No abstract

This study examines the changing presentation of coronary heart disease (CHD) in an inpatient population at Brooke Army Medical Center. The specific objectives of the study were to examine the presentation of CHD in a population unbiased by diagnosis-related group (DRG) reimbursements and to assess the importance of unstable angina and prior history of disease in the presentation of CHD. One thousand fifteen discharges in 1985 and 1,304 discharges in 1990 with the diagnosis of CHD were reviewed by cardiologists for evidence of symptomatic heart disease at the time of hospitalization. Forty percent of these charts were accepted into this study. The presentation rates of CHD were 1% with sudden death, 26% with myocardial infarction, 64% with angina, and 9% with congestive heart failure (CHF). During the study period, stable angina, Q-wave infarctions, and the myocardial infarction case fatality rate decreased (p < 0.05) and CHF and non-Q wave infarcts increased (p < 0.001). However, unstable angina was the most common presentation of CHD, and differences (p < 0.05) were noted in the presentation of CHD in patients with and without a prior history of disease. This study demonstrates the significance of unstable angina and prior history of CHD in an environment free of bias from DRG reimbursements.

Seven patients with atherosclerotic coronary artery disease documented by coronary angiography and exercise stress testing were treated with the American Heart Association Step II Diet, a walking program, and combination drug therapy with niacin, cholestyramine, gemfibrozil, and/or lovastatin. As a result of this intervention, there was a mean weight loss of 24.7 pounds, a mean reduction in cholesterol from 297 mg% to 167 mg%, a mean increase in high density lipoprotein cholesterol from 33 mg% to 55 mg%, and a mean reduction in triglyceride levels from 248 mg% to 58 mg%. Repeat exercise stress testing and coronary angiography were performed 2 years after the initial catheterization. Photographs of end-diastolic frames were compared utilizing the same views with the same magnification. In six of the seven patients, there was a mean increase in luminal area at the greatest stenosis of 1.3 mm2 in eight lesions present at initial catheterization. In four of these six patients, there was evidence for improvement in coronary blood flow manifested by improvement in electrocardiogram (ECG) exercise stress testing and/or exercise thallium stress testing. In one patient, there was a mean decrease in luminal area at greatest stenosis of 1.35 mm2 in two lesions and the development of an additional plaque in an area which was previously normal. In addition, this patient had evidence for progression by ECG exercise stress testing. Aggressive risk factor modification can reverse what were previously considered "fixed" atherosclerotic lesions in selected patients.