Over a one-year period, i858 episodes of suspected acute heart attack occurring in the Edinburgh population under the age of 70 were documentedfrom a notification survey conducted by a special team in liaison with general practitioners, hospitals, and police surgeons.The overall annual incidence of episodes of acute heart attack in the population aged 40 While epidemiological studies have made a major contribution to knowledge about some of the causes of coronary heart disease, the natural history of acute heart attacks is still obscure. Though it is now known that efficient intensive care can prevent some early deaths in those surviving long enough to reach hospital (Lawrie et al., i967), further advances must depend upon a better understanding of this natural history. In order to obtain information about the sequence of events immediately after such attacks, an attempt was made to record data about every acute coronary heart attack in the city of Edinburgh over a period of one year. The preliminary findings have already been reported (Fulton, Julian, and Oliver, I969) and this definitive report sets out 'to complete the clinical picture' (Morris, i964) of acute heart attacks and thus to provide a factual basis for

No abstract

SummaryThe natural history of new and worsening angina pectoris was studied in 251 men aged under 70 years. Most were ambulant and all were referred by selected general practitioners to a special hospital clinic over two and a half years. Heart attacks developed in 39 patients, nine of whom died. Seventy-two per cent of the attacks occurred within six weeks of the onset or worsening of angina. Of the 212 patients who did not suffer myocardial infarction and who were clinically reviewed six months after their first attendance 66 had been pain free for the previous three months and 14 had experienced only infrequent attacks of angina. Of the 128 men aged under 65 years who were previously in employment 810 had returned to fulltime work six months after their first attendance.A discriminant function analysis using many variables was made to develop a predictive index that would allow patients with new or worsening angina who were likely to develop serious cardiac complications to be identified.

The blood pressure was studied in 42 males and 36 females in 2 groups of nomadic Bushmen, living near Ghanzi in the Kalahari Desert, as well as in a third group of 21 Bushmen prisoners and farm laborers from the same region. The pressures were also "corrected" for arm girth. The average systolic pressures were 108.4 mm. Hg (S.D. 11.4) for men and 112.8 mm. Hg (S.D. 14.6) for women. The average diastolic pressures were 66.2 mm. Hg (S.D. 6.9) and 69.6 mm. Hg (S.D. 8.0) for men and women, respectively. These pressures with stated exception, are considered to be lower than for most populations. In the women, the systolic and diastolic pressures were higher than those in the men. The blood pressure showed no tendency to rise with age, an observation in contrast to that found in most other populations. It was suggested that an increase of the blood pressure with age may be an indication of the existence of essential hypertension within that population. The blood pressures of Bushmen prisoners and farm laborers were higher than those in nomadic Bushmen. Further investigation is needed of the genetic and environmental factors affecting the blood pressure in the nomadic Bushmen.

From 1975to 1979 patients undergoing valve replacement were entered into a randomized trial and received either a Bjdrk-Shiley (273 patients) or a porcine heterograft prosthesis (initially a Hancock valve [107 patients] and later a Carpentier-Edwards prosthesis [ 160 patients]). Two hundred and sixty-two patients required mitral valve replacement, 210 required aortic valve replacement, 60 required mitral and aortic valve replacement, and eight also required associated tricuspid valve replacement (six mitral valve replacement; two mitral plus aortic valve replacement). Analysis of 34 preoperative and operative variables showed the treatment groups to be well randomized. In-hospital mortality was not significantly different among patients receiving the three prostheses for aortic valve replacement (7.6% overall) and mitral plus aortic valve replacement (10% overall), but there was a higher in-hospital mortality for patients undergoing mitral valve replacement with the CarpentierEdwards prosthesis (15.5% compared with 8.8% overall; p = .03). This difference could not be explained on the basis of any preoperative or operative variable. Median follow-up was 5.6 (range 2.8 to 8.3) years. Actuarial survival after mitral valve replacement was 56.7 + 7.0% at 7 years, that after aortic valve replacement was 69.6 ± 9.6% at 7 years, and that after mitral plus aortic valve replacement was 62.5 ± 20.0% at 7 years. There was no significant difference in actuarial survival of patients receiving the three prostheses within the mitral, aortic, and mitral plus aortic valve replacement groups, nor was there a difference when these groups were amalgamated. Thirty-seven patients required reoperation for valve failure (15 with Bjbrk-Shiley, 12 with Hancock, and 10 with Carpentier-Edwards valves; p = NS) and 11 died at reoperation (four with Bjdrk-Shiley, four with Hancock, and three with Carpentier-Edwards valves; overall operative mortality 29.7%). Up to 7 years after surgery, there was no significant difference in the incidence of thromboembolism in patients with the different prostheses undergoing mitral or aortic valve replacement. There were too few patients undergoing mitral plus aortic valve replacement for meaningful comparison. There was no significant beneficial effect of anticoagulants in patients undergoing mitral or aortic valve replacement with porcine prostheses, but patients were not randomly allocated to anticoagulant treatment. All patients with Bjdrk-Shiley prostheses received anticoagulants. Multivariate analysis of factors associated with embolism identified atrial fibrillation with mitral valve replacement (p < .001) and age less than 65 years (p < .01) and a rheumatic cause of valvular disease (p < .01) with aortic valve replacement. The risks of anticoagulation were low, with an overall incidence of complications of approximately one per 100 years treatment. To date no significant advantage of any of the three prostheses has been observed, but further follow-up is necessary because important differenc...