The wide variation in severity of cardiac infarction is well known. At one extreme the patient is admitted in severe irreversible shock, cold, clammy, and dazed with a rapid feeble pulse, low or perhaps immeasurable blood pressure, and widespread changes of severe degree in the cardiogram: his chances of surviving the acute stage of the illness are indeed slender. At the opposite extreme is the patient with cardiac pain, perhaps felt only on effort, of good colour, without shock or breathlessness, with normal pulse and blood pressure, and with limited cardiographic changes: such a patient is most unlucky if he does not survive the acute stage. Between these all possible gradations are met. As a consequence very large numbers are required (preferably 200 or more) if two groups on different therapeutic regimes are to be compared. With smaller groups, even though sampling has been strictly random, one is often left with the impression that one group has contained a larger number of the more serious cases.It seemed to us that a numerical system might be devised that would express the severity in an individual case, on lines similar to the "diagnostic score" advocated for thyrotoxicosis (Crooks, Murray, and Wayne, 1959). Such a system has previously been proposed by Schnur (1953a andb and) but we feel that in some respects this was too detailed while in others it left too much latitude for individual opinion; for example, the complication of diabetes might be allotted anywhere between 10 and 25 on his scoring system. We have attempted to devise a system in which the number of factors to be taken into account is kept to the minimum compatible with providing a reasonably close correlation between the total score and the mortality expectation. We have tried to limit the latitude allowed to the observer by defining strict criteria for the award of a given score for each factor. We have aimed at producing a method that can be easily memorized and rapidly applied, and one where the possibility of observer error is minimized. We fully realize that it is impossible to eliminate observer error completely: for example, in a borderline case one observer might well regard a patient as mildly shocked while another would classify him as having no shock. The more strictly we define the conditions qualifying for "black marks," the less room there will be for such differences of opinion.A study of data collected since 1930 has convinced us that the important factors covering the immediate prognosis (i.e. the prognosis for the first four weeks) after cardiac infarction are age, sex, previous history, degree, and severity of shock, prese4ce and severity of heart failure, cardiac rhythm, and the nature and extent of cardiographic signs. We shall discuss these factors individually. METHOD AND MATERIALInitially we drew up a purely arbitrary score for each factor, based on our general clinical impression of its importance for prognosis. We
Age and sex have hitherto received less consideration than they merit in publications dealing with prognosis and mortality in coronary artery disease. Yet a clear knowledge of all factors that influence mortality is of paramount importance at a time when the efficicacy of modern methods of treatment is under critical review. Even in the matter of their influence on etiology, age and sex have received less prominence than the facts would seem to justify.It is common knowledge that coronary artery disease is much more frequent in men than women: estimates have varied between seven to one (Mackenzie, 1923) and four to one (Block et al., 1952). It is also widely recognized that coronary artery disease reaches its maximum incidence in the fifth, sixth, and seventh decades of life. Nevertheless few references can be found to the striking difference between the age incidence in males and that in females. Block et al. (1952) hint at the existence of such a difference when they state that the preponderance of men becomes less in the older age groups. Johnston (1954) thinks the age incidence is about ten years later in women than in men.Mortality figures are usually quoted for entire groups of patients comprising both sexes and all ages, as though the mortality were not appreciably affected by age or sex. Yet, without actually saying so, Mackenzie (1923) implies that the disease is more rapidly fatal in the elderly than in the young when he writes (p. 138) " If we put aside the relativelyfew patients in whom death occurred before 50 years ofage we will find that the deaths follow closely that of the general death rate " (my italics). Of his 214 patients whose age at death is given (p. 118), 24 were aged under 50; the largest number of deaths occurred in the quinquennium 61-65 (p. 116). The figures of Block et al. (1952) show a steadily diminishing percentage of survivors, both at five and at ten years after onset, as the age at onset advances from under 40 to over 80. Cole et al. (1954) quote figures that show a later incidence in women than men, a steadily rising mortality in men as age increases, a relatively higher mortality in women than in men of the lower age groups, and a considerably smaller rise in mortality with increasing age in women. MATERIAL AND METHODSThe investigations, in the course of which the present observations were made, were originally begun for a different purpose, namely to assess the immediate and remote prognosis in patients who have had what may be termed an " acute coronary episode." The material therefore includes patients who have experienced such an episode-an attack of cardiac infarction, an attack of angina pectoris (" acute coronary insufficiency " or " acute cardiac ischemia "), abrupt onset of effort angina, or abrupt change in the severity or behaviour of pre-existing effort angina. It does not include cases of chronic angina of effort which have started so insidiously and progressed so slowly that no definite " episode" could be recognized. The patients were seen in consulting pr...
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