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The clinical course of angina pectoris was studied in a follow-up study of 427 patients with angina from a general population sample. The subjects were men aged 56-65 years at the time of follow-up. After a mean follow-up time of 5.8 years, 55% were still suffering from angina pectoris, 15% had died and a further 19% were either free from chest pain or had chest pain considered to be of different origin. In the group with definite angina pectoris at follow-up (n = 236), 29% had sustained a myocardial infarction, 23% had symptoms of intermittent claudication, 36% were treated for hypertension and 15% had diabetes. Many of the angina patients suffered from other chest conditions in addition to anginal symptoms. Most of the patients (56%) had infrequent attacks (a few times per month or less often) and were not severely incapacitated by their symptoms. Only one fifth worked full time compared with more than half of those in the same age groups in the general population. Only 16 of those interviewed had undergone bypass surgery and a further 16 had disabling angina but, for various reasons, they had not been operated on. The implications are that most angina patients do well on pharmacological treatment alone even though they are limited socially as well as physically. Precipitating factors other than physical activity were also investigated and associations were found between susceptibility to cold, early morning angina, angina at rest and attacks of long duration, possibly indicating a mechanism of vasospasm superimposed on a fixed stenosis.
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PMID:Clinical course and symptomatology of angina pectoris in a population study. 377 87

To evaluate the frequency of painless myocardial ischemia, all patients with positive exercise tolerance test responses (at least 2 mm of ST depression) from 1983 to 1985 were examined. Of the 211 patients with exercise-induced ischemia, 101 (48%) did not have pain during the ischemic period; 26 (12%) had diabetes mellitus, 24 of whom (92%) had type II diabetes mellitus. Lack of pain was not correlated with age, gender, history of cigarette smoking, systemic hypertension, past acute myocardial infarction, coronary artery bypass grafting, use of beta-blocking or calcium-channel blocking drugs, number of narrowed coronary arteries or average calculated ejection fraction at cardiac catheterization. Patients with painless myocardial ischemia were less often taking nitrates (39% vs 55%, p less than 0.05) and reported prior episodes of chest pain less often (50% vs 82%, p less than 0.01) than control subjects. There was no difference in the frequency of painless myocardial ischemia between patients with and without diabetes mellitus (54% vs 47%). Duration of exercise was shorter in patients with diabetes mellitus and in patients who had pain with myocardial ischemia. No significant difference in age, gender, use of nitrates, beta-blocking or calcium-channel blocking drugs, history of myocardial infarction, angina pectoris or cigarette smoking was found between diabetic and nondiabetic patients. Systemic hypertension was more common in diabetic patients. Thus, painless myocardial ischemia is common in our patients with positive exercise tolerance test responses, but its frequency is similar in diabetic and nondiabetic patients.
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PMID:Frequency of painless myocardial ischemia during exercise tolerance testing in patients with and without diabetes mellitus. 381 54

The clinical features and course of 30 patients (26 men and 4 women) under 30 years of age (mean age 27.3 years) with an acute myocardial infarction (MI) are described. The most common risk factor among this group of patients was smoking in 20 patients (66%). The prevalence of the other risk factors was low: hyperlipidemia in four patients and family history of ischemic disease in another four patients, diabetes mellitus, hypertension, and obesity each in one patient. Seven patients (23%) had none of the conventional risk factors. Three patients were exerting themselves prior to the onset of their MI pain; all of them had normal coronaries. Five patients experienced chest pain prior to MI, among them only two experienced classical angina pectoris. Eighteen patients underwent uncomplicated MI. The complications in the other 12 during the acute MI were rhythm disturbances in eight and congestive heart failure in four. Cardiac catheterization was performed in 25 patients. The occurrence of zero, one, or multivessel disease was equal. The 30 patients were followed up from six months to 15 years (mean 7 years). In 18 patients circulating aggregated platelets were measured one year after the MI. Elevated values were found in all of them (mean +/- SD 34.9 +/- 9.1%). In 6 of the 18, all heavy smokers, extreme values were found in the range of 39-55%. Three out of the 30 patients died within five years after their first MI. The other 15 patients developed complications, most of them angina pectoris. Five patients were hospitalized for reinfarction. None of the 30 underwent aortocoronary bypass operation.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Myocardial infarction in young adults under 30 years: risk factors and clinical course. 381 21

A prospective study on 184 consecutive patients presenting with the chief complaint of recurrent chest pain (RP) for diagnostic coronary arteriography (CA) was conducted utilizing a simple questionnaire of historical, physical and electrocardiographic variables. A linear logistic regression analysis yielded a final data set of 13 variables. Concurrently, staff cardiologists who obtained the questionnaire data through direct questioning rendered a clinical diagnosis of either angina (coronary artery disease [CAD]) or noncardiac chest pain. Utilization of the regression analysis increased diagnostic accuracy from 69 to 86% (p less than 0.0003); sensitivity from 83 to 88% (NS) and specificity from 49 to 84% (p less than 0.0001). The best predictive variables for the presence or absence of obstructive CAD documented by CA were in order of decreasing value: age, electrocardiogram, pain aggravated by sex, sex (gender), pain aggravated by movement, diabetes mellitus, pain described as prickling, pain described as burning, pain relieved by rest, pain with radiation to both arms, associated nausea, associated dyspnea, and a history of a lipid disorder. Four variables were predictive of normal coronary anatomy (NCA), pain aggravated by movement, prickling, nausea, and dyspnea. Although this set of predictor variables may not apply equally well to all populations of cardiac patients, the availability and relative simplicity of the program allow for adding or deleting variables and thus provide for considerable potential in the diagnostic assessment of RP. An inexpensive pocket computer can utilize the coefficients generated by the logistic regression program to calculate the probability of CAD as the cause of RP.
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PMID:Analysis of historical variables, risk factors and the resting electrocardiogram as an aid in the clinical diagnosis of recurrent chest pain. 388 75

In a large machinery factory a cohort of 3754 men aged between 40 and 50 years have been studied for 5 years. Total and coronary mortality rates have been determined and also the incidence of certain non-fatal states which required hospitalization due to various types of coronary heart disease (CHD), hypertension, brain apoplexy, diabetes mellitus and malignancies. Among the subjects exposed to CHD risk factors (RF), i.e. among smokers, hypertensive and hypercholesterolemic subjects, and among those who had a positive coronary family history and a positive cardiovascular (chest pain) questionnaire, both total and coronary mortality rates were several fold higher and they increased almost exponentially with increasing numbers of RF. Among the RF it was the cardiovascular (chest pain) questionnaire which had the highest prognostic value. Workmen manifested a higher total and coronary mortality than did the employees in the technico-economical professions (TEP). The highest mortality rate was found among the workmen employed in heavy manual occupation. In contrast the lowest total coronary mortality rate was observed in the TEP having little responsibility in their vocation and also among qualified workmen and specialized technical and scientifical workers.
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PMID:Incidence and risk of coronary heart disease in an industrial population. A five-year prospective study. 392 16

Cardiac rupture occurs in 10 per cent of patients who die with acute myocardial infarction, but the pathogenesis remains unclear. Twenty randomly selected patients with cardiac rupture were reviewed retrospectively at autopsy, and the findings were compared with those of 20 age- and sex-matched control subjects who had died of acute transmural myocardial infarction without rupture. The times from the onset of chest pain to death were similar in the two groups (5.7 +/- 5.8 days for patients with rupture versus 4.2 +/- 4.9 days for control subjects), and there were no differences in the incidences of systemic hypertension, diabetes mellitus, hypercholesterolemia, history of myocardial infarction, or angina pectoris. The severity of coronary atherosclerosis was different in the two groups, with 55 per cent of the patients with cardiac rupture having single-vessel disease and 70 per cent of the patients without cardiac rupture having disease in three vessels. Additionally, the incidence of thrombosis was greater in patients with cardiac rupture than in those without. The inflammatory cell response in each patient was quantitated microscopically (number and type of leukocytes) in ten high-power fields. The inflammatory response was greater in patients with cardiac rupture. The number of eosinophils in the inflammatory response was significantly (P less than 0.01) greater in hearts associated with cardiac rupture (29.5 +/- 4 per cent) than in control hearts (11.7 +/- 3.1 per cent). It is postulated that eosinophils rich in arylsulfatase B, peroxidase, glucuronidase, beta-glycerophosphatase, major basic protein, and eosinophilic cationic protein may further weaken the necrotic myocardium and, in part, determine whether acute myocardial infarction will eventually result in cardiac rupture.
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PMID:Association of eosinophils with cardiac rupture. 399 34

To evaluate the cardiovascular response to exercise in diabetes, a graded maximal exercise test was performed on 50 women with insulin-dependent diabetes mellitus, aged 15-40 years, and on 15 healthy women in the same age group. The diabetic subjects were divided into 3 groups according to the duration of disease: group 1: 0-5 years, group 2: 6-14 years, group 3: 15-29 years. The maximal work load was lower in the diabetic subjects than in the controls. The difference was most marked between the controls and group 3 (167 +/- 14 W vs 132 +/- 23 W, p less than 0.001). The maximal heart rate was lower in groups 2 and 3 than in the controls (173 +/- 16 vs 187 +/- 11, p less than 0.05). The diabetic women with long-standing disease had a slightly higher blood pressure response to exercise resulting in comparable rate-pressure products in the study groups. Two diabetic women in group 3 and one healthy woman had 1 mm ST depressions during the test without appearance of arrhythmias or chest pain. These studies suggest that exercise tolerance is reduced in young diabetic women, especially in patients with long-standing disease. The frequency of pathological exercise ECGs does not, however, seem to be increased.
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PMID:Cardiovascular response to exercise in young women with insulin-dependent diabetes mellitus. 400 94

2 young, menstruating females without any of the major risk factors (hypertension, diabetes mellitus, hyperlipidemia) developed acute myocaridal infarctions while taking oral contraceptives; their clinical histories and laboratory and arteriographic studies are presented. In the first patient (aged 29) who took Ortho-Novum 2 mg. for 11 months prior to infarction and who had an abnormal glucose tolerance test, selective coronary angiography revealed a segmental occlusion of the proximal left anterior descending coronary artery. In the second patient (aged 38) who took Enovid for several years prior to infarction, selective coronary angiography showed slight irregularity of the left anterior descending coronary artery; no evidence of akinesis or dyskinesis of the ventricular wall was noted. Although incidence of coronary artery disease in young, menstruating women has always been very low, recently there have been scattered case reports of women with acute myocardial infarction in absence of major risk factors; all cases shared the common features of oral contraceptive use prior to infarction, and unusual distribution and peculiar appearance of lesions in coronary arteries. Such reports, although rare, in young females taking synthetic estrogen do suggest that a relationship may exist between oral contraceptive agents and thromboembolic phenomena, especially coronary thrombosis. Mechanisms by which oral contraceptives might precipitate thrombosis are discussed. It is suggested that coronary artery disease should be suspected in young oral contraceptors suffering chest pain even though they are still menstruating and are free of major risk factors.
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PMID:Coronary thrombosis in young women on oral contraceptives: report of two cases and review of the literature. 470 63

Hyperglycaemia occurring at admission in patients with suspected acute myocardial infarction is generally held to represent stress hyperglycaemia. 26 patients, not previously known to be diabetic, had blood glucose values greater than or equal to 10 mmol/l on admission to a coronary care unit. 16 survived for 2 months at which time a 75 g oral glucose tolerance test (OGTT) showed diabetes in 10 (63%) and impaired glucose tolerance in 1 (WHO criteria). All those with abnormal glucose tolerance at 2 months had had raised glycosylated haemoglobin (HbA1) (greater than 7.5%) on admission, indicating pre-existing diabetes. All those with a HbA1 level over 8% had abnormal glucose tolerance. 7 of the 10 who died or did not have an OGTT also had raised HbA1 at admission. An admission blood glucose greater than or equal to 10 mmol/l in patients with severe chest pain is more likely to indicate previously undiagnosed diabetes than "stress" hyperglycaemia. There is no evidence that myocardial infarction precipitates diabetes. The glycosylated haemoglobin concentration can be used to distinguish between stress hyperglycaemia and hyperglycaemia caused by diabetes.
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PMID:"Stress" hyperglycaemia during acute myocardial infarction: an indicator of pre-existing diabetes? 613 25

Esophageal motility disturbances are common in diabetics in general and are most prevalent in these with peripheral neuropathy or autonomic neuropathy. The usual findings are a decrease in the amplitude of esophageal contractions in the smooth muscle portion of the body, frequent absence of primary peristalsis, simultaneous or repetitive body contractions, and a decrease in the velocity of peristalsis. Radiographically, this may be manifest as delayed esophageal emptying. These changes do not produce symptoms. Dysphagia and chest pain should be thoroughly evaluated and not ascribed to the diabetes. Candidiasis may be more common in diabetics.
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PMID:Esophageal disorders in diabetes mellitus. 642 49


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