min 30-S9 min 60 -1 19 min Z-3 hours 4 - Z3 hour• 1 day + Total No. with information No. wi thout information B . Female a Under 30 min 30-S9 min 60- 119 min Z-3 hour ■ 4-Zl hour• l day ♦ Total No. with information No. without information I Z6 I 1 5 Z4 43 100 l0Z 11 10 0 0 0 47 4J JOO JO 8 TIME ELAPSED BETWEEN ONSET OF ATTACK AND DEATH, EX C LUDING PATIENTS IN "AMI NONE" GROUP (in perc entage a) Centre s z 3 4 6 1 8 9 10 II l Z I 3 14 15 17 18 43 Z1 47 zo 39 38 J7 47 39 ZJ 19 14 41 50 z 6 IZ 8 1 6 4 4 5 8 9 10 0 IZ 5 z 4 4 4 1 5 4 6 J 8 1 lZ 5 II 0 1 J 4 6 3 5 4 6 5 • J 6 5 8 0 5 JO 14 9 ZS 11 II I 5 IZ 9 18 19 41 14 15 39 J4 40 Z6 38 J4 38 JZ Z6 JI 39 35 36 IJ JO 46 100 100 JOO JOO JOO 100 100 100 100 100 100 100 100 100 100 30 ZS 6 4 4 I Z 49 100 168 109 HZ 110 I 30 409 140 186 99 Z46 sz ll 83 zo 59 248 1 15 8 6 9 &5 JO 6 ll J J 1 ZJ zo I 16 4Z 4Z IZ 50 16 38 JS 57 47 19 11 6 0 zz ll 10 Zl 8 l Z 5 6 1 I 5 9 J 8 19 0 17 11 0 J 4 8 6 6 J 4 0 1 J l 19 0 6 0 0 1 0 8 6 J J l 9 1 J 9 0 II 6 0 0 1 0 8 9 6 14 14 9 9 ZS 11 19 zz JI II zo II 46 54 ZS 63 J4 44 zo Z l 47 sz 38 67 39 56 • 10 56 JOO 100 100 100 100 JOO 100 JOO 100 100 100 100 100 100 100 100 Z6 Z6 124 JZ 29 94 44 4l JZ 88 16 9 18 9 JO 71 I 5 0 8 z 14 11 l J 11 z 4 4 0 J 18 31 50 JS ZS 9 0 5 3 9 6 5 33 37 33 JOO JOO 43 36 1 JJ ZS 6 5 0 5 6 0 6 15 JS 50 47 100 JOO zo 17 I Z4 Total J4 6 5 5 14 JS 100 2604 355 JO 5 5 4 14 4Z 100 738 lZ I ..... ..... ..... ex, N Fig . 36 PROPORTION OF PATIENTS IN RELATION TO EVENTS DURING 24 HOURS ELAPSED SINCE ONSET OF ATTACK C a ll to doctor I st med, exam. Hospitalization 1 OO % C entre 90 80 70 60 50 40 30 20 10 0 / ~ I I 2 4 ,--- 8 ,ooo'VV' '>f'>IYVV' v,W De a th % 0 -- I 0 20 24 hrs Time elapsed since onset 100 90 80 70 % Centr e 2 % 0 10 20 60 +-+-+--+---+--------~ 50 40 +++-+----:::r."'r=----::::;;-,:::_ __ --1 30 20 +."'+-:olf--- +-------, I O o -H---+----1----------, 30 2 4 24 hrs - call dr !s t med. exam. hospitali- zation » death /::: d eath afte r med. exam. JOO % Centre 4 % 0 •••••• : •• ❖ .................... , •• •,•········:;:···:···:·:·:::; 90 I 0 80 70 - 20 30 +-IH---+----tr---- -----,, 40 60 50 40 30 20 10 0 I 2 4 8 24 hrs at 100 / 0 90 80 70 60 50 40 30 20 10 0 Centre 6 I 2 4 II I 0 20 30 l4 hrs 7 6"++-+-+----t-- -------, 10 20 30 100 90 110 70 bO 50 40 30 20 10 0 I 2 4 8 24 hrs % Cen tr e 7 % -~=■=m o 10 20 30 +++-+--t-:=~:""""'--'~---; 40 I 2 4 II 24 hrs ...... ...... ...... (X) (.,-) Fig. 36 (contd) Call to doctor 1st med. exam. Hospitalization 100 % Centre 8 90 80 70 60 50 40 30 20 10 0 10 20 3 0 I 2 4 8 24 hrs Time elapsed since onset 100 % Centre 11 9 O w: • • .... ... •:❖:❖• r:::: % •. : J ~.,.., ::::::t-': •• :: ... :. Q "' ~ "' ~ 8 0 vv "-"-' 70 60 ""'~ v,;,v >O % 50 /- 40 +-1-4--11'-'---+-------~ 30 I 201-<l#-l---+--+----------1 10 0 .._........_ _____ ---------4 0 10 20 30 1 2 4 8 24 hrs Centre 9 70 10 20 3 0 60 tt-t-+-- +------=.....,:='"-t 4 0 50 40+-++-¥;.,.:.._....,..-,c::_ _____ --+ 30 20+-IH---+- -+---------; 10 0 -+-+-+--+-- -+----------< I 2 4 8 24 hrs 90 80 70 60tt+-t>----r-----~=_, 50 40-H,H,--+-.,;c..-+---------t 30 20---------------1 10 0-H-+--+---+---------; 10 20 I 2 4 8 24 hrs 80 70 6 0 50 40 30 20 10 0 90 80 70 60 50 40 30 20 10 0 I 2 4 8 Centre 13 I 2 4 8 24 hrs 24 hrs ...... ...... ...... co ~ Fi~ (contd ) C a ll to do c tor l st med . exa m. Hos pita liz a tion Death lOO % Centre 14 % 0 90 8 0 70 60 50 10 111 L--?-r-=: ~---= I 30 20 1n,r1 1 1 10 o ++-+-+---+------l I 0 20 3 0 4 0 50 I 2 4 8 24 hr s T i me el a p se d since o nset 90 m~m~~ ...... _% 0 8 0 nrt-F~"""'&?~l>Q<~lll~ 1 0 70 20 :: m,/r-=--- -~-~_:;;;:::::=:;::d-- 3 0 Centr e 18 4 0 1111 -= 3 0 J.:.---- I ~~ IA YI I I 0 +++-+--+-- -_J I 2 4 8 24 h r s C en tr e 1 5 % o I 0 90 80 70 ::J 111 :: 50 4 0 I I J?f A----= I 60 70 HO 30~~, ::M I I " ::~o I 2 4 H I 00 % Cen tr e 30 90 80 70 ,,..0 b O I I I I I =-=-- -=-=-i 50 40 IIVVI I 30 20 l~Y I I I I 0 0 -fL+-+---+--+-------l 0 I 0 20 30 I 2 4 8 24 h r s 100 90 80 70 ~ bO +--<-+--+--+----------+ 50 4 0 1 11 I 7 ~ I 30 20 I~¥ I I I 0 I 0 20 30 40 50 6 0 7 0 8 0 t 90 1 ~~1 I I 24 ~~s0 I 2 4 8 100% Ce n t re 31 90 "'• 0 10 20 30 80 tt+-+---+-- - - --- - -+ 70 60 111 J:-<-'f =...----------= I 50 4 0 I Vif A' I I 3 0 20 11,t/1 I I I 10 o_-+---+- -----i I 2 4 8 24 h r s ► :::1 :::1 (b >< 1---< ...... ..... (X) l11 Fi~ (contd) Call to doctor 1st med. exam. Hospitalization Death 100 % Centre 50 Y: 0 90 80 70 ·=~=~=· 60 1111 I ~1 50 40 11 l/i,, • J:-.-------== I 30 20 IA1l7i I I 10 0 --.--~----~ Time elapsed since onset 10 20 30 % All centres combined % 0 100 f~~, .. i·i~~i·.~·i····1··1NiNl ..... !·~-;«;»~;·~~i»~~❖i~ri:ri~ri~r;~~i= 90 10 80 20 70 ~ 30 60 ---=-' ------- -- 50 40 11 i.~171 I 30 20 lhl I I I 10 0 -S.-.-+--+---6---------__. 1 2 4 8 24 hrs ► ::, ::, (1) >< ..... ..... Table 64 Place of death I 2 Work 3 3 Home 41 38 Hospital 36 38 Other 20 22 Unknown I 0 Total 100 100 Number of patients 157 218 -a:, 0-- Table 65 I 2 Witnessed 70 81 Not witnessed 29 18 Unknown I I Total 100 100 Number of patients 101 136 3 6 6 1 21 12 0 100 161 PLACE OF DEATH, EXCLUDING PATIENTS IN "AMI NONE" GROUP (in percentages) 4 6 7 8 9 10 II 12 13 14 15 17 3 4 2 2 7 3 4 4 4 4 7 7 53 47 41 27 41 45 24 35 33 32 52 53 32 42 50 46 38 35 57 55 54 41 22 33 10 7 8 24 13 15 16 5 6 17 20 7 I 0 0 0 I 2 0 2 4 6 0 0 18 3 40 48 9 0 100 100 100 100 100 100 100 100 100 100 100 100 100 509 163 183 60 I 259 282 161 383 80 105 168 30 88 WITNESSED AND UNWITNESSED DEATHS OCCURRING OUTSIDE HOSPITAL, EXCLUDING PATIENTS IN "AMI NONE" GROUP (1 n percentages) 3 4 6 7 8 9 JO II 12 13 14 15 17 18 78 80 6 3 75 48 45 78 53 64 70 37 77 60 70 20 18 31 10 34 46 16 41 21 5 24 21 40 9 2 7 6 15 20 9 6 6 15 24 39 2 0 22 JOO 100 100 100 100 100 100 100 100 100 100 100 100 100 127 344 94 92 322 160 182 70 174 37 62 131 20 46 30 31 50 3 6 0 45 26 40 33 54 48 18 7 12 0 7 0 100 100 100 380 85 83 30 31 50 63 77 19 26 8 7 II 15 74 100 100 100 253 39 43 51 52 0 0 32 36 57 36 II 0 0 27 100 100 28 11 5 1 52 33 43 25 0 42 57 100 100 12 7 ► ::l ::l ~ >< ,_. ,_. Total 4 40 41 14 l 100 4135 Total 65 23 12 100 2452 Table 66 Centre 1 2 3 4 6 7 8 9 10 11 12 13 14 15 17 18 31 All centres except 30 COMPARISON OF "HIGH" AND "LOW" PERIODS OF DAILY INCIDENCE Mean daily incidences In the "high" In the "low" In the rest season season of year 12 Feb. - 3 June 2 July - 21 Oct. 1971 1. 7 5 1. 10 1. 13 0.61 0.46 0.68 0.65 0.29 0.39 1. 79 1.34 1. 74 0.60 0.35 0 . 50 0.68 0.57 0 . 62 3.38 3. 17 3 . 18 0.83 0.62 0 . 71 0.97 o. 79 0 . 85 o. 7 3 0.84 0 . 67 2. 15 1. 41 1. 65 ,0. 45 0.44 o. 57 0.33 0.26 o. 35 0.68 0.40 0.61 0.23 0.21 0. 16 0.64 0.49 0.65 0.88 0.63 o. 7 4 17.36 13.35 15.21 187 Annex II Overall daily mean 1. 31 0.59 0.44 1. 63 0.48 0.62 3. 24 0.72 0.87 o. 74 1. 7 3 0.49 0.32 0.57 o. 20 0. 60 o. 7 5 15.30 Annex II Fig. 37 FREQUENCY DISTRIBUTION OF TIME OF ONSET OF ATTACK, EXCLUDING CASES IN "AMI NONE" GROUP 19 18 17 15 19 18 17 23 0 l ot~enbur 2 13 12 11 23 0 1 2? I I / ,2 3. Buch are st 5 6 7 9 5 6 7 19 5 18----'{""~~~==:~--6 17 7 13 12 11 188 19 18 17 21 19 18 17 2 23 0 l 22 I I 2 3 13 12 1 1 23 0 l 22 I / 2 6. Dublin/ 3 . / // 23 0 1 22 I i / 2 7'. Hei eloer 4 5 6 7 5 6 7 5 !l---;i::.~jjg:~-- 6 7 1~ 11 Annex II t~ig. 37 (contd) 0 I 23 0 I I I 2 22 \ I J 2 21 ' 11. Tam ere' 3 I/ 4 5 5 Ill 6 18 6 17 7 17 7 16 8 15 ' 13 I 1 10 12 13 1 1 0 23 0 I I 22 I I 2 22 \ I I 2 I 21 12. W a rsaw 3 / 2 4 5 I 9 5 18 6 18 6 17 7 17 7 13 12 11 0 t1 , 2 2 I Lublin 3 / I 9 5 / 5 18 6 18 6 17 7 17 7 13 12 11 12 11 189 Annex II F i g . 37 (c ontd ) 13 22 21 20 19 18 17 15 13 12 11 0 I 12 I I 2 4 5 6 7 6 7 5 6 7 190 19 5 18, ___ +:;jii§:=z:.:~-- b 18 13 12 11 22 2 5 8----t-=~~f--- 6 7 11 0 I 5 b 17 ·, 8 13 12 11 Fig. 37 (contd) 0 1 22 I I 2 5 18 6 17 7 21 1 191 Annex II 23 0 22 \ I , 1 2 \ All centres 3 combined 13 11 12 5 6 7 8 Annex II Table 67 PERCENTAGE 1 OF PATIENTS FALLING ILL AT THE PLACE OF WORK, BY TIME OF ONSET OF ATTACK, AGE AND SEX, EXCLUDING CASES IN 11 AMI NONE 11 GROUP Centre 1 Time of onset of attack Sex Age Day-time Night-time Total % % % Under 45 (55. 6) 7.7 27.3 Male 45-54 21. 9 0. 0 11. 7 55-64 20.6 1.5 13. 9 Total 22.6 1. 5 14. 0 Under 45 ( o. 0) (0. 0) ( o. 0) Female 45-54 (22. 2) (0. 0) 15. 4 55-64 6. 1 9. 1 7.3 Total 8.9 7. 1 8.2 Under 45 41.7 6. 7 22.2 Both sexes 45-54 21. 9 o. 0 12. 0 55-64 17.6 3.3 12.4 Total 20. 1 2.4 13.0 Centre 2 Under 45 23.5 0.0 10.8 Male 45-54 20.0 3.8 11. 3 55 -64 14. 8 1. 7 8. 7 Total 16.8 2. 1 9.6 Under 45 ( o. 0) (0. 0) ( o. 0) Female 45-54 (28. 6) (0. 0) 12. 5 55-64 9. 7 o. 0 4. 5 Total 12.8 0.0 5. 9 Under 45 22.2 o. 0 10.0 Both sexes 45-54 21. 2 3.3 11. 5 55-64 13. 9 1. 3 7.8 Total 16. 1 I. 7 8. 9 1 p t Onset at place of work 100 ercen age = Onset at all places x Note: Percentages in brackets are based on a denominator of less than 10. 192 Annex II Table 67 (contd) Centre 3 Time of onset of a ttac k Sex Age Day-time Night-time Total % % % Under 45 (33. 3) 16. 7 22.2 Male 45-54 25.0 5.4 13.8 55-64 11. 4 1. 4 6.6 Total 16. 4 4.7 1 o. 2 Under 45 (42. 9) (0. 0) (37. 5) Female 45-54 15.4 o. 0 8. 7 55-64 0.0 o.o 0.0 Total 9.8 0.0 5,7 Under 45 37. 5 15. 8 25. 7 Both sexes 45-54 22.0 4.3 12. 5 55-64 8. 2 1.0 4.8 Total 14. 4 3.7 9. 1 Centre 4 Under 45 25.9 6.8 17.3 Male 45-54 27.6 4.3 1 7. 1 55-64 12. 1 3. 7 8,6 Total 17. 9 4 .3 12. 0 Under 45 7.7 (0. 0 ) 5 .0 Female 45-54 20.0 6.2 16. 4 55-64 2.8 1.4 2.3 Total 7.9 2. 2 5. 9 Under 45 22.4 5.9 15.3 Both sexes 45-54 25. 5 4.5 17.0 55-64 9.4 3. 1 6.8 Total 15.2 3.8 10. 5 193 Annex II Table 67 (contd) Centre 6 Time of onset of attack Sex Age Day-time Night-time Total % % % Under 45 0.0 (22 . 2) 1 O. 0 Male 45-54 39 . 2 6 . 5 23.7 55-64 13. 1 2. 6 7 . 2 Total 22.8 5.3 13. 7 Under 45 ( o. 0) (0. 0) ( o. 0) Fema le 45-54 23 . 1 0.0 9. 7 55-64 7.4 0 . 0 4 . 3 Total 11. 6 o. 0 6.0 Under 45 o. 0 18. 2 8.0 Both sexes 45-54 35.9 4. 7 20.3 55-64 11. 4 2. 1 6. 5 Total 19. 9 4 . 1 11. 8 Centre 7 Under 45 14. 6 13. 6 14. 3 Male 45-54 28 . 8 2. 7 18. 7 55-64 16. 8 1. 1 9.9 Total 1 9. 7 3.4 13 . 0 Under 45 ( o. 0) ( o. 0) ( o. 0) Female 45-54 (14. 3) (0. 0) 10.0 55-64 5 . 9 0 . 0 3. 7 Total 7. 1 o. 0 4 . 5 Under 45 14.3 12. 5 13. 6 Both sexes 45-54 27.3 2. 5 17. 9 55-64 14.3 0.9 8.6 Total 17. 6 2.9 11. 7 194 Annex II Table 67 (contd) Centre 8 Time of onset of attack Sex Age Day-time Night-time Total % % % Under 45 24.3 3.9 12. 5 Male 45-54 25. 2 0.0 12. 6 55-64 14. 8 1. 4 8. 1 Total 19. 1 1. 3 10.1 Under 45 ( o. 0) (20. 0) 9. 1 Female 45-54 17.6 0.0 9.4 55-64 5. 9 o.o 3.0 Total 8.5 0.8 4.8 Under 45 20.9 5. 4 12. 1 Both sexes 45-54 23.6 0.0 12.0 55-64 12. 0 0. 9 6. 5 Total 16.3 1. 1 8.7 Centre 9 Under 45 29.2 3.4 15. 1 Male 45-54 31. 7 7.8 20.7 55-64 22.3 3. 1 13. 5 Total 26.0 4. 5 15. 9 Under 45 ( 14. 3) (0. 0) 10 .0 Female 45-54 (22.2) 6.7 12. 5 55-64 8. 1 3.0 5.7 Total 11. 3 3.9 7. 7 Under 45 25.8 3. 1 14. 3 Both sexes 45-54 30.4 7.6 19.3 55-64 18. 8 3. 1 11. 5 Total 22.9 4.4 14. 1 195 Annex II Table 67 (contd) Centre 10 Time of onset of attack Sex Age Day-time Night-time Total % % % Unde r 45 13.3 0.0 6. 9 Male 45-54 14. 3 6.0 9.9 55-64 16.4 o. 8 9.2 Total 15. 4 2. 5 9.2 Under 45 ( o. 0) (0. 0) o.o Female 45-54 ( o. 0) 0.0 o.o 55-64 o.o 2. 2 1. 3 Total o.o 1. 6 o. 9 Under 45 10.8 o. 0 5. 7 Both sexes 45-54 12. 9 5. 2 8. 8 55-64 13. 7 1. 1 7. 5 Total 13. 1 2.3 7.7 Centre 11 Un der 45 46.2 0.0 20.0 Male 45-54 26.8 o.o 13 . 9 55-64 15.8 o.o 8.0 Tota l 22.3 o.o 11. 2 Under 45 * * * Female 45-54 (22. 2) (0. 0) 12. 5 55-64 0. 0 3.6 2.0 Total 6. 5 2. 9 4. 5 Under 45 46.2 o. 0 20.0 Both sexes 45 - 54 26.0 o. 0 13.7 55-64 12. 2 1.0 6. 5 Total 19.3 o.6 9.8 * No female patient under 45 years of age w a s registered. 196 Annex II Table 67 (contd) Centre 12 Time of onset of attack Sex Age Day-time Night-time Total % % % Under 45 28.3 3.6 16.4 Male 45-54 35. 6 3.4 22.8 55-64 24.3 5.0 16.9 Total 28.5 4. 2 18.7 Under 45 30. 8 (0. 0) 22.2 Female 45-54 1 9. 1 6. 1 13. 7 55-64 10.3 0.0 5. 6 Total 14.4 1. 6 8.8 Under 45 28.8 3.3 17.2 Both sexes 45-54 31. 3 4. 1 20.4 55-64 19. 8 3.0 12.9 Total 24.5 3.4 15. 8 Centre 13 Under 45 44.8 o.o 31. 0 Male 45-54 28.6 3.7 17.7 55-64 21. 0 3.0 14.7 Total 28.6 2. 7 19. 1 Under 45 ( o. 0) (0. 0) ( o. 0) Female 45-54 ( o. 0) (0. 0) o. 0 55-64 o. 0 0.0 o.o . Total o.o o. 0 o.o Under 45 41. 9 0.0 27.7 Both sexes 45-54 24.4 3. 1 15. 1 55-64 16. 5 2. 1 11. 1 Total 23.8 2. 1 15. 4 197 Annex II Table 67 (contd) Centre 14 Time of onset of attack Sex Age Day-time Night-time Total % % "lo Under 45 (12.5) (0. 0) 7. 1 Male 45-54 30.0 (0. 0) 16. 7 55-64 36.4 9. 1 27.3 Total 30.0 4.0 20.0 Under 45 ( o. 0) * ( o. 0) Female 45-54 ( o. 0) (0. 0) ( o. 0) 55-64 ( o. 0) (0. 0) o.o Total o.o ( o. 0) o.o Under 45 10.0 (0. 0) 6.2 Both sexes 45-54 25,0 o. 0 12.0 55-64 26.7 6.7 20.0 Total 23. 1 2.9 15. 1 * No female patient under 45 years of age had onset of attack during the night. Centre 15 Under 45 30.8 o.o 16. 3 Male 45-54 29.4 5. 7 17.4 55-64 9.4 4.9 7.6 Total 19. 4 4.0 12. 6 Under 45 (33. 3) (0. 0) (25. 0) Female 45-54 ( o. 0) (0. 0) o.o 55-64 o. 0 o. 0 o.o Total 4.2 o.o 2. 1 Under 45 31. 0 o.o 17.0 Both sexes 45-54 24.4 5. 0 14.8 55-64 7. 7 3.4 5.9 Total 16. 9 3.3 1 o. 7 198 Annex II Table 67 (contd) Centre 17 Time of onset of attack Sex Age Day-time Night-time Total % % % Under 45 (33.3) (0. 0) (25. 0) Male 45-54 54.5 (0. 0) 37.5 55-64 18. 2 o. 0 12. 5 Total 30.6 o.o 21. 2 Under 45 * * * Female 45-54 ( 0. 0) (0. 0) ( o. 0) 55-64 ( o. 0) (0. O) ( o. 0) Total ( o. 0) (0. 0) o.o Under 45 (33. 3) (0. 0) (25. 0) Both sexes 45-54 42.9 ( o. 0) 26. 1 55-64 13.8 0.0 9.8 Total 23.9 o.o 16.2 * No female patient under 45 years of age was registered. Centre 18 Under 45 33.3 10. 0 22.7 Male 45-54 29.0 25.0 27. 7 55-64 27.0 9.4 18.8 Total 28.7 13.8 22.5 Under 45 ( o. 0) * ( O. O-) Female 45-54 ( o. 0) (0. 0) ( o. 0) 55-64 ( o. 0) (0. 0) ( o. 0) Total ( o. 0) (0. 0) o. 0 Under 45 30.8 1 o. 0 21. 7 Both sexes 45-54 27.3 23.5 26.0 55-64 23.3 8. 8 16.9 Total 25.8 13. 1 20.7 * No female patient under 45 years of age had onset of attack during the night. 199 Annex II Table 67 (contd) Centre 30 Time of onset of attack Sex Age Day-time Night-time Total % % % Under 45 42. 1 13.3 29.4 Male 45-54 33.3 5. 5 19. 6 55-64 24.0 2.9 14.5 Total 29.2 5. 0 18.0 Under 45 ( 14. 3) (0. 0) 8.3 Female 45-54 15.8 3.3 8.2 55-64 3. 1 o. 0 1. 8 Total 6.7 1. 2 4.0 Under 45 37.8 11. 4 26.2 Both sexes 45-54 30.4 5.0 17.2 55-64 18.2 2. 2 11. 1 Total 24.0 4. 1 14. 7 Centre 31 Under 45 36.8 (0. 0) 31. 8 Male 45-54 45.0 11. 1 34.5 55-64 21. 2 2.3 13.6 Total 31. 2 4.6 22. 1 Under 45 ( o. 0) ( o. 0) ( o. 0) Female 45-54 o.o (0. 0) o.o 55-64 3.8 o. 0 2. 3 · Total 2.6 o.o 1.5 Under 45 3 5. 0 (0. 0) 29.2 Both sexes 45-54 34.6 7. 7 25.6 55-64 16.3 I. 6 1 o. 5 Total 24.4 3.3 16. 9 200 Annex II Table 67 (contd) Centre 50 Time of onset of attack Sex Age Day-time Night-time Total % % % Under 45 12. 5 o.o 7.4 Male 45-54 25.0 5.0 13.9 55-64 30.4 5.9 17. 5 Total 25.6 4.9 15.0 Under 45 ( 0. 0) (100.0) (50. 0) 45-54 7. 1 * 7. 1 Female 55-64 5. 0 4.2 4.5 Total 5. 7 8. 0 6.7 Under 45 11. 8 8.3 10.3 Both sexes 45-54 16. 7 5.0 12.0 55-64 22.7 5.3 13. 5 Total 19. 5 5. 6 12. 7 * No female patient aged 45-54 had onset of attack during the night. Centres - All Under 45 27.9 5. 4 17. 3 Male 45-54 29.0 4 .2 17. 5 55-64 18. 2 2.6 11. 3 Total 22. 6 3.5 14. 0 Under 45 14. 1 4.4 1 o. 6 Female 45-54 15. 8 2 .3 9. 8 55-64 5 .0 1. 1 3.2 Total 8.3 1. 6 5.3 Under 45 25.8 5.3 16. 5 Both sexes 45-54 26 . 4 3.8 16. 0 55-64 14. 7 2.2 9. 1 Total 19. 4 3. 1 12. 0 201 Table 68 TRANSPORT TO HOSPITAL. (I) All hours of the day Tran■port I 2 3 4 6 Ambulance 52 82 59 80 68 Private car 16 9 7 3 13 Taxi 16 l 12 2 3 Other 5 4 14 4 8 None, onset in hospital 2 2 1 5 6 Unknown, alive I I 0 I 1 Unknown, dead 8 0 6 5 I Totals 100 100 100 100 100 Number of patients 492 407 211 844 354 CASES OF "AMI NONE" ARE EXCLUDED. (in percentages) 7 8 9 10 11 12 13 14 64 52 62 69 54 83 83 59 15 II 14 19 17 3 4 13 9 20 4 5 18 3 7 3 4 6 13 I 6 3 2 5 7 7 4 5 5 5 2 3 0 2 2 I 0 0 1 10 I 2 0 0 I 2 2 6 100 100 100 100 100 100 100 100 402 1101 480 637 357 951 255 229 HOSPITAUZED PATIENTS ONLY. 15 17 18 30 31 50 54 52 68 58 52 80 I 31 11 31 14 2 1 9 2 3 23 2 11 2 11 3 3 5 4 6 2 4 1 3 1 0 2 0 0 3 29 0 5 0 6 7 100 100 100 100 100 100 390 54 191 653 277 119 N. B. Thia part of the table include a aho patients !or whom the exact time of hospitalization is unknown. N (2) Arrival in hospital during daytime (0600-1759 hours} 0 N Ambulance 53 83 56 82 63 Private car 19 8 8 4 16 Taxi 20 1 16 3 4 Other 6 5 13 5 12 None, onset in hospital I I 2 5 5 Unknown, alive I I 0 I 0 Unknown, dead 0 0 0 0 0 Totals 100 100 100 100 100 Number of pat ients 281 285 156 518 197 (3) Arrival in hospital during night (1800-0559 houri) Ambulance 64 82 90 89 81 Private c ar 18 13 5 2 II Taxi 15 I 0 0 l Other 3 2 5 I 2 None, onaet in hoapital I 3 0 5 5 Unknown, alive 0 0 0 I 0 Unknown, dead 0 0 0 0 0 Total• 100 100 100 100 100 Number of patient• 148 112 41 274 142 62 17 II 4 6 0 0 100 264 74 10 7 2 7 0 0 100 116 50 57 64 12 16 22 22 4 8 8 17 I 5 4 4 2 I 0 1 0 0 100 100 100 616 282 371 58 70 77 10 13 15 19 5 3 3 8 0 7 3 5 2 0 0 I 0 0 100 100 100 461 178 252 49 82 80 63 n 50 68 54 47 86 17 4 4 14 I 39 15 33 17 I 23 4 10 4 1 II I 4 32 3 8 5 3 8 21 0 12 4 3 6 3 5 3 3 5 0 2 4 I I 0 0 I 7 0 0 0 I 0 3 0 0 0 2 0 0 2 I I 0 100 100 100 100 100 100 100 100 100 100 191 558 151 119 189 38 99 386 149 70 61 91 93 68 86 60 79 63 67 90 18 2 2 16 I 13 4 30 13 3 14 2 2 4 3 7 4 2 16 0 2 I 0 I 4 7 8 I 3 6 6 5 I 0 6 13 2 4 I 0 0 0 I 4 0 ' 0 2 0 0 0 0 0 0 5 0 0 0 0 0 0 I 100 100 100 100 100 100 100 100 100 100 159 360 85 73 78 15 48 263 10 I 31 51 52 59 83 9 3 4 0 6 3 2 10 6 0 15 0 100 100 105 29 67 87 II 4 6 0 9 4 2 4 6 0 0 0 100 100 66 23 78 60 9 0 0 0 0 0 4 40 4 0 4 0 100 100 23 5 ► ::l ::l (b >< ..... ..... Total 66 12 8 5 4 I 4 100 8538 65 13 9 7 4 1 0 100 5009 74 II 7 2 5 I 0 100 2966 N 0 w Table 69 A. Males , excluding cases in "AMI none" group History I 2 3 4 6 Myocard. inf. {all) 30 35 28 25 27 Angina pectoris 44 43 48 38 41 Cer.vasc.a. {all) 4 7 3 7 5 Intermittent claud. 4 16 10 II 12 Diabetes m. (all) 7 9 8 15 4 Hypertension (all) 22 35 37 36 23 Other cardiov . dis. 3 17 9 18 6 Any of the above 65 77 72 72 66 Total 100 100 100 100 100 No. with information 353 404 260 782 291 No. without 42 22 18 52 7 information B . Females, excluding cases in 11 AMI none" group Myocard. inf. {all) 19 28 23 16 28 Angina pectoris 44 61 62 38 44 Cer.vasc .a. (all) 9 1 5 4 0 lnte rmittent c laud , 4 10 2 5 10 Diabetes m. (all) 13 17 7 24 5 Hypertension (all) 44 56 69 56 43 Other cardiov. dis. 4 20 7 25 5 Any o{ the above 73 91 89 83 68 - Total 100 100 100 100 100 No. with information 79 92 93 275 99 No. without 20 I 2 6 I information FREQUENCY OF PREVIOUS MEDICAL HISTORY {in percentages) 7 8 9 10 II 12 13 14 15 29 38 37 28 39 27 26 35 20 46 63 41 48 57 56 53 36 62 8 10 6 2 4 4 5 7 4 14 24 10 8 12 l 3 37 18 7 23 12 7 5 9 6 4 21 6 37 22 16 14 14 25 30 29 29 18 38 14 7 2 4 10 38 I 80 80 64 60 75 71 70 81 75 100 100 100 100 100 100 100 100 100 398 882 425 649 283 745 208 186 288 10 54 8 5 6 41 I 3 27 29 26 32 32 17 38 26 33 18 13 52 71 36 43 71 71 81 45 75 6 10 7 6 12 7 7 5 6 4 14 II 5 8 6 50 18 4 22 21 16 9 12 8 7 18 14 53 49 31 34 43 47 40 48 33 31 so 26 8 3 7 6 55 3 84 88 80 66 92 88 89 90 85 100 100 100 100 100 100 100 100 100 77 304 114 140 75 305 53 48 65 2 10 2 3 I 8 2 7 8 17 18 30 31 28 24 35 46 43 54 41 40 11 13 6 3 13 6 9 6 7 15 5 25 30 56 29 27 19 10 28 12 70 89 72 77 100 100 100 100 54 167 634 207 0 34 39 16 33 14 33 36 56 86 41 58 6 6 7 6 28 6 8 3 22 55 9 42 50 71 53 46 24 14 32 18 83 100 82 90 100 100 100 100 18 24 198 68 0 I 12 4 50 51 29 II 43 18 8 4 24 12 15 16 31 31 21 8 77 52 100 100 71 75 35 5 23 10 43 39 II 0 16 21 17 29 54 53 18 11 92 80 100 100 49 20 12 5 52 19 26 0 9 23 25 21 83 100 23 5 0 80 0 0 50 57 0 100 100 6 2 Total 31 48 6 13 10 27 16 72 100 7385 468 26 55 7 9 16 48 21 84 100 2202 109 > ::s ::s n, >< ...... ...... N 0 ,I>- Table 70 FREQUENCY OF SYMPTOMS IN THE 28 DAYS PRECEDING ONSET OF ATTACK {1n perc e ntages) A. Excluding cases in "AMI none" group Symptom ■ 1 2 3 4 6 7 8 9 10 II 12 13 14 15 17 18 30 Ang. peel, fresh 5 12 19 19 14 9 7 9 II 5 17 29 23 16 12 38 10 Ang. pect, pre-exi1t. 15 16 37 30 10 14 II 13 13 2 I 41 39 20 52 20 36 12 Di ■ comfort in cbe1t 28 22 30 45 10 21 32 16 21 6 47 14 33 8 27 40 18 Heavine ■■ in arm{ ■ ) 3 II 14 28 2 12 10 2 6 14 22 5 15 6 13 18 5 Unu■ual tiredne11 6 18 25 32 11 15 II 9 6 9 32 2 16 13 5 36 7 Unuaual breathle11nea1 5 14 26 23 10 13 13 9 5 12 20 4 19 7 5 22 II Palpitations I 3 9 8 2 5 3 2 I I 9 4 9 I 2 18 3 Any of the above 40 54 77 67 43 45 46 42 43 43 74 74 70 76 50 86 44 Total 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 No. with information 418 448 346 1065 374 402 1136 527 789 348 1054 244 180 354 60 176 729 No. without 76 71 27 50 24 85 114 22 8 17 45 32 88 36 12 50 154 information B. 11 AMI none" group Ang. pect, fre ■h 6 2 3 10 4 6 3 10 6 3 15 22 0 7 0 27 5 Ang. pect. pre-exi ■t 8 7 22 16 8 3 13 7 12 15 37 21 35 61 II 34 7 Di ■ comfort in cheat 21 25 64 36 13 19 29 15 16 9 51 23 41 5 16 31 14 Heavine ■ 1 in arm( ■ ) 3 4 24 16 0 3 12 2 5 3 17 9 7 2 5 16 2 Unu■ual tiredne11 8 13 22 23 8 25 12 10 5 9 33 8 50 10 0 30 6 Unuaual breathle11ne11 8 12 19 17 12 6 21 17 7 4 19 8 18 12 II 22 9 Palpitation• 3 7 13 9 I 3 I 5 5 3 17 6 12 2 0 23 4 Any of the above 33 42 82 54 35 41 44 47 40 33 74 64 71 76 26 83 33 Total 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 No. with information 63 653 468 953 130 27 95 104 136 66 785 124 17 41 19 42 103 No. without 35 22 10 6 I 10 7 0 2 I 10 21 3 0 3 20 3 information C . Definite AMI, alive at first review Ang. peel, freoh 5 17 30 22 17 10 9 13 12 6 23 36 25 26 II 42 10 Ang. pect, pre-exi ■t 14 14 40 24 9 15 II 13 10 21 37 34 17 59 17 36 10 Di ■ comfort in cheat 29 23 27 43 9 24 34 16 21 6 50 10 30 10 26 41 18 Heavine11 in arm{1) 3 12 17 ZS z 14 12 3 7 17 24 5 15 9 17 18 6 Unu■ual tiredne11 6 16 24 35 10 18 9 10 5 6 30 I 15 14 0 40 8 Unusual breathle11ne1a 4 9 2:7 24 6 14 II 10 5 7 18 3 18 8 3 20 9 Palpitation• I 2 9 9 1 6 3 3 1 I 8 2 8 0 0 16 3 Any of the above 40 55 86 64 43 47 48 44 44 43 75 76 68 90 43 91 43 Total 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 No. with information 336 245 143 382 204 298 589 262 521 174 57 5 141 137 201 35 98 518 No. without I 3 1 3 I 25 8 l information 1 2 ~ 10 12 I 6 16 3 i - 31 50 51 27 13 19 17 17 16 39 28 29 16 13 20 16 12 9 17 18 4 7 10 6 61 59 49 100 100 100 271 120 96 24 47 9 II 5 0 12 20 0 27 18 0 8 2 0 14 12 100 14 9 100 8 14 0 47 51 100 100 100 100 92 45 I 2 77 0 33 17 18 20 13 17 38 24 33 16 8 23 20 8 8 22 13 3 7 10 6 67 55 55 100 100 100 138 62 66 0 l 0 52 19 15 27 II 6 15 II 67 100 21 15 25 0 20 0 0 50 20 100 100 5 7 29 6 13 13 6 19 I 3 56 100 16 1 Total 14 22 28 12 16 14 5 56 100 9158 1006 9 19 35 I 2 20 15 10 57 100 3969 240 17 20 27 I 3 15 12 4 56 100 5141 105 ► ::i ::i ro ~ ...... ...... N 0 u, Table 71 PERCENTAGE OF PATIENTS DYING WITHIN 24 HOURS OF ONSET OF ATTACK WHO HAD CONSULTED DOCTOR IN PREVIOUS TWO WEEKS 1 (in percentages) Consulted doctor 1 2 3 4 6 7 8 9 10 11 12 13 14 15 17 18 30 31 50 Yes 11 59 18 33 26 32 18 35 27 22 40 7 37 29 27 46 4 6 41 18 No 62 37 72 62 64 48 55 59 69 68 47 10 27 67 73 30 50 31 11 Unknown 27 4 11 5 11 20 27 5 4 10 13 83 35 4 0 24 4 28 72 No. of patients 79 117 95 299 74 81 284 130 156 63 155 30 51 96 15 37 195 32 57 1 Non-hospital deaths only, excluding cases in "AMI none" group. Totals 31 54 15 2044 > 5 (b >< H H Annex II Table 72 PROPORTION OF PATIENTS SMOKING 15 CIGARETTES OR MORE PER DAY {AGE-STANDARDIZED PERCENTAGES), BY PREVIOUS MEDICAL HISTORY OF MYOCARDIAL INFARCTION Age- standardized percentage of smokers of 15 cigarettes or more per dayl Centre males females with history without history with history without history 1 24. 2 30.3 12. 5 16. 0 2 19. 5 44. 1 9.0 7.7 3 20. 1 35.6 0 . 0 4.2 4 24.9 47. 3 12.2 11. 3 6 28.4 54.5 19.4 20. 3 7 25.3 36.7 8.2 21. 0 8 37.7 47. 7 11. 7 15. 8 9 31. 5 43.6 27.2 38.8 10 24.8 47. 0 13. 5 17. l 11 25.2 44. l 1.9 5.2 12 28.9 48.9 l 0 . 2 15. 5 13 17. 5 52.2 0.0 12. 0 14 21. 5 62 . 3 12.8 11. 4 15 27. 0 45.8 0.0 5. 0 17 4.0 13. 3 0.0 4. 1 18 14. 8 41. 2 o. 0 3.6 30 36.2 51. 3 18.2 31. 1 31 15.4 27.4 15. 0 8.6 50 2. 3 23.6 o.o 9.6 Totals 26.2 44.7 11. 7 13.8 1 For the computation of age-standardized percentages, the age/sex composition of the registered patients in all centres combined was used as the standard age composition for each sex. 206 N 0 -..J Table 73 FREQUENCY OF COMPLICATIONS IN DIFFERENT INTERVALS , EXCLUDl!'-IG C ASES IN " AMI NO !'-IE" GROUP (in pe r ce ntages) ( ;i ) ln the interval be twe en onse t and first review Complica tions I 2 3 4 6 ] 8 9 10 II 12 13 14 15 17 18 30 31 50 51 Conge stive heart f. 13 24 17 41 15 26 58 2 4 35 36 19 15 31 26 II 2 4 55 33 26 II Sho ck 3 8 4 12 6 7 II 12 8 15 13 9 16 8 9 21 II 10 6 8 Th rombo - embolism 2 I 2 3 4 I 2 4 0 3 2 2 2 I 0 2 7 3 2 2 Cardi ac arrest 2 2 0 0 4 I 5 2 6 4 2 2 I 4 0 3 4 I 0 0 Re- infar c tion 6 2 I 2 2 7 2 2 2 1 4 0 7 2 7 3 4 3 3 2 Ang . pe c t. of effort 19 19 52 10 3 34 7 12 5 10 38 12 22 50 30 6 1 38 22 29 I Death be£. 1st e xam . 8 20 2 1 24 16 14 2 4 25 16 18 12 9 25 23 22 12 22 4 35 I Death after 1s t e xam. 16 14 14 16 15 17 17 15 15 22 19 16 8 16 8 20 I 3 20 10 24 Any of the above 47 56 75 68 46 62 79 60 58 61 63 44 66 80 58 78 8 1 55 64 31 T o ta l 100 100 100 100 I OU I 1 OU 100 100 I 00 100 I 00 100 100 100 100 100 100 100 100 100 No. with in!orma.tion 49 4 519 37 3 11114 398 48 7 12}8 549 7% 364 1096 27 5 241 390 65 215 883 292 165 104 No . without information 0 0 0 I 0 0 12 0 1 I 3 I 26 0 7 II 0 2 2 I (b) In the interval be tween first and s eco nd re vie w Cong e stive he art f. 13 18 15 23 8 23 64 13 6 18 16 5 31 9 8 13 20 22 67 16 Sho ck 0 0 0 2 1 I 1 I 2 0 2 0 3 0 0 4 2 2 2 0 Thrombo-embolism 0 I I 2 1 I 1 I I 0 I I 0 0 2 1 4 I 0 0 Cardiac arrest 0 0 0 0 0 I 0 0 1 0 I 0 0 0 0 I 0 I 0 0 Re - infar c tion 3 6 I 3 3 4 9 5 3 0 3 I 5 1 10 I 9 4 4 0 Ang . pe ct. of effort 58 45 53 34 23 50 7 4 50 29 65 6 1 64 45 61 54 53 35 50 66 45 Death 2 4 3 3 5 4 4 6 3 4 2 1 7 3 6 4 5 2 2 0 Any of the above 64 55 57 48 33 60 87 61 36 73 66 66 58 67 6 4 6 1 49 58 81 52 Total 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 I 00 100 100 100 100 No.with information 359 338 240 I 656 272 331 732 325 542 211 7 42 2 05 166 239 50 137 565 2 17 91 67 No . without information 13 I 3 5 3 5 6 9 7 10 17 0 12 I 0 11 7 3 2 2 ( c ) In the interval between second and third review (for patients alive at se c on d re view only ) Congestive heart f. 7 18 10 20 8 2 0 66 14 6 18 18 7 32 1 3 19 II 25 19 59 17 Shock 0 I I 1 1 2 1 2 I 2 2 0 3 0 0 0 3 I 0 0 Tbrombo-emboliam 0 I 0 2 0 I 1 I 2 4 I 0 I 0 0 I 4 0 0 0 Cardiac arrest 0 0 0 0 0 0 0 0 I I 0 0 0 0 0 0 0 0 0 2 Re-infar c tion 8 4 2 4 7 3 15 6 3 4 5 2 5 5 1 3 2 10 6 4 3 Ang. pe c t. of effort 63 52 48 28 29 53 84 52 30 67 67 69 45 53 62 6 1 51 32 6 2 52 Death 8 7 10 5 9 5 9 7 3 4 3 2 3 5 II 4 8 5 8 I Any of the above 68 61 54 44 39 61 93 59 36 74 71 72 56 6 1 72 67 61 42 81 54 Total 100 100 100 100 100 100 100 100 I 00 I 00 I 00 100 100 100 100 100 100 100 100 100 No. with information 353 326 227 636 2 55 317 689 300 4 08 194 709 200 147 226 47 122 538 153 88 65 - No. without information 10 I 7 0 3 2 20 9 7 11 28 I 9 8 0 I 3 5 6 I 2 52 54 19 0 5 8 13 19 II 7 5 100 32 4 18 0 0 0 0 14 0 32 100 22 3 10 0 0 0 0 10 0 19 1 00 21 4 Total 32 I 0 3 3 3 22 19 16 65 100 10 090 72 22 1 1 0 4 50 4 59 100 6 507 120 22 1 1 0 6 54 6 62 100 6 02 1 147 ~ ::, ::, (b X ...... ...... Annex II Table 7 4 FREQUENCY OF COMPLICATIONS ACCORDING TO PREVIOUS MEDICAL HISTORY A. Complications in the interval between onset and first review Frequency of complications( %)among patients with history of: 1 Centre Myocardial Angina Hyper- Any of the None infarction pectoris Diabetes tension 4 histories without MI 1 57 48 43 34 47 27 2 66 56 54 63 60 37 3 83 80 77 73 77 66 4 72 69 74 71 71 56 6 52 40 72 53 50 37 7 64 65 57 61 62 59 8 88 78 88 83 83 60 9 66 67 78 65 66 51 10 66 55 81 58 61 54 11 76 56 72 71 66 42 12 70 63 66 64 65 54 13 57 38 46 40 45 33 14 72 61 59 59 65 44 15 86 80 71 74 80 72 17 79 40 ( 88) 60 61 54 18 82 80 84 8 5 80 64 30 88 88 88 81 84 71 31 66 50 63 64 61 30 50 69 55 47 56 61 13 51 50 6 56 36 33 14 52 (100) ( 63) ( 6 3) (7 8) 75 (57) All centres 73 65 71 67 68 52 1 Percentages in brackets are based on a denominator of less than 10. 208 Annex II Table 74 (co ntd) B. Complications in the interval between first and second reviews Frequency of complications(%) among patients with history of:l Centre Myocardial Angina Hyper- Any of the pectoris Diabetes None infarction without MI tension 4 histories 1 80 73 68 66 71 53 2 71 64 57 56 61 42 3 65 68 52 55 59 51 4 63 52 49 53 52 40 6 52 32 36 36 41 21 7 75 69 63 61 65 47 8 93 92 96 92 92 75 9 74 83 61 61 70 47 10 50 43 50 34 43 28 11 89 78 76 84 81 54 12 81 74 78 74 73 50 13 69 69 (89) 71 69 61 14 71 63 47 59 61 57 15 77 75 71 67 72 53 17 55 73 ( 100) 61 63 65 18 71 58 63 66 63 63 30 66 54 61 53 56 39 31 67 73 68 63 65 41 50 89 83 73 74 82 80 51 (60) 77 ( 7 5) 59 63 39 52 (0) ( 1 7) (40) (29) 23 38 All centres 73 68 65 63 66 47 1 Percentages in brackets are based on a denominator of less than 10. 209 Annex II Table 7 4 ( contd ) C . Complications in the interval between second and third reviews Frequency of complications(%) among patients with history of:l C entr e Myocardial Angina Hyper- Any of the I infarction pectoris Diabetes tension 4 histories None without MI 1 86 80 70 74 78 51 2 69 84 79 72 71 39 3 59 65 45 55 56 50 4 57 47 51 48 48 35 6 55 49 (44) 43 48 26 7 71 65 63 62 65 50 8 97 95 98 95 95 86 9 76 77 50 55 69 44 10 52 43 44 35 45 25 11 91 75 69 81 80 60 12 83 75 97 78 77 55 13 83 82 (88) 70 79 56 14 64 46 56 55 52 67 15 79 65 74 60 65 52 17 82 85 (100) 67 79 63 18 84 65 69 68 69 59 30 83 70 77 65 70 48 31 62 42 64 47 47 30 50 89 8 3 82 77 83 76 51 (80) 82 ( 7 5) 55 64 42 52 (0) 1 7 (40) (29) 23 (0) All centres 76 70 69 65 68 48 1 Percentages in brackets are based on a denominator of less than 10. 210 Annex II T able 75 I-YEAR SURVIVAL RATE BY AGE AND SEX, ALL PATIENTS 1 Male Female Both sexes Sex with Age/Sex Centre Age No. of Survival No. of patients 1 year patients % < 45 24 87 . 5 5 45-54 134 76.9 19 I 55-64 237 66. 7 , 5 Total 39 5 7 1. 4 99 < 45 41 68 . 3 2 45-54 10 6 68 . 9 17 2 55-64 279 49. 8 74 Total 42 6 56 . 3 93 < 45 32 65.6 9 45-54 73 56 . 2 25 3 55- 64 17 3 5 1. 4 I 6 1 Total 278 54. 3 95 < 45 106 64.2 23 45-54 230 65.2 66 4 55-64 498 48,4 192 Total 834 55.0 281 < 45 26 7 3. l 5 45-54 110 65 . 5 35 6 55-6 4 162 53 . 7 60 T otal 298 59. 7 JOO < 45 66 81. 8 4 45-54 109 72. 5 13 7 55-64 2 33 53.6 62 Total 408 63. 2 79 < 45 104 60. 6 13 45-54 292 52. 7 69 8 55- 64 540 43.0 232 Total 936 48 .0 314 < 45 60 56 . 7 11 45-54 128 67.2 23 9 55-64 245 47.8 82 Total 433 54, 7 116 < 45 66 71. 2 12 45-54 172 6 1. 6 21 10 55- 64 30 3 59 . 7 85 Total 541 6 1. 7 118 * significant at 5 % pr ob ability le vel . *** signifi cant at 0, 1 % probability level. signi fic antly standardized Survival No. of Survival higher survival rate ' 1 ye ar pat ie nts 1 year survival % % % 100.0 29 89. 7 57.9 153 74. 5 58 . 7 312 64. 7 60 .6 494 69.2 69.9 50 . 0 43 6,. 4 88.2 123 71. 5 64 .9 353 53.0 Female ,:, 68.8 519 58.6 60 . 7 77.8 41 68 . 3 80.0 98 62 .2 59,0 234 53.4 66 .3 373 57 . 4 I 57.2 I 60. 9 129 63.6 71. 2 296 66.6 45 . 8 690 I 47, 7 53 .0 1115 54.5 55,0 80 , 0 31 74.2 57. I 145 6 3. 4 55.0 222 54. I 57.0 39 8 59.0 59. 3 50.0 70 80. 0 84. 6 122 73 . 8 54. 8 295 53.9 59.5 48 7 62. 6 62.8 69.2 11 7 6 I. 5 84. l 361 58. 7 Female *** 57 .3 772 47.3 Female *** 63 . 7 1250 51. 9 52.0 54.5 71 56. 3 47,8 151 64 . 2 46. 3 327 47.4 47.4 549 53.2 53.2 75. 0 78 71. 8 57. l 193 61. I 56,5 388 59.0 58.5 659 61. 2 60 . 9 For centre JO, onset up to May 1972 . 2 For computation of age / sex survival rates, see Note, page 219 211 Annex II T able 75 (contd) Male Fem ale Both s exe s Sex wi th Age / Sex si gnifi cantly ~entre Age No. of Su r viva l No . of Survival No. of Sur vi va l higher standardiz ed pat ie nts I year patie nts I year patie nts I ye ar survival survival rate % % % % ' 45 33 54 . 5 0 - 33 54. 5 45-54 88 67 . 0 16 68.8 104 67. 3 11 55- 64 168 52 . 4 60 46. 7 22 8 50. 9 Tota l 289 57. l 76 51. 3 365 55.9 - < 45 135 66 . 7 19 57.9 154 65.6 45-54 244 70 . 9 84 72. 6 328 71. 3 12 55-64 407 59.5 210 66. 7 6 17 6 1. 9 T otal 786 64. 2 31 3 67. 7 10 99 65 .2 64.8 < 45 46 65. 2 6 50.0 52 63. 5 45 - 54 69 84. l 12 75.0 8 1 82.7 13 55 - 64 106 67 .0 37 67. 6 143 67 . l T ot a l 22 1 7 1. 9 55 67.3 27 6 71. 0 71. 2 < 45 28 75 . 0 2 100. 0 30 76 . 7 45-5 4 60 68 . 3 14 7 1. 4 74 68 . 9 14 55- 6 4 124 56 .5 39 53.8 16 3 55. 8 T otal 21 2 62 . 3 55 60. 0 26 7 6 1. 8 62.2 < 45 73 64 . 4 4 i 50 . 0 77 63.6 45-5 4 96 6 1. 5 17 I 58. 8 113 61. l 15 55-6 4 148 49 . 3 52 59. 6 200 52.0 T ota l 31 7 56 . 5 73 I 58.9 390 56 . 9 55.9 < 45 4 75 .0 0 I - 4 75 . 0 45 -5 4 16 81. 3 7 I 42. 9 23 69 . 6 17 55- 64 34 50 .0 11 54. 5 45 51. l Total 54 6 1. l 18 50 . 0 72 58. 3 - < 45 31 74 . 2 2 50. 0 33 72 . 7 45-54 68 72.l 4 50.0 72 70. 8 18 55- 64 10 2 52 . 9 19 47. 4 12 1 52 . I T otal 20 l 62. 7 I 25 48. 0 22 6 6 1. l 58.6 I < 45 75 77.3 14 7 1. 4 89 76 . 4 45- 54 213 65. 7 54 68 . 5 267 66. 3 30 55-64 385 47. 5 142 52. 8 52 7 49.0 Total 673 56 . 6 21 0 58. l 883 57.0 57.2 < 45 2 3 87. 0 3 100.0 26 88.5 45- 54 70 78 . 6 21 76.2 9 1 78.0 31 55- 64 129 65 . 9 48 62 . 5 177 65.0 Tota l 22 2 72 . I 72 68. l 294 71. I 71. 6 < 45 13 84 . 6 2 o. o 15 73.3 45-54 20 65 .0 11 6 3. 6 31 64.5 50 55-64 73 45.2 48 41. 7 121 43. 8 Total 106 53 .8 61 44.3 167 50. 3 53. 7 212 Annex II Table 75 (contd} Male F emale Both sexes Sex with Age / Sex significantly Centre Age No. of Surviva l No. of Survival No. of Survival higher standardized patients 1 yea r patients 1 year patients 1 year surviva l sur v ival r ate % % % % < 45 13 84 . 6 2 100 . 0 15 86. 7 45-54 16 93 . 8 5 60.0 21 85. 7 51 55- 6 4 51 74.5 18 50. 0 69 68 . I Tota l 80 80.0 25 56.0 105 74. 3 Male * 75.8 < 45 4 75.0 0 - 4 75.0 45-54 6 50 . 0 I 100 . 0 7 57. I 52 55- 6 4 18 72. 2 7 71. 4 25 72. 0 Tota l 28 67.9 8 75.0 36 69 .4 - < 45 JOO 3 68.8 138 6 5.9 1141 68.4 45-54 2320 66. 5 534 70.2 2854 67.2 All 55-64 4415 52.9 1614 55.8 602 9 53 . 7 Female ;;: Tota l 7738 59.0 2286 59. 8 10024 59.2 59.4 ,:, significant at 5 % probab ility leve l. 213 Annex II Table 75(a) NUMBER OF PATIENTS USED FOR SURVIVAL ANALYSIS BY AGE, SEX AND CENTRE All patients, excluding "AMI none" group Centre Age Male Female Both sexes < 45 24 5 29 45-54 134 19 153 1 55-64 237 75 312 Total 395 99 494 < 45 41 2 43 45-54 105 17 122 2 55-64 276 72 348 Total 422 91 513 < 45 32 9 41 45-54 73 24 97 3 55-64 172 61 233 Total 277 94 371 < 45 106 23 129 45-54 229 66 295 4 55-64 496 192 688 Total 831 281 1112 < 45 26 5 31 45-54 107 32 139 6 55-64 156 58 214 Total 289 95 384 < 45 66 4 70 45-54 109 13 122 7 55-64 232 62 294 - Total 407 79 486 < 45 99 13 112 45-54 287 69 356 8 55-64 521 230 751 Total 907 312 1219 214 Annex II Table 7 5(a) {contd) I Centre Age Male Female Both sexes < 45 58 10 68 45-54 124 23 147 9 55-64 238 80 318 Total 420 113 533 < 45 65 12 77 45-54 172 21 193 10 55-64 30 l 84 385 Total 538 117 655 < 45 33 0 33 45-54 85 16 10 l 11 55-64 157 57 214 Total 275 73 348 < 45 131 18 149 45-54 241 84 325 12 55-64 402 209 611 Total 774 311 1085 < 45 45 6 51 45-54 69 12 81 13 55-64 106 36 142 Total 220 54 274 < 45 27 2 29 45-54 59 14 73 14 55-64 123 39 162 Total 209 55 264 < 45 72 4 76 45-54 95 17 112 15 55-64 139 51 190 Total 306 72 378 215 Annex II Table 75(a) (contd) Centre Age Male Female Both sext:::. I < 45 4 0 4 45-54 16 7 23 17 55-64 34 11 45 Total 54 18 72 < 45 28 2 30 45-54 64 4 68 18 55-64 99 17 116 Total 191 23 214 <45 74 14 88 45-54 213 54 267 30 55-64 381 142 523 Total 668 210 878 <45 23 3 26 45-54 70 21 91 31 55-64 128 48 176 Total 221 72 293 <4 5 30 4 34 45-54 42 16 58 50 55-64 142 73 215 Total 214 93 307 <45 984 136 1120 45-54 2294 529 2823 All 55-64 4340 1597 5937 Total 7618 2262 9880 216 Tab le 76 Centre Age < 45 45-54 I 55-64 Total < 45 45 -5 4 2 55-64 Total < 45 45-54 3 55-64 Total I < 45 45-54 4 55-64 Total < 45 45-54 6 55- 64 Tota l < 45 45-54 7 55- 64 Total < 45 45-54 8 55-64 Total < 45 45-54 9 55-64 Total < 45 45-54 JO 55- 64 Tota l !-YEAR SURVIVAL RATES BY AGE AND SEX FOR ALL HOSPITALIZED PATIENTS (DEAD OR ALIVE) Male Female Both sexes Sex wi th significantly No. of Survival No. of Survi va l No. of Surv ival higher pati ents l ye a r patients 1 yea r patients 1 yea r survival i % % % 23 87 .0 5 100.0 28 89 . 3 133 76. 7 19 57.9 152 74.3 237 66 . 7 75 58. 7 312 64. 7 393 7 l. 2 99 60. 6 492 69. l 32 84.4 I 100.0 33 84.8 88 83.0 16 93.8 104 84 . 6 210 ' 66. 2 60 80.0 270 69. 3 i 330 72. -l n 83 . l 407 74 .4 21 81.0 2 100.0 23 82 . 6 48 79. 2 12 83. 3 60 80. 0 99 62. 6 29 55. 2 128 60.9 168 I 69.6 43 65. I 21 I 68 . 7 86 11.9 17 I 82.4 10 3 78 . 6 I 185 81. I 53 88 . 7 238 82.8 361 66 .5 142 62.0 50 3 I 65. 2 63 2 72. 3 212 I I 70. 3 i 844 I 71. 8 I 21 8 1 . 0 I 4 I 75. 0 I 25 I 80.0 I 10 I 71. 3 32 59 . 4 13 3 68 .4 I 14-l 59 .0 52 59. 6 196 59.2 I 266 65.4 88 60.2 I 354 64 . I 58 89. 7 I 3 66 . 7 6 1 88.5 I 95 82. I 10 100 . 0 10 5 83.8 186 66 . 7 50 68.0 23 6 66.9 339 74. 9 63 73.0 402 74. 6 92 67. 4 I II 72. 7 10 3 68 .0 253 59. 3 66 86 .-! 319 64.9 Female ::, i:c-::c 47 6 48. 7 20 3 64. 5 679 53.5 F e male ** 1:C I 821 5-!. I 280 70.0 110 I 58. I 55 60. 0 9 66. 7 64 60. 9 112 75.0 21 52.4 133 71. 4 217 51. 2 66 54.5 283 51. 9 384 59 .4 96 55.2 480 58.5 68 92. 6 12 91. 7 80 92.5 175 83.4 21 76.2 196 82.7 280 78.9 81 75. 3 361 78. 1 523 82.2 114 77.2 637 81. 3 Annex II Age / Sex standardized surv ival rate 1 % 69 . 9 I I ' 76 . 3 i I 68 . 9 71. 8 64. 5 74 . 7 58. I 58.6 80.8 **'' significant at 0. 1 % probabil ity level For computation of age / sex standardized survival rates, see Note, page 219 217 Annex II Table 76 (contd) Male Female Both sexes Sex with Age/Sex significantly Centr< Age No. of Survival No.of Survival No. of Survival higher standardized patients I year patients l year patients l year survival survival rate % % o/o % < 45 32 56. 3 0 - 32 56. 3 45-54 85 69.4 16 68.8 10 l 69.3 11 55-64 165 53. 3 59 47 .5 224 51. 8 Total 282 58.5 75 52.0 357 57. l - < 45 108 81. 5 18 61. l 12 6 78.6 45-54 212 81. l 79 77. 2 291 80. l 12 55-64 343 70.0 191 72. 8 534 71. 0 Total 663 75.4 288 73. 3 951 74.8 74. 5 < 45 37 81. l 6 50.0 43 76. 7 45-54 69 84. l 11 81.8 80 83.8 13 55-64 98 72.4 34 73.5 132 72.7 Total 204 77 . 9 51 72.5 255 76. 9 76 .4 < 45 25 84.0 2 100 .0 27 85.2 45-54 54 75.9 13 76. 9 67 76. l 14 55-64 100 68.0 34 61. 8 134 66.4 Total 179 72. 6 49 67. 3 228 71. 5 71. 5 < 45 73 64.4 4 50.0 77 63.6 45-54 96 6 1. 5 17 58. !:S 11 3 61. l 15 55-64 148 49. 3 52 59 .6 200 52.0 Total 317 56. 5 I 73 58. 9 390 56.9 55.9 < 45 3 66. 7 0 - 3 66. 7 45-54 13 92. 3 6 50.0 19 78.9 17 55- 64 24 70. 8 8 62. 5 32 68.8 Total 40 77 .5 14 57. 1 54 72. 2 - < 45 28 82. l 1 100.0 29 82. 8 45-54 61 80. 3 3 66. 7 64 79.7 18 55-64 80 61. 3 18 50.0 98 59.2 Total 169 71. 6 22 54. 5 191 69.6 67.0 < 45 64 89. l II 90. 9 75 89. 3 45-54 168 82. 7 44 79.5 212 82. I 30 55-64 264 66.7 102 73.5 36 6 68.6 Total 496 75.0 157 76.4 653 75. 3 75.0 < 45 23 87.0 3 100.0 26 88.5 45-54 65 84.6 21 76.2 86 82.6 31 55-64 122 69.7 42 71. 4 164 70. I Total 210 76.2 66 74.2 276 75.7 76. I < 45 11 100.0 l o.o 12 91. 7 45-54 14 92.9 8 87.5 22 90. 9 50 55-64 47 66.0 38 52.6 85 60.0 Total 72 76.4 47 57.4 119 68.9 Male * 73.8 * significant at So/, probability level 218 Annex II T able 76 (contd) Male Female B o th sexes Sex with Age / Sex sign ificantly Cent r e Age No . of Surviva l No. of Surviva l No. of Survival higher standardized survival r a te pat ients l year patients I year patients I year survi val % % % % < 45 l 3 84.6 2 100 .0 15 86. 7 45 -54 16 93.8 5 60 .0 21 85. 7 51 55- 6 -! 5 1 H.5 18 50.0 69 68. I T o t a l 80 80 , 0 25 56 ,0 105 74. 3 M a le ,, 75.8 < 45 3 100. 0 0 - 3 100 . 0 -!5 - 54 5 60 . 0 l 100,0 6 66. 7 52 55-64 15 86. 7 5 100.0 20 90 . 0 Total 23 8 2 .6 6 100. 0 29 86 . 2 - < 45 876 78, 7 112 76.8 988 78. 4 4 5 - 5 4 20 4 8 76.6 4 74 76 . 8 2522 76 . 6 All 55- 6 -! 3667 63 . 3 1 359 6 5.2 5026 63.8 T o t a l 659 2 69 .5 1945 68. 7 8537 69 . 3 69. 3 .:, sign i fi ca nt ,,t 5 % pro bab1ltty le vel No t e to T abl e s 75 1 75(a} and 76 COM P U TATION OF AGE / SEX STANDARDIZ ED SURVIVAL RAT E S The age / s ~x com posit ion of th e p atien ts r egi st e red a t all t he co ll abo ratin g centres was use d a s the standard a nd the st a nd a rd ize d survival r a t e wa.s computed by a pp lyi ng th e standard weight to each of th e six age / s ex gr ou ps as follows : Age / Sex st a nd a rd ized r a t e Sex M F l: (weight x rate fo r each age/ oex) (6 age / sex groups) Age Weight < 4 5 0. 101 -15- 54 0. 240 55-6 4 0.428 < 45 0. 0 15 45-54 0 . 0 53 55-64 0 . 163 All age / sex groups 1,000 219 N N 0 Table 77 SURVIVAL RATE BY AGE AND SEX, AT 24 HOURS, I WEEK, 4 WEEKS AND 3 MONTHS AFTER ONSET OF ATTACK {in percentages) All patients, excluding 11 AMI none" Male Female Both sexes Centre Age 24 hrs 7 day• 28 days 3 mnths 24 hrs 7 days 28 days 3 mntho 24 hrs 7 days 28 dayo < 45 96 96 96 96 100 100 100 100 97 97 97 45-54 86 85 84 80 74 68 63 63 84 83 82 I 55-64 78 76 74 73 72 68 64 63 77 74 72 Total 82 81 79 76 74 70 66 65 80 78 76 Age/sex standardized rate: 80.9 78.8 76. 8 < 45 71 68 68 68 50 50 50 50 70 67 67 45-54 79 74 72 70 94 88 88 88 81 76 75 2 55-64 70 65 60 58 82 76 71 68 72 68 62 Total 72 68 64 62 84 78 74 71 74 70 66 Age/sex standardized rate: 7 5. 2 70. 2 66.8 < 45 75 75 75 69 89 78 78 78 78 76 76 45-54 66 64 63 62 83 83 83 83 70 69 68 55-64 70 65 3 61 59 80 75 72 69 73 67 64 Total 69 66 63 61 82 78 76 73 73 69 66 Age/sex standardized rate: 72. I 68.5 66. 1 < 45 75 70 69 69 65 61 61 61 73 68 67 45-54 73 72 70 68 74 73 73 71 74 72 71 4 55-64 62 58 54 52 63 55 53 49 63 57 54 Total 67 63 60 5~ 66 60 58 55 67 62 60 Age / oex standardized rate: 66 . 8 62.9 60. 3 < 45 81 81 77 77 100 80 80 80 84 81 77 45-54 79 77 74 71 91 88 88 78 82 79 77 6 55-64 76 71 66 62 81 72 71 66 78 71 67 Total 78 74 70 66 85 78 77 71 80 75 72 Age/oex standardized rate: 7 9. 2 74.6 71. 2 < 45 86 83 82 82 50 50 50 50 84 81 80 45-54 84 80 78 76 85 85 85 85 84 80 79 7 55-64 72 65 63 59 73 69 65 60 72 66 63 Total 78 72 70 67 73 71 67 63 77 72 70 Age/sex standardized rate: 76.8 71.9 69.8 < 45 71 68 68 68 69 69 69 69 71 68 68 45-54 71 65 62 60 86 84 84 84 74 69 67 55-64 65 59 53 50 76 69 64 62 69 62 56 8 Total 68 62 57 55 78 72 69 67 70 65 60 Age / sex standardized rate: 70. 0 6~.5 60.4 3 mnths 97 78 70 74 7 5. 2 67 73 60 64 65. 0 71 67 62 64 63. 9 67 68 51 58 58. 2 77 73 63 67 67.4 80 77 59 66 66.8 68 64 54 58 58. 3 ► 5 CD >< H H N N ...... Table 77 {contd) Centr e Agl' <4 5 45 - 54 55-6 4 9 Total <45 45- 54 55-64 10 Total < 45 45-54 55-6 4 11 Tota l < 45 45-54 55-64 ll Tota l < 45 45-54 55-64 1 3 Total < 45 45-54 55-64 14 Total < 45 45-54 55-64 1 5 Tota l I L4 hrs 74 77 68 72 Bl 71 7 J 7j 6 4 79 7 {J 72 78 80 75 77 73 90 7 'I 8 1 85 76 7 1 7 4 7 1 66 68 68 t,..t.dc 7 d..l y s .!8 d..tys 3 mnlh s L4 hrs 66 bl 62 bU 74 7 J ; 1 6 1 63 59 54 68 67 64 60 65 78 77 7 5 7 5 6 7 66 64 ; 1 b8 65 ol 68 69 67 6 4 6 9 61 u l 58 I 75 I 7 J 7j HH I 66 611 SK 7 l I 68 6 4 bl 77 I 75 72 7 0 83 77 74 7 3 81 7 0 66 t:3 H5 73 69 67 8 4 71 6 '/ 67 50 I 88 88 88 7 5 75 ;o 69 86 78 75 7 5 80 I I 81 I 8 1 81 100 76 I 75 73 86 69 66 61 74 73 70 67 78 68 68 68 50 66 65 64 88 65 60 57 75 66 63 62 76 Fema l e 7 d..lyS l8 days .3 mnths 2-t hrs 60 60 60 72 57 57 57 74 63 60 55 68 6 1 59 56 70 Age/sex standa rd ized r a te: 7 0 . 3 75 75 75 81 7 1 67 67 71 6 4 6 1 58 72 67 63 62 73 Age /sex stand a rdiz e d r a te: 7 2. 5 - I - 64 81 6'/ 69 80 67 i 58 52 7 1 70 I 60 5(, 73 Age / sex st..1nda r dized rate: 83 72 67 79 79 77 75 80 76 7 1 6 9 79 77 73 7 I 7'I Age / sex s tanda rdi zed r a te : 78.6 so 50 50 7 1 75 75 75 88 81 72 72 8 1 7l> 70 70 81 Age / sex s tanda rdi zc<l ra te: 81. 5 100 100 100 86 7'/ 7 I 71 78 69 6 4 62 72 73 67 65 75 Age / sex standardi zed r a te : 7 5. 3 50 50 50 70 76 76 7 1 70 67 63 61 69 68 65 62 7 0 Age / sex standardize d rate : 69 . 8 Both sexes 7 days 28 days 65 62 7 1 7 I 63 59 66 63 65. 6 62.7 78 77 67 66 68 64 6 '1 66 68 .4 66. 1 61 61 76 72 66 59 6 '1 63 - - 76 72 78 75 72 68 74 70 7 3 . 8 70. 0 6'1 67 86 86 76 70 78 74 78.3 74. 5 83 83 77 74 69 65 73 70 7 2. 9 70 . 1 67 67 68 67 66 6 1 67 6 4 66.2 63 . 2 3 mnths 62 69 54 59 59. 3 75 6 4 6 1 64 63.6 58 72 56 61 - 70 74 65 68 67.8 65 86 70 74 73.9 83 73 6 1 67 67 .2 67 65 58 62 61. I ► 5 Cb ~ ...... ...... N N N Table 77 (contd) Centre Age < 45 45-54 55-64 17 Total < 45 45-54 55-64 18 Total < 45 45-54 55-64 30 Total < 45 45-54 55-b4 31 Total < 45 45-54 55-b4 5 0 Total ' 45 45-54 55-64 All Total 24 hrs JOO 81 65 72 82 88 73 79 86 79 69 74 I 00 I 86 ' 81 85 I ; 87 ; 81 68 73 78 77 70 73 Male 7 days 28 days 3 moths 24 hrs JOO 100 JOO - 81 81 81 86 62 62 59 73 70 70 69 78 82 82 82 50 83 81 80 50 70 65 59 94 76 73 69 83 84 84 82 86 77 72 70 85 61 56 53 7 I 68 b4 62 76 96 87 87 JOO 84 83 83 81 76 72 69 81 81 77 7b 82 87 87 83 50 74 74 74 75 b5 bl bl 6b 70 b8 6b 67 7S 74 73 74 74 72 70 81 65 61 58 74 b9 bb 64 1b Female 7 days 28 days 3 moths 24 hrs - - - 100 71 71 57 83 64 64 55 67 67 67 56 74 Age/sex standardi:z.ed rate: - 50 50 50 80 50 50 50 85 76 59 59 76 70 57 57 79 Ag~/sex standardized rate: 79.4 79 79 79 86 81 78 74 81 63 60 58 69 69 6b b4 74 Age/sex standardized rate : 74. 5 JOO JOO JOO 100 81 81 81 85 71 65 bl 81 75 71 b~ R4 Age/sex standardized rate: 84.4 50 50 50 82 75 b9 b9 79 5~ 55 53 6 7 61 57 56 71 Age/s e x standardized rate: 72 . 8 71 69 68 78 78 76 74 78 b8 bl 60 71 70 b1 64 74 Age/sex standardized rate: 7 3. 8 Both sexes 7 days 28 days JOO I 00 78 78 62 62 69 69 - - 80 80 81 79 71 64 75 71 73.9 68.6 83 83 78 73 6 1 57 68 65 b8.8 64.8 96 88 84 82 74 70 79 75 79. 7 7 5. 9 82 82 74 72 bl 60 67 64 68.7 66. 5 75 73 75 73 6b bl 70 66 69.4 66.2 3 moths 100 74 58 65 - 80 78 59 68 65.8 82 71 55 62 b2.3 88 82 68 74 74. I 79 72 58 63 65. 3 72 71 59 64 63.7 ► ::l ::l (1) >< H H A nne x II Table 78 PERCENTAGE OF PA TIEN TS ENGAGED IN NORMAL ACTIVITY AT TIME OF SECOND REVIEW, BY AGE AND SEX EXCLUDING CASES IN "AMI NONE" GROUP Centre Male Female Under 45 45-54 55-64 Under 45 45-54 55-64 1 40 1a 29 o/o 18 1o (60)% 0 1a 12 2 0 9 3 ( 0) 11 3 3 38 24 23 ( 55) 52 42 4 13 7 5 13 19 2 6 45 28 27 (80) 4 2 35 7 13 7 7 ( 0) 17 9 8 18 13 6 ( 8) 18 7 9 20 27 1 5 ( 58) ( 1 7) 11 10 15 9 9 ( 1 7) 14 7 11 20 17 19 ., . 19 20 . ,. 12 28 23 16 16 1 5 13 13 17 16 1 3 ( 2 5) ( 8) 6 14 0 21 5 ( 100) ( 1 7) ( 0) 15 18 11 9 ( 0) 0 19 17 ( 7 5) 0 3 :::;: ( 0) ( 0) 18 28 15 11 (50) (30) 11 30 45 36 18 14 50 23 31 62 45 23 ( 67) 40 29 Total 23 19 12 23 21 13 Notes: Percentages in brackets are based on a denominator of less than 10. The denominator also includes those patients who had died before the first review. * No patient registered in this age / sex group. 223 1a ANNEX III PUBLICATIONS OF COLLABORATING CENTRES 1. GOTHENBURG Bengisson, C. (1973) Ischaemic heart disease in women, Acta med. Scand. (Suppl.), 2_ (49), 1-128 Elmfeldt, D. et al. (1975) A postmyocardial infarction clinic in Goteborg, Sweden. A follow-up of MI patients in a specialized outpatient clinic, Acta med. Scand., 197, 497-502 Elmfeldt, D. et al. (1975) Registration of myocardial infarction in the city of Goteborg, Sweden. A community study, J. chron. Dis., 28, 173-186 4. BUDAPEST Gyarfas, I. (1972) The epidemiology of acute myocardial infarction, Cardiologia Hungarica, _!_, 65 Gyarfas, I. (1973) H ealth education problem s of acute myocardial infarc- tion, Egeszsegug. Felvil., 14, 60 Lamm, G. et al. (1972) Cardiovascular epidemiological examinations. First part: de scriptive studies, Nepegeszsegugy, 21, 19 Gyarfas, I. infarction, Problems of the prehospital phase of acute myocardial Cardiologia Hungarica (in press) Gyarfas, I. Prodromal symptoms of acute myocardial infarction: A retrospective study, Cardiologia Hungarica (in press) Gyarfas, I. & Csukas, M. Epidemiology of acute myocardial infarction: A population-wide study in the South-Pest area. I. Incidence of acute myocardial infarction (in press) Gyarfas, I. & Csukas, M. Epidemiology of acute myocardial infarction: A population-wide study in the South-Pest area. II. Mortality of acute myocardial infarction. Ill. Time and place of onset of heart attack and seasonal variation of acute myocardial infarction, Nepegeszsegugy (in press) 5. COPENHAGEN Horwitz, 0. (1972) Registrering af akut myokardieinfarkt i Stork~benhavn ffiegistration of acute myocardial infarction in Greater Copenhage.!!7 Ugeskr. Laeg., 134, 75-78 224 Annex III K,...i,eldsen, K. (1972) Hjertesygdommenes betydning for dj6°deligheden LThe relationship between cardiac diseases and mortality rate~7 Ugeskr. Laeg., 134, 1917-1922 K,Jeldsen, K. (1973) Prognose for patienter med akut myokardie infarkt LPrognosis for patients with acute myocardial infarctio!2_7 Sundhedsstyrelsen, 12, 141-143 Kjeldsen, K. Q..974) Vurdering af forskellige sygdommes betydning for dj6°deligheden LAssessment of the relationship between various diseases and mortality rate~7 Ugeskr. Laeg., 136, 2313-2318 Kjeldsen, K. & Hansen, B. (1974) Risikoen for akut hjerteinfarkt stj6°rst hos maend .[i'he risk of acute myocardial infarction is g r eater in me!:7 Sygeplejersken, 11, 8-11 6. DUBLIN Radie, A. & Dean, G. (1974) Incidence of acute ischaemic heart attacks m a defined population of South Dublin, J. Irish med. ass., B_, 235-242 7. HEIDELBERG Hehl, F. -J. & Nussel, E. (1972) Prodromalerscheinungen des Herzinfarktes _Lprodromal symptoms of myocardial infarctio.!!7, Verh . dtsch. Ges. inn. Med., 78, 1011-1014 Hopker, W. -W. et al. (1972) Statistische Modellstudie zum Verlauf und Ausbreitungsmuster der Arterioskle rose ffitatistical model-study of course and propagation patterns of arteriosclerosi_il, Verh. dtsch. Ges . Path.• 56, 670 Nussel, E. & Hehl, F. -J. (1972) Rauchen und koronare Herz-krankheiten ffimoking and coronary heart diseas~7, 1, Teil, Rehabilitation, 25, 3-4 NUssel, E. & Hehl, F. -J. (1972) Morbiditat und Letalita.t des Herzinfarktes ffeorbidity and lethality of myocardial infarctio!2_7, Verh. dtsch. Ges. inn. Med., 78, 1014 Nussel, E., Hehl, F.-J. &Greiner, C. (197l)Dieepidemiologiedes Herzinfarktes fipidemiology of myocardial infarctio!!/ In: Basler, R. • ed., Die Rehabilitation von Herz-Kreislaufkranken, Freiburg/Br., Farmitalia GmbH, p. 27 Nussel, E. & H~ker, W. -W. (1973) Rauchen und morphometrische Gefa.ssbefunde LSmoking and morphometric findings in blood vessel~?, In : Schettler, G., ed., Fortschritte in der Arterioskleroseforschun , ffidvances in arteriosclerosis research Munchen-Gra.felfing, Werk- Verlag, p. 32 225 Annex III NUssel, E. & Keil U. (1970) Rauchen und Herzinfarkt ffimoking and myo- cardial infarctio!:_/, In: Dtsch. Hauptstelle gegen Suchtgefahren, ed., Chancen fur den Raucher, Hamm, Hoheneck-Verlag, p. 23 Nussel, E. & Kirschner, H.G. (1973) Epidemiologie der koronaren Herz- krankheiten fipidemiology of coronary heart diseas~7, Med. Welt, 24, 1931 Nussel, E. & Kohler, C. (1973) Definition und Determination des Herz- infarkte s ffiefinition and determination of myocardial infarction/ In: Lange, H. -J. & Wagner, G. ed., Com uterunterstUtzte a.rztliclle Dia - nostik ,Lcomputer- supported medical diagnosis , Stuttgart - New York, Schattauer NUssel, E. & Rhomberg, H.P. (1974) Su~ektive Symptome in der Vor- geschichte von Kranken mit Herzinfarkt LSubjective symptoms in the previous history of patients with myocardial infarction?, Inn. Med., 1, 162 - - Nussel, E. & Weise, J. (1974) Study on symptoms and signs predicting acute myocardial infarction and sudden death - preliminary results, Arch. Mal. Coeur (special number) 68, 1 74 Nussel, E. & Wilcke, S. (1975) Rauchen als Risikofaktor beim Herzinfarkt ffimoking as a risk factor of myocardial infarctio.!!7, Fortschr. Med., 93, 489 Schettler, G. & Nussel, E. (1974) Risk factors in coronary heart disease - new results in the Federal Republic of Germany, G. ital. Cardiol., i(3), 366 Schettler, G. & NUssel, E. (1974) Neuere Resultate aus der epidemiolo- gischen Herzinfarktforschung in Heidelberg .LLatest results of the epidemio- logical myocardial infarction research in Heidelbery, Dtsch. med. Wschr., 99, 2003 Schettler, G. & NUssel, E. (1975) Massnahmen zur Pra.vention der Arterio- sklerose ffeeasures for the prevention of arteriosclerosiy, Arbeits- medizin-Sozialmedizin-Pra.ventivmedizin, .!Q, 25 Nussel, E. & Kohler, C., Herzinfarkt und Totenschein ffeyocardial infarction and death record/ In: Nacke, 0. & Wagner, G. ed., Doku- mentation und Information-im Dienste der Gesundheits £le e, Stuttgart - New York, Schattauer in press Nussel, E. & Kohler, C. Differenzierun von Herzinfarkt und An ina pectoris in der Pra.ventivmedizin Differentiation of myocardial infarction and angina pectoris of effort in preventive medicin~7 In: Koller, S. ed., Klinisch-statistische Forschung, Stuttgart - New York, Schattauer (in press) 226 Annex III Nussel, E. & Wilcke, S. Risk factors in myocardial infarction: results from the WHO Register study, In: ISC ed., Psychological approach to the rehabilitation of coronary patients (in press) 9. TOWER HAMLETS (London) Tunstall P e doe, H. ( 1972) Tower Hamlets coronary proj e ct, Brit. J. prev. soc. Med., ~(l), 61 Tunstall P e do e , H. (1975) Myocardial infarction in East London, Brit. Heart J., E, 551 Tunstall Pedoe, H. et al. (1975) Coronary heart attacks in East London, Lan ce t, I, 833 Tunstall Pedoe, H. Uses of heart attack registers. Memorial Lecture for 1975) (awaiting publication) (The John French Tunstall Pedoe , H. A heart attack register in East London. Thesis for University of Cambridge) (awaiting submission) 11. TAMPERE Hytonen, I. (1972) He ar t ambulanc e , Duodecim (in Finnish) (M.D. Rahe, R.H. et a l. (1973) Subj ects' recent life changes and corona ry heart d i sease in Finland, Amer. J. Psych., 130, 1222-1226 Rahe, R.H. et al. (1974) R e cent life changes, myocardial infarction and abrupt coronary de ath, Arch. intern. M e d., 133, 221-228 Rissanen, V. et al. (1971) Sudden c oronary death on the basis of WHO ischaemic heart disease register in Helsinki, Scand. J. clin . lab. Invest., £!._, suppl. 116, p. 18 Rissanen, V. et al. (1975) Deaths from ischaemic h ea rt disease in persons aged 65 or younger in Hels i nki in 1970, Acta med. scand., 197, 51-60 Romo, M. (1969) The ischaemic heart dis ea s e r egister in Helsinki, Helsing. Laakaril., 1_, 51 (in Finnish) Romo, M. (1969) The ischaemic he a rt dise a se r egis ter in Helsinki is functioning, H e lsing. Laakaril., 4-5, 76 (in Finnish) Romo, M. (1970) The ischaemic heart disease register in Helsinki, Suom. Laakaril., 1_, 1 77 (in F innish) 227 Annex III Romo, M. & Siltanen, P. (1970) Infarct mortality in Helsinki, Helsing. Laakaril., _!, 90-91 (in Finnish) Romo, M. et al. (1970) The ischaemic heart disease register in Helsinki. A pre-pilot study, Suom. Laakaril., 25, 2520 (in Finnish) Romo, M. et al. (1971) The mortality from coronary disease in Helsinki on the basis of WHO ischaemic heart disease register, Scand. J. clin. lab. Invest., 27, suppl. 116, p. 18 Romo, M. (1972) Factors related to sudden death in acute ischaemic heart disease, Acta med. scand., suppl. 547 Romo, M. (1974) Coronary heart disease as reflected by the ischaemic heart disease register in Helsinki. Nordic Council for Arctic Medical Research, Report No. 7, p. 31 Romo, M. et al. (1974) Work behaviour, time urgency and life dissatis- factions in subjects of myocardial infarction : A cross-cultural study, J. psychol. Res., ~. 1-8 Ruosteenoja, R. (1972) The diagnostic criteria of acute myocardial infarction, J. Finnish med. ass., 27, 3197-3199 (in Finnish) Ruosteenoja, R. et al. (1974) The social and medical background of myo- cardial infarction patients, J. soc. Med. (Finland), _!, 239-247 (in Finnish, with English summary) Siltanen, P. et al. (1970) The ischaemic heart disease register. A pre- pilot study, 75uodecim, .!_2 (in Finnish) Siltanen, P. et al. (1970) A pre-pilot study on ischaemic heart disease register in Helsinki, Scand. J. clin. lab. Invest., 25, suppl. 113 Siltanen, P. et al. (1971) One-year follow-up of patients of acute ischaemic heart disease on the basis of WHO ischaemic heart disease register in Helsinki, Scand. J. clin. lab. Invest., '!:J..., suppl. 116, p.19 Siltanen, P. (1972) The ischaemic heart disease register as a frame for preventive measures, Advanc. Cardiol., ~. 214-225 Siltanen, P. et al. Feasibility study on mobile coronary care unit in Helsinki (in press) Siltanen, P. Physical activity and coronary heart disease in Helsinki coronary register, Advanc. Cardiol. (in press) 228 Annex III 12 . WARSAW Korewicki , J. et al. ( 1974) Deaths due to acute myocardial infarction in the population of Warsaw, Pol. Tyg. lek., 29, 1259 (in Polish) Rywik, S . et al. (1973) Methodology of expanded cardiological epidemio- logical studies illustrated by myocardial infarction registration in Warsaw, Kard. Pol., ~ . 6, 467-474, and 475-483 (in Polish) Cooperative study (1973) Morbidity from myocardial infarction in the city of W arsaw - Results of one-year registration programme, Kard. Pol., 16, 6, 475 (in Polish) Mikofajczyk, W. et al. Prodromal symptoms in recent myocardial infarc- tion, Kard. Pol~Polish) Cooperative study: Registration of myocardial infarction in Warsaw and Lublin . Part I: General data concerning morbidity, Pol. Tyg. Lek. (in press) Cooperative study: Registration of myocardial infarction in Warsaw and Lublin. Part II : Prehospital care of registered patients, Pol. Tyg. Lek. (in press) Cooperative study: Registration of myocardial infarction in Warsaw and Lublin . Part III : Prodromal symptoms of myocardial i nfarction in registered patients, Pol. Tyg. Lek. (in press) 13. LUBLIN Bednarzewski, J. et al. (1973) Zgony wsr6d chorych na zawa-r serca w okresie 12 miesi~cy rejestracji zawaru serca w Lublinie .[Mortality among myocardial infarction patients over a 12-month period of myocardial infarction registration in Lubli_!Y Pol. Tyg. Lek . , 28, 205 and 60 9-611 Kedra, M. et al. (1973) Wyniki 12 miesi~cy rejestracji zawalu serca w Lublinie ffiesults of a 12-month registration of myocardial infarction in LubliE.7 Pol. Tyg . Lek., 28, 160-162, 1496-1500 and 1761-1764 Szczepanski, L. et al. ( 197 3) Effect of meteorological conditions on the incidence of myocardial infarction, Pol. Tyg. Lek., 28(32), 1225-1228 Cooperative study : (1975) Rejestracja zawalu serca w Warszawie i Lublinie. CzfSC pierwsza: dane og6lne dotycz?-ce zachorowalnosci. ffiegistration of myocardial infarction in Warsaw and Lublin. Part I: General data concerning morbidity7Pol. Tyg. Lek., 30, 551 Cooperative study: ( 197 5) Rejestracja zawalu serca w Warszawie i Lublinie. Cz~sc druga: opieka przedszpitalna natl zarejestrowanymi chorymi ffiegistration of myocardial infarction in Warsaw and Lublin. Part II: Pre-hospital care of registered patient~7Pol. Tyg . Lek., lQ_, 597 229 Annex III Cooperative stud[: (1975) Rejestracja zawa-lu serca w Warszawie i Lublinie. Cz1r s trzecia: Objawy prodromalne zawa-lu serca u zarejestro- wanych .[Registration of myocardial infarction in Warsaw and Lublin. Part III: Prodromal symptoms of myocardial infarction in registered patient~ Pol. Tyg. Lek. , 30, 621 15. KAUNAS Baubinene, A., Misjunene, N. & Milasauskene, M. (1971) Organizacija omosci bol'n m infarktom miokarda V do- i oststacionarn • eriod Organization of care for myocardial infarction patients before and after hospitalization? In: S eciali aci ·a i vnutrennie bolezni. Material dokladov VS 'ezda terapetvov Estonskoj SSR Specialization and internal diseases. Reports delivered at Fifth Congress of Therapeutists of EstonianSS~7 Tallin, pp. 21-23 Baubinene, A. & Milasauskene, M. {_!971) K voprosu o metodike uceta infarkta miokarda v gorode Kaunas LMethodology of registration of myo- c;ardial infarction cases in Kauna~ In: Naucnye trudy, vypusk 10 9. Epidemiologija hroniceskih neinfekcionnyh zabolevanij ZScientific works, No. 109. Epidemiology of chronic non-infectious diseases? Irkutsk, pp. 104-105 - Milasauskene, M. (1971) Vneza na·a smert' ot infarkta miokarda i ostro· koronarnoj nedostatocnosti v dobol'nicnyh uslovijah Sudden death from myocardial infarction and acute coronary insufficiency in prehospitalization conditions? In : Sovremenn e roblem isemicesko · bolezni serdca ,Lcontemporary problems of ischaemic heart disease Kaunas, pp. 157-162 Milasauskene, M. (1972) Analiz vneza n h dobol'nicn h smerte· ot infarkta miokarda i ostroj koronarnoj nedostatocnosti v gorode Kaunas Analysis of sudden prehospital deaths from myocardial infarction and acute coronary insufficiency in Kauna~ In: Kardiologija, 1972. Materialy III konferencii naucno o obscestva kardiolo ov Litovsko · SSR, Kaunas, 16-18 nojabrja 1972 Cardiology, 1972. Proc. Third Con£. of Scientific Soc. of Cardio- logists of Lithuanian SSR, Kaunas, 16-18 November 197'!:.7 Kaunas, pp. 40-41 Januskevicius, z. et al. (1972) K VO rosu or anizacii srocno· do OS ital 'noj pomosci bol'nyminfarktom miokarda Organization of emergency prehospital care for myocardial infarction patient~? Materialy III kon- ferencii naucno o obscestva kardiolo ov Litovsko· SSR, Kaunas, 16-18 nojabrja 1972 Proc. Third Con£. of Scientific Soc. of Cardiologists of Lithuanian SSR, Kaunas, 16-18 November 197[/ Kaunas, pp. 57-59 Janu;kev i;ius, Z. (1972) Sistema bor'b s isemicesko· bolezn 1 ·u serdca ffiystem for the control of ischaemic heart diseas~ In: Ostraja koron- arna ·a nedostatocnost'. Infarkt miokarda LA.cute coronary insufficiency. Myocardial infarctio~ Moscow, pp. 106-107 230 Annex III Januskevicius, Z. (1972) Sistema bor'b s isemicesko · bolezn• ·u serdca _LSystem for the control of ischaemic h e art dis e as~ In: Materialy III konferencii naucno o obscestva kardiolo ov Litovsko · SSR, Kaunas, 16-18 nojabrja 1972 Proc. Third Con£. of Scientific Soc. of Cardi ologists of Lithuanian SSR, Kaunas, 16-18 November 197'?:._7 Kaunas, pp. 55-56 Januskevicius, z. et aL_jl972) Nekotorye rezul'taty lecenija infarkta mio- karda v go rode Kaunas LSome results of treatment of myocardial infarction in Kaunas/ In: Ostra·a koronarna·a nedostatocnost'. Infarkt miokarda fa.cute coronary insufficiency. Myocardial infarctioE_ Moscow, pp . 105-106 Januskevicius, Z . (1973) 0 tor anizacii bor'b s isemicesko · bolezn• ·u serdca v Litovskoj SSR Experience in the organization of i schaemic heart disease control in the Lithuanian SS~7 Kardiologija, J__, 13-21 Januskevicius, Z., Baubinene, A . & Milasauskene, M. (1973) Vnezapnaja dobol'nicna ·a smert' ot ostro o infarkta miokarda i ostro · koronarno· nedo- statocnosti - aktual'naja problema zdravoohranenija Sudden prehospital death from acute myocardial infarction and acute coronary insufficiency - a topical health care proble~7 Zdravoohranenie, J__, 37-42 (in Lithuanian) Januskevicius, Z . et al. (1973) Re istraci·a ostro o infarkta miokarda v sisteme bor'by c isemiceskoj bolezn'ju serdca Registration of acute myocardial infarction in a system of ischaemic heart disease control? In : Isemice ska . a bolezn ' se rdca. 2- . Vse so ·uzn • S 'ezd Kardiolo ov, 26- 30 ijunja 197 3 Isch aemic heart dis e as e . Proc. S e cond All- Union Congress of Cardiologists, 2 6 -30 June 19737 Mosco w , pp. 113-116 Milasauskene, M. et al. (1974) Puti i vozmoznosti ulu c seni ·a bor 'b s isemiceskoj bolezn']li"serdca Ways and possibilities of improving ischaemic heart disease control? Document d e posite d with a specialized institute of the State Committee for Science and Technology, USSR Council of Ministers Januskevicius, Z. & Bloozhas, J. (1974) Four-year experienc e with the register of myocardial infarction in Kaunas. In : VII World Congress of Cardiology, Buenos Aires, Argentina, 1- 7 September 1974 Milasauskene, M. & Seskevicius , A. (1975) Registracija ostrogo in fa rkta miokarda i e o rakticeskoe znacenie dl ·a or anizacii zdravoohraneni·a Registration of acute myocardial infarction and its practi cal significance for health service organization? Proc. of XXIII Scientific Con£. of Kaunas Med. Inst., Kaunas, pp. 16 1-162 Seskevicius, A . U 975) Registr infarkta miokarda i vne zapnoj sme rti v gorode Kaunas LRegister of myocardial infarction and sudden death in Kaunas/ Proc. of Inter-republican Con£. of Young Scientists, pp. 136-138 2 31 Annex III 31. TEL AVIV Altman, S. et al. Mortality and morbidity of acute myocardial infarction {A WHO cooperative study of ischaemic heart disease register, 1971) Harefuah {in press) Brunner, D., Altman, S. & Meshulam, N. The profile of acute myo- cardial infarction {in preparation) 50. BERLIN Aurish, R. et al. {1972) Herzinfarktregister Berlin-Lichtenberg - Anlage und Zwischenergebnisse, Sante Publique Revue Int. (Bucharest), 1_, 311-318 {English summary) Bothig, S. et al. ( 1972) Herzinfarktregister Berlin, Erfurt, Pasewalk- Konzeption und Zwischenergebnisse, Dtsch. Gesundh Wes., '!:]_, 1501-1506 (English summary) Schneider, I. & Bothig, S. (1974) Epidemiologie des Herzinfarkts - Ergeb- nisse des He rzinfarktregisters Berlin - Lichtenberg 1970/71, Wissenschaft- liche Zertschrift der Humboldt- Universitat zu Berlin, Math. -Nat. R., 23, 21-23 - 232 No. 1 No. 2 No. 3 No. 4 PUBLIC HEALTH IN EUROPE Health Planning and Organization of Medical Care Chronic Diseases Communicable Diseases Glossary of Health Care Terminology