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Long survival following myocardial infarction
Long
Survival
Following
Myocardial
Infarction Report
on 255 Patients Longer
Living
or
After the First Attack
LOUIS H. SIGLER, Brooklyn,
M.D.,
F.A.C.C.
New York
I
N 1951 a report was made on a series of 1,700 cases1 of coronary disease observed over a At that time, 1,021 period of twenty-five years. These were followed patients were still living. over an additional period of nine years and a subsequent report was made in 1960.2 Of these, 456 patients could not be followed over the nine year period ; however, the remaining 565 patients were still under observation, of whom 270 were living. This is an analysis of 255 of the surviving patients, brought up-to-date, who had at least one attack of myocardial infarction and lived ten years or longer after the attack; 210 of these are still living.
(68.4 per cent) have already lived 10 to 14 years or longer after the first attack of infarction, 50 (27.3 per cent), 15 to 19 years and 8 (4.3 Of the per cent), 20 years or longer (Table II). 43 males who have died, 32 (74.4 per cent) had lived 10 years or longer, 11 (31.6 per cent), 15 years or longer, and 1 (2.3 per cent), 22 years or Of the 29 females longer after their first attack. still alive, 26 (89.8 per cent) already have lived 10 to 14 years, 1 (3.4 per cent), 15 years, 1 (3.4 per cent), 23 years and 1 (3.4 per cent), 25 Taking the life expectancy in years or longer. the year 1957 to be 73.5 years for females and 67.1 years for males,3 upward of 28 per cent of our males and 30 per cent of the females, who are still alive, have already lived beyond expecOf the males who have died, upward of tancy. 33 per cent had lived beyond expectancy. Present Ages of the Living Patients and Ages at Death: Percentagewise, relatively more females than males who are still living, have reached an older age (Table III). Of the 43 males who have died, none was younger than 40 years of age, and the highest percentage was between 60 and 69 years of age; 12 (27.9 per cent) lived beyond 70 years. Location of Infarction: Of the 255 patients, 236 (92.5 per cent) had one infarction and 19 (7.5 per cent) had more than one at different In 142 of this number (55.6 periods (Table IV). per cent), the infarction occurred in the anterior wall of the left ventricle, 28.2 per cent involving the entire anterior wall, 25.5 per cent only the anteroseptal portion and 1.9 per cent the anterolateral portion. In 92 patients (36.1 per cent), the infarction occurred in the posterior wall, and in 2 (0.8 per cent) in the upper lateral region. Of the 19 patients with more than one
OBSERVATIONS Male to Female Ratio: Of the 255 patients, 226 are males and 29 females; the male to feIn the original series of male ratio is 7.8:1. 1,700 cases, the male to female ratio was 3.2: 1. Mode of Onset of Clinical Manifestations: In the entire group of 255 cases, 207 patients (81.2 per cent) had an abrupt onset of acute infarction and in 48 (18.8 per cent), angina pectoris preceded infarction by 1 month to as In the original series of long as several years. 1,700 cases, only 52.4 per cent had an abrupt onset of myocardial infarction. Age at First Attack of Infarction: The greatest percentage of patients had their first attack of infarction between 50 and 59 years of age (Table I). Percentagewise, more females had their first attack after 60 years of age, while more males suffered an attack at an earlier age than their 49th year. Length of Survival Following First Attack of Infarction: Of the 183 males still living, 125 APRIL 1962
Ten Years
547
548
Sigler TABLE
Age
at First Attack
Age (v-s.)
I
TABLE
of Myocardial
Infarction
Males
Females
(226)
(29)
Present
Age
of the
I /O
Females
(183)
(29)
Ko.
4
20-29
13
5.8
2
7.2
30-39
88
38.9
4
14.3
40-49
50-59
91
40.3
16
55.2
so-59
1 l ~ 3:
60-69
95
70-79
‘g i ‘::I
1
60-69
28
12.1
6
21.3
70-79
2
1.0
1
3.0
51.5
55.2
yr.
80-89 Mean
yr,
Youngest
23 yr.
30 yr.
Oldest
72 yr.
74 yr.
infarction, only 2 died during the second infarc-
v>* Occupation and Postinfarction Status: The 29 females in this series were all housewives and TABLE
Length
Dead Patients Males (43)
%
Living
Group
(183)
Age
1
P.,’
20 8 51.9
3.4
2
6.9
14
48.4
11
37 9
1
11
25.6
1
2.3
3.4
63.8 yr.
67 I yr.
63.3 yr.
Youngest
39 yr.
43 yr.
47 yr.
Oldest
86 yr.
86 yr.
x3 yr.
Dead Group
II
of Survival
Males
T
(226)
Still Living*
Total
Still
Living
Females
Living
%
No.
No.
%
No.
(‘i
7.1 13.7 17.5 13.7 16.4 8.2 11.4 3.3 2.2 2.2 1.1
11
32 23 17 10 8 5 3
74.4 53.7 39.5 23.3 18.6 17.7 7.0
19 20
13 25 32 25 30 15 21 6 4 4 2
2
4.6
45 48 49 35 38 20 24 6 4 6 2
15.8 16.8 17.2 12.5 13.3 7.0 8.3 2.3 1.4 2.3 0.7
21
2
1.1
2
0.7
22
2
1.1
1
2.3
3
1.1
23
1
0.5
0
0.0
1
0.3
24
1
0.5
1
0.3
15 or more
58
30.7
11
31.6
69
26.1
20 or more
8
4.3
1
2.3
9
3.2
9 6 7 2 3 2
/C
Group
No.
0’
3 4 8 6 5 1
10.3 14.0 27.7 20.6 17.2 3.4
,o
3.4 3.4
25
* Represents
(29)
(29)
(43)
No. 10 11 12 13 14 15 16 17 18
at Death
all returned to their regular but supervised work, 2 to 5 months after recovery from infarction. Of the 226 males, 151 (66.8 per cent) were engaged in business, professional or clerical work, and 75 (33.2 per cent) in manual work. The business group of 106 (46.9 per cent)
tion. The rest are either still living or have died long after the second or third infarction (Table
Years After First Infarction
No.
%
30-39
Age
Age
1.9
40-49
Mean
and
h?ales
(yrs.1
C’
No.
III
Patients
Living Patients
kc
No.
Living
the remaining
living
patients
in the “Dead
Group”
at the respective THli
3 2
10.2
~
6.8
years after the first infarction.
AMERICAK
JOURSAL
OF CARDIOLOGY
Long TABLE
Survival
Following
Myocardial
Infarction
549
TABLE VI
IV
Number and Percentage of Cases in Given Areas of Infarction Location of Infarction (Left Ventricle)
Occupation
and Postinfarction 226 Males Returned
Status
to Work
%
Retired Occupations
Posterior wall
92
36.1
Anterior wall
72
28.2
Anteroseptal
65
25.5
Anterolateral
5
1.9
Upper lateral
2
0.8
19
7.5
More than one infarction
Regular
No.
No.
Modified
%
No.
70
___ Alloccupations
226
100.0
161
71.2
54
Business
106
46.9
86
81.2
18
16.9
Professional
31
13.7
21
67.7
10
32.3
Clerical
14
6.2
9
64.9
5
35.1
Ma”Ul workers
75
33.2
45
/
60.0
23.9
/ 21 ~28.0
TABLE v Patients with RecurrinP Infarction Agr at Onset in Years
Case
First Infarct
Angina
Second Infarct
Third Infarct
As
Age
Still Living
Dead
-l-
hi& D. L.
51
57
hf.
53
66
B. s.
51
58
R. R.
40
52
A. S.
59
73
s.
63’/r 66 61 54
57 83 75
s. D.
65
69
H. B.
55
55
H. G.
52
54
66
J. C.
48
54
60
s. s.
59
69
70
A. D.
62
65
75
I.. P.
49
58
72
39
41
52
55
56
67
28
35
J. S. F. %.
49
J. P.
25
i
H. R.
I
44
.I. L.
(
43
j
::
61
65
49
~
58
58
and designers, maintenance workers, printers and chauffeurs. Most of the patients were engaged in these pursuits for many years before the first attack of infarction. About 2 to 6 months after the attack, 161 (71.2 per cent) returned to their regular work and continued working for years; in 54 (23.9 per cent) a change of work was necessary, and 11 (4.9 per cent) were obliged to give up their work after the first attack. Several patients voluntarily retired after the age of 65. The percentage of patients who returned to work varied in different groups (Table VI). As many as 86 (81.2 per cent) of the business group but only 45 (60 per cent) of the manual workers continued their regular occupations. Of the 11 patients who had to give up their work, 9 were manual workers and 2 were businessmen. None of the professional nor clerical workers had to give up his work. However, the number of patients in these two groups is too small for comparison.
Female A. D. L. H.
ILLUSTRATIVE
:: -
Average duration betwren first and second infarct 6.5 yr.; first and third infarct 10 y-r,; first infarct and present age 14.7 y’.; second infarct and present age 8.8 y’.; first infarct and death 13.7 y’.; second infarct and death 6.6 y’.
patients consisted of shopkeepers and salesman, insurance brokers or agents, manufacturers, realtors, bank managers, organizers and other enterprises of a similar nature. The professional of 31 patients included physicians, group pharmacists, accountants, teachers and lawyers. The 14 clerical workers were shipping clerks, auditors, cashiers and proofreaders. The 75 manual workers were mechanics, machinists, electricians, clothing operators, cutters, pressers APRIL
1962
CASES
The following four cases illustrate some of the features observed in this series of 255 cases. Inasmuch as the cases cover long periods of observation, the histories are of necessity greatly abbreviated. CASE 1. M. O., male, owner of a wholesale drygoods business for many years, was seen for the first time on April 1, 1944 at 56 years of age. The day before he suddenly developed severe constricting pain in the anterior chest radiating to the left arm, lasting two hours, associated with cold, clammy perspiration, and requiring morphine for relief. An electrocardiogram (Fig. 1A) showed an early phase of acute posterior wall infarction with subendocardial myocardial ischemia of the anterior wall. He made a good clinical recovery after six weeks.
aVL
aVF
FIG. 1. Case 1. A, April 1,1944, early phase, acute posterior infarction and subendocardial ischemia of anterior wall. B, June 17, 1944, late phase of posterior infarction. C, February 2, 1952, residual changes of old posterior wall infarction. (Figure retouched for clarity.)
FIG. 2. Case 2. A, December 25, 1937, anterior wall infarction. Old lead IVF used in those days yields a reversed polarity so that the tall R and T waves are equivalent to a deep Q and inverted T. B, November 13,1958, C, May 10, 1951, posterior wall infarction. tracing within normal limits. D, August 15, 1951, remains of posterior wall infarction and subendocardial ischemia of anterolateral wall. E, August 15, 1955. residual changes. F, January 7, 1961, residual changes still present, but less marked.
Long Survival
Following
Examination on June 17, 1944 revealed a heart rate of 80, normal heart sounds, blood pressure 170/110 and some congestion at the bases of the Subjectively, he was well and could walk lungs. six to ten blocks without discomfort. An electrocardiogram (Fig. 1B) showed the remains of the posterior wall infarction. Subsequent examinations showed the same findings. His blood pressure varied between 130/85 and 170/110. He was practically symptom-free except for occasional palpitation and slight pain in the left arm. On February 2, 1952 he had an episode of pain in the right lower anterior part of the chest radiating to the interscapular region lasting 20 to 25 minutes, but there were no changes in the physical findings. The electrocardiogram (Fig. 1C) remained the same as before. On May 14, 1953 he had an upper respiratory infection for which he was given penicillin and which was followed by a severe rash. Antihistamines gave relief, but were followed by constricting chest pain which lasted on and off for one day without demonstrable acute changes in the heart. At the present writing (May 10, 1961) about 17 years after the attack and at 73 years of age, he is still alive and well, directing his business in an active manner. CASE 2. A. S., male, was first seen on December 22, 1937 when he was 59 years old. He has been in the retail jewelry business since 20 years of age. He visits boats on their arrival in New York ports and sells his wares to foreign sailors. He has to do considerable walking and stair climbing. He gave a history of lues which he contracted at 28 years of age and received antiluetic treatment for several years. Aside from that he was always well. For five weeks he experienced left precordial pain radiating to the left arm on exertion. The night before the examination he was awakened from sleep at 12:30 A.M. by severe anterior chest pain with cold sweat, marked pallor and fainting sensation. He required 30 mg. of morphine for relief. Examination revealed a tall, well preserved individual, height 73 inches, weight 175 pounds. His temperature during the first four days ranged between lOlo and 102OF., pulse 95-100, the leukocyte count was 15,500, with 79 per cent polymorphonuclears. The sedimentation rate was 32 mm. in 1 hour. An electrocardiogram (Fig. 2A) 3 days after the onset showed acute anterior wall inNo unipolar extremity and precordial farction. leads were in use at that time, except for a lead IV obtained by placing the right arm electrode at the apex coupled to the left leg electrode, giving a polarity opposite to that obtained by later methods. In other words, the low voltage notched R wave in the lead IV of Figure 2A was really a Q wave and the positive T wave would be negative in present day electrocardiograms. He recovered after six weeks of bed rest and returned to his usual work three months later, which he continued without interruption. APRIL 1962
Myocardial
Infarction
On January 16,1946 he had an episode of momentary unconsciousness with nausea and pain in the right scapular region, but there was no demonstrable evidence of recurring acute myocardial damage. He was symptom-free thereafter. An electrocardiogram obtained on November 13, 1948 (Fig. 2B), 11 years after the infarction, showed no gross abnormalities. On April 3, 1951 he again began to experience midsternal pressure and some pain radiating to the upper part of the left arm on walking against the wind, and 22 days later, he had another severe spontaneous attack of pressure pain in the anterior chest radiating to the left arm and interscapular region lasting 2 hours and relieved by morphine. This was followed by other clinical findings of acute infarction, shown by an electrocardiogram (Fig. 2C) to involve the posterior wall. He again made a good clinical recovery. He became, however, greatly depressed and worried when his family physician told him he would have to retire from his business because of his heart condition. However, with my assurance that he would be able to resume his business activities An electrocardiogram (Fig. 2D) after a short rest. taken 2 months after the second infarction showed residual findings of the infarct and subendocardial ischemia of the anterolateral wall. He was observed thereafter for 3 months at which time he showed progressive
improvement
He was then allowed continued
working
in
to return
his
cardiac
to his business
full time, feeling
reserve. and he
well for the next
five years. From time to time he was subject to the angina1 syndrome m a mild form on excessive strain or when worried. His blood pressure ranged between 125/70 and 160/100. An electrocardiogram obtained on October 15, 1955 (Fig. 2E) still indicated the remains of the posterior wall infarction with a greater degree of ischemia in the anterolateral wall. In view of his age of approximately 77 years at that time, he was advised to continue his work on a three to four hour a day basis and to rest on the days when he was subject to the angina1 pain. This he has done for the last six years. In February of 1960 he had an episode of bronchopneumonia which confined him to bed for five weeks. At the height of the disease, when the temperature was 104’F., he was delirious for 2 days and received massive doses of antibiotics. He made a good recovery. Examination on January 7, 1961, at 83 years of age and 24 years after his first myocardial infarction, revealed him to be in relatively good condition. The electrocardiogram (Fig. 2F) still showed the remains of his posterior wall infarction, but the ischemic pattern in the anterolateral wall was diminished. An interesting feature in this case is that the tests of his blood serology obtained on several occasions over the years of observation were all strongly positive for lues without any detectable clinical manifestations of the disease. Another important observation is that he felt best when no drugs were used. Reas-
552
Fig. 3.
Sigler
Case 3.
‘4, June 7, 1949, anterior
infarction
with septal involvement
June 2, 1949, later phase. C-D, October 24, 1951 and March 16, 1956, exaggeration of QRS complex and high R-T take-off in leads Vz through tember 25, 1959, 4 davs before death. Marked chanzxs in the ventricular to 0.17 second. ’
surance, relaxation from the occasional
CASE 3.
and careful chest pain.
dieting
gave
relief
S. N., male, a machine operator on embroidery for many years, was seen for the first time on June 10, 1949 when he was 64 years old. Ten days previously, after each meal he began to feel uncomfortable. On June 7, 1949 he had an attack of severe pressure in his chest radiating to the left arm and sweating. Assuming that he had indigestion, he took citrocarbonate and lemonade which made him vomit. He felt somewhat better, but the pain continued in milder form throughout the night and the following day. When first seen, he was acutely ill. He had an ashen pallor and was dyspneic. The heart was moderately enlarged, rate 110, regular rhythm. The first sound was greatly diminished in intensity, the second sound accentuated and split at the pulmonic area. There was a proto-
and right bundle branch block. B, respectively, showing persistent changes with VS due to left ventricular aneurysm. E, Sepcomplexes with delay in the QRS conduction
diastolic gallop rhythm and a grinding friction rub. The lungs showed massive edema. therapy
He
improved
with
but his condition
the following
10 days.
oxygen
continued
and
for about
to normal
by the end of 15 days.
5 days,
gradually
digitalis
to be critical
His temperature
to 104OF.
pericardial pulmonary for
was 102.5’ coming
down
He had a leukocytosis of 19,500 with a polymorphonucleosis of 80 per cent. An electrocardiogram obtained on the third day of his illness (Fig. 3A) showed acute anterior wall infarction with extensive septal involvement and right bundle branch block. Two weeks later another tracing (Fig. 3B) showed a later phase of the infarction. He gradually improved enough to be discharged from the hospital in six weeks. After several months he was practically symptom-free except for some left precordial pain and dyspnea on exertion. His blood pressure varied between 120/75 TIIE
AMERICAN
JOURNAL
OF CARDIOLOGY
Long Survival A
B
C
D
E
Following F
G
Myocardial A
Infarction B
C
553 D
E
F
G
August 20, 1949, acute anterior wall infarction. B, September 14, 1949. C-D, May 25, 1957, respectively, showing persistence of the changes with a greater degree of ischemia in the 1958, early stage of posterior wall infarction and remains of previous anterior infarction. F, of anterior and posterior wall infarction. G, August 17, 1960, same as F, plus left ventricular hypertrophy and greater ischemia of anterolateral wall. H, November 22, 1960, complete A-V block and idioventricuProlonged ventricular asystole in lead VI. lar rhythm of left ventricular origin.
FIG. 4. Case 4. A, 1955, and October 29, latter, E, March 21, June 18, 1958, remains
and 170/90. His heart rate was 96 on discharge from the hospital and dropped to levels of 58 to 65 later. With diuretic therapy, his lungs remained clear.
Six
months
after
his work on a gradually ill effects. ual terior
features
attack
The electrocardiograms of right
wall infarction,
ventricular
the
aneurysm
he returned
increasing bundle
showed
branch
with changes (Fig.
schedule
to
without the resid-
block indicative
and anof left
3C and D).
He continued working until the early part of 1957, at about 72 years of age and 8 years after the onset He then began to develop severe of infarction. progressive heart failure. There was increase in liver enlargement and pulmonary congestion which responded fairly well to treatment until the early part of 1959. This soon became more severe and he developed massive ascites which required frequent abdominal paracentesis. He died on September 29, 1959, at about 74 years of age and more than 10 years after the onset of the massive infarction. An electrocardiogram obtained 4 days before death APRIL 1962
(Fig. 3E) showed marked changes in the ventricular complexes with suggestion of fresh infarction in the anterolateral wall of the left ventricle. CASE 4. H. K., male, owner of a photoengraving business for many years, was seen for the first time on August 20,1949 when he was 63 years old. He was a mild diabetic for a number of years and a frequent devotee of “wine, women and song,” living a rather merry life. About 20 years before, he had had an attack which a doctor told him was a “mild coronary” and which debilitated him for several weeks. Since 1947 he was subject to some retrosternal pain on exertion. On August 19, 1949, at 4 P.M. after partaking of a heavy meal, he developed severe burning and pressure sensation in the retrosternal region lasting several hours and which recurred in milder form throughout the night. The following day he appeared acutely ill. There was marked congestion at the bases of the lungs. The blood pressure was 95/70. An electrocardiogram (Fig. 4A) revealed an early phase of
554
Sigler
anterior wall infarction. His clinical course was rather stormy, with periods of mental confusion and disorientation. An electrocardiogram on September 14, 1949 (Fig. 4B) showed a later stage of the infarction. He finally made a good recovery after six weeks in bed and resumed his business activities 2 months later. He felt well for several years except for occasional headaches and some precordial discomfort, especially when indulging in excesses. An electrocardiogram obtained on May 25, 1955 about six years later (Fig. 4C) still showed some remains of the infarction. On October 28, 1957 he had another episode of severe anterior chest pain lasting a half-hour after an exciting argument. An electrocardiogram the following day (Fig. 4D) revealed ischemia in the area of the previous infarction. He was asymptomatic, however, and returned to his activities a few days later. On April 10, 1958 he suddenly experienced severe pain in the interscapular region radiating to the epigastrium, with marked dizziness, fainting sensation and vomiting. The pain continued for several hours. His blood pressure dropped to 90/60 from the usual levels of 130/75 to 150/l 10. An electrocardiogram (Fig. 4E) revealed an early stage of acute posterior wall infarction in addition to the remains of the previous anterior wall infarction. The leukocyte count was 11,000 on the second day and 17,000 on the fourth day. The transaminase was 75 units on the second day, and the blood sugar varied between 156 He ran a typical clinical and 262 mg. per cent. course of infarction from which he recovered after 5 He again returned to his business activities weeks. 2 months later and he was symptom-free except for dizziness and at times mild mental confusion. An electrocardiogram (Fig. 4F) showed the remains of his posterior and the previous anterior infarction. He continued feeling well for two and a half years. In May, 1960, more than 2 years after the second myocardial infarction, he suddenly developed a cerebral vascular accident with partial left hemiplegia, loss of power to articulate, some dysphasia and marked After 2 weeks in the confusion and disorientation. hospital, his condition greatly improved and he regained most of the cerebral functions. His cardiac status remained the same except for increased cardiac An electrocardiogram (Fig. 4G) on enlargement. August 17, 1960, about two and a half years after the second infarction, showed evidence of left ventricular hypertrophy and extensive myocardial ischemia of the anterior and posterior walls of the left ventricle at the sites of the previous infarctions. On November 4, 1960, more than 11 years after his first infarction, he suddenly developed recurring lapses into within
unconsciousness 2 hours,
and
without
An electrocardiogram
convulsions
responding
obtained
and
during
these attacks,
parts of which are shown in Figure 4H, indicated plete pulses
atrioventricular originating
block
with
died
to any therapy.
idioventricular
in the left ventricle,
comim-
terminating
in complete ventricular asystole, with atria1 contractions continuing. If it is true that he had an attack of myocardial infarction 20 years before when he was first seen, it would place the onset of the first manifestations of coronary disease at upward of 31 years before his death.
DISCUSSION Immediate Mortality: These observations indicate that the prognosis of myocardial infarction is far better than it was hitherto considered to be. embracing relatively small Other reports4-” numbers of patients seem to corroborate this impression. This report, however, is not offered to show the average prognosis of myocardial infarction, but rather the great longevity of many of these patients. To determine the average prognosis, we must include patients who die during the acute phase or during convalescence, those who die one or more years later, those who die suddenly with no history of an attack and autospy findings of acute coronary occlusion, and those with asymptomatic infarction who recovered without medical attention only to be discovered later by a chance electrocardiographic examination. Such average prognosis has been included in previous reports. It is also understandable that no real average prognosis can be obtained unless many series of observations by different authors are combined. Each author presents his own personal experiIn addition, the years covered by any ences. given report is a factor in the study of the average Thus, in my experience dating back prognosis. to the early 1920’s, I found that up to about 1930 the immediate mortality rate was as high as 15 to 20 per cent. As the years rolled by, the immediate death rates have progressively diminished and the average longevity has increased, so that in the years between 1941 and 1950 the immediate mortality rates were about 7 to 8 per cent, which correspond to those Since 1950 the of Beer and co-workers.12 immediate average yearly mortality rate seldom surpassed 5 per cent, and it is usually less. The recent progressive decrease in the immediate mortality rates is attributed to early diagnosis and treatment of the disease, less delay on the part of the patient in seeking proper therapy, the proper use of digitalis and the newer diuretics when called for, proper rest, carefully regulated food intake during the acute phase, a better psychological approach to the patient, the effective employment of anticoagulant therapy and better therapy upon the early manifestations THE AMERICAN
JOURNAL
OF
CARDIOLOGY
Long Survival
Following
of shock. The high mortality rates reported from some hospitals, especially to 1940 or even to 1950, running in some cases as high as 50 per cent, are very unusual and are not observed in private practice. They are due probably to admissions of neglected and moribund cases, and possibly also to insufficient private medical and nursing care. Lang Term Prognosis: Perhaps a fair average longevity following myocardial infarction for those patients who survived and lived 3 months or longer is given by Waldron and Constable.r3 These authors analyzed 1,551 case reports of myocardial infarction from the files of the Mutual Life Insurance Company, comprising persons who claimed disability. The average life expectancy was found to vary with the age of onset of the disease. Thus, the average longevity in individuals who developed the disease between 30 and 39 years of age was 11.5 years against a normal expectancy of 33.4 years; in individuals who developed the disease between 40 and 49 years of age the longevity was 10.5 years against a normal expectancy of 25.2 years ; and in those who developed the disease between 50 and 60 years of age, the average longevity was 8.5 y-ears against a normal expectancy of 17.8 years. These, of course, are not true figures of the average prognosis of myocardial infarction as they do not include the immediate mortalities mentioned above. The observations reported in this paper may have some bearing on the prognosis. Percentagewise, more females than males reach an older age after infarction. This appears to be due mainly to the older age at which infarction However, the ratio of develops in females. males to females who live longer after infarction is greater than the ratio of those who develop disease generally. An infarction of coronary abrupt onset and without antecedent angina pectoris over a long period of time seems to have a better prognosis, unlike the observations of Boas’” in a small number of cases of short longevity. The probable explanation is that some individuals without antecedent angina pectoris have a lesser degree of coronary atheromatosis leading to infarction. A person with infarction occurring earlier in life appears to have a chance for longer survival. The location of infarction seems to have no definite prognostic significance, although in our group there was a relatively greater percentage of cases with posterior wall infarction than infarction of the entire anterior wall of the left APRIL
1962
Myocardial
Infarction
555
ventricle as compared with a group of cases of a short survival. More than one infarction occurring after long intervals did not seem to influence the longevity in this series, unlike the observations of Honey and Truelove.15 However, recurrence after short intervals definitely decreases longevity. My findings confirm those of other authors6J6-ig that return to work after recovery from infarction does not affect and may even improve the prognosis. In this series of 255 cases, the percentage of patients who returned to work was greater than in most other reports. This is probably due to the fact that this is a select group and that most of the patients were self-employed in business or professions where activities could be more easily regulated. Factors Determining Longevity: On the basis of these observations, the most important factor which determines the longevity following myocardial infarction is the inherent hereditary constitutional state of the individual and his reaction to the cardiac injury as well as to other diseased bodily states, as in Case 2. There are marked differences in the constitutional and psychological make-up of the patient and his reactivity to intrinsic and extrinsic environmental conditions. Early death in some and great longevity in others following infarction cannot be explained by local structural cardiac pathology alone. In this series of cases there were individuals with massive structural myocardial damage who underwent considerable strain over several years with no apparent ill effects, as illustrated by Case 3, while other patients with relatively little cardiac damage succumbed early to the disease or were more or less completely disabled. The variations in the reactivity of the heart itself to injury also appears to depend mainly upon the constitutional and psychic state of the individual from time to time. This is demonstrated by the changing character in the manifestations of existing coronary disease and organized myocardial infarction with changes in the general condition of the patient and his environment. It is my belief that the cardiac and constitutional reactions to intrinsic and extrinsic environmental conditions cannot be studied in the laboratory alone but require long term clinical observation and recording on a statistical basis. There is need for such enterprise by the clinician in private practice who is in direct contact with each patient for years. The study should include the hereditary background, which appears
to be most important, the environment of the patient, emotional strains to which he is exposed, psychic make-up of the individual, his occupational pursuits and efforts applied to them, climatic conditions, infections, intoxications, various organic diseases or disturbances outside the heart, and other factors that may affect the general health of the individual and predispose him to early death from coronary disease. Medical schools would do well to prepare graduates for such an undertaking and future statistics should be gathered from such sources, and not from death certificates or from hospital records.
Two hundred and fifty-five patients are reported who have lived or are still living 10 years or longer following acute myocardial infarction. They are part of a series of 1,700 patients observed over a period of thirty-four years, preThe male to female ratio in viously reported. these 255 cases was 7.8 : 1 as compared to 3.2 : 1 in the entire series. The onset of acute infarction was abrupt, without antecedent angina, in 81.2 per cent of the cases while in the original series it was 52.4 per cent. The age at onset of the first attack of infarction corresponded to that of the entire series, the usual age being between 50 to 69 years. About 68.4 per cent males and 89.8 per cent females still living have already lived 10 to 14 years or longer after their first infarction attack; 27.3 per cent males, 15 to 19 years; and 4.3 per cent, 20 years or longer; of the females, one is alive 15 years, one 23 years and one 25 years or longer. Of the 43 males who have died, 74.4 per cent lived 10 years or longer, 31.6 per cent 15 years or longer and 2.3 per cent 22 years or longer. A large percentage of patients have surpassed the average life exPercentagewise, relatively more pectancy. females than males have reached an older age. Anterior wall infarction occurred in 55.6 per cent of the patients; posterior wall infarction in upper lateral infarction in 1.9 36.1 per cent; per cent and multiple infarction at different times in 7.5 per cent. Only two patients died during a second infarction ; the rest are either still alive or died long after a second or third infarction. Of the males, 66.8 per cent were in profesand business enterprises and sional, clerical 33.2 per cent were manual workers. Of these only 4.9 per cent had to give up work because of The others resumed their the heart disease.
regular or modified work. A greater percentage of businessmen than other workers returned to their regular work. Retirement because of illness was most frequent in manual workers. Of the females, all returned to their housework. Our observations in this group indicate that more females than males reach an older age probably because infarction on the average occurs later in females. The ratio of males to females who live longer after infarction is greater than the ratio developing coronary disease generally. Infarction developing without antecedent angina pectoris seems to have a better prognosis. The location of infarction seems to have no prognostic significance, although infarction of the posterior wall appears to hav-e a better prognosis than of the entire anterior wall. Return to work after infarction does not affect and may even improve the prognosis. Based on our findings the most important factor which determines longevity following myocardial infarction is the inherent hereditary constitutional state of the individual and his reaction to cardiac injury as well as to other diseased bodily states. Intrinsic and extrinsic environmental conditions are also operative factors. REFERENCES 1. SIGLER, L. H. Prognosis of angina pcctoris and coronary occlusion. Follow-up of 1,700 cases. J.A.M.A., 146: 998, 1951. 2. SIGLER, L. H. Prognosis of angina pcctoris and myocardial infarction, further report. Am. J. Cardiol., 6: 252, 1960. 3. Statistical Bulletin, Metropolitan Life Insurance co., vol. 40, July 1959. 4. MASTER, A. M. and JAFFE, H. L. Complete functional recovery after coronary occlusion and insufficiency. J.A.AM.A., 147: 1721, 1951. 5. MASTER, A. M., JAEFE, H. L., TEICH, E. M. and BRINBERG, L. Survival and rehabilitation aftw coronary occlusion. J.A.lM.A., 156: 1552, 1954. 6. BIORCK, G., BLOMQWST, G. and SIEVERS, .I. Myocardial infarction. Acta med. scandinav., 162: 81, 1958. 7. COLE, D. R., SINGIAN, E. B. and KATZ, L. N. Long term prognosis following myocardial infarction and some factors which affect it. Circulation,9 : 321, 1954. 8. LINDEN, L. Prognostic aspect of myocardial infarction. Acta med. scandinau., 143: 464, 1952. 3. SMITH, C. farction.
Length of survival after myocardial J.A.M.A., 151: 167, 1953.
in-
10. BREGANI,P., SELVINI,A. and PAVESI, V. The long term prognosis following myocardial infarction : clinical control of 180 patients after 1 to 18 years. :Minerua med.. 50: 2343, 1959. 11. WHITE, P. D.; BLAND, ‘E. F. and LEVINE, S. A. THE AMERICANJOURNAL OF CARDIOLOGY
Long Survival Following
12.
13.
14.
15.
Further observations concerning the prognosis of myocardial infarction due to coronary thrombosis. Ann. Znt. Med., 48: 39, 1958. BEER, S., HEINE, W. I. and KRASNOFF, S. 0. The mortality of acute myocardial infarction in private practice. Am. J. M. SC., 222: 500, 1951. WALDRON, F. A. and CONSTABLE,N. P. Myocardial infarction, a mortality study. Tr. A. Life Znsur. M. Dir. America, 34: 69, 1950. BOAS, E. P. Natural history of coronary artery disease of long duration. Am. Heart J., 41: 323, 1951. HONEY,G. E. and TRUELOVE, S. C. Prognostic factors in myocardial infarction. Lancet, 1 : 1209, 1957.
APRIL 1962
Myocardial
Infarction
557
16. CRAIN, R. B. and MISSAL, M. E. Industrial cmployee with myocardial infarction and his ability to return to work: follow up report. New York J. Med., 56: 2238, 1956. 17. IISALO, E., KALLIOLA, A., KASANEN,A. and LINKO, E. Prognosis and work capacity after cardiac infarction. Nerd. med., 59: 264, 1958. 18. WEISS, M. M., SR. and WEISS, M. M., JR. Fiveyear follow-up study of men who returned to work after a myocardial infarction. J.A.M.A., 168: 17, 1958. 19. MORRIS, J. N., HEADY, J. A., RAFFLE, P. A. B., ROBERTS, C. G. and PARRES, J. W. Coronary heart disease and physical activity of work. Lnncet, 6795: 1053, 1953; 6796: 1111, 1953.
Survival
Following
Myocardial
Infarction Report
on 255 Patients Longer
Living
or
After the First Attack
LOUIS H. SIGLER, Brooklyn,
M.D.,
F.A.C.C.
New York
I
N 1951 a report was made on a series of 1,700 cases1 of coronary disease observed over a At that time, 1,021 period of twenty-five years. These were followed patients were still living. over an additional period of nine years and a subsequent report was made in 1960.2 Of these, 456 patients could not be followed over the nine year period ; however, the remaining 565 patients were still under observation, of whom 270 were living. This is an analysis of 255 of the surviving patients, brought up-to-date, who had at least one attack of myocardial infarction and lived ten years or longer after the attack; 210 of these are still living.
(68.4 per cent) have already lived 10 to 14 years or longer after the first attack of infarction, 50 (27.3 per cent), 15 to 19 years and 8 (4.3 Of the per cent), 20 years or longer (Table II). 43 males who have died, 32 (74.4 per cent) had lived 10 years or longer, 11 (31.6 per cent), 15 years or longer, and 1 (2.3 per cent), 22 years or Of the 29 females longer after their first attack. still alive, 26 (89.8 per cent) already have lived 10 to 14 years, 1 (3.4 per cent), 15 years, 1 (3.4 per cent), 23 years and 1 (3.4 per cent), 25 Taking the life expectancy in years or longer. the year 1957 to be 73.5 years for females and 67.1 years for males,3 upward of 28 per cent of our males and 30 per cent of the females, who are still alive, have already lived beyond expecOf the males who have died, upward of tancy. 33 per cent had lived beyond expectancy. Present Ages of the Living Patients and Ages at Death: Percentagewise, relatively more females than males who are still living, have reached an older age (Table III). Of the 43 males who have died, none was younger than 40 years of age, and the highest percentage was between 60 and 69 years of age; 12 (27.9 per cent) lived beyond 70 years. Location of Infarction: Of the 255 patients, 236 (92.5 per cent) had one infarction and 19 (7.5 per cent) had more than one at different In 142 of this number (55.6 periods (Table IV). per cent), the infarction occurred in the anterior wall of the left ventricle, 28.2 per cent involving the entire anterior wall, 25.5 per cent only the anteroseptal portion and 1.9 per cent the anterolateral portion. In 92 patients (36.1 per cent), the infarction occurred in the posterior wall, and in 2 (0.8 per cent) in the upper lateral region. Of the 19 patients with more than one
OBSERVATIONS Male to Female Ratio: Of the 255 patients, 226 are males and 29 females; the male to feIn the original series of male ratio is 7.8:1. 1,700 cases, the male to female ratio was 3.2: 1. Mode of Onset of Clinical Manifestations: In the entire group of 255 cases, 207 patients (81.2 per cent) had an abrupt onset of acute infarction and in 48 (18.8 per cent), angina pectoris preceded infarction by 1 month to as In the original series of long as several years. 1,700 cases, only 52.4 per cent had an abrupt onset of myocardial infarction. Age at First Attack of Infarction: The greatest percentage of patients had their first attack of infarction between 50 and 59 years of age (Table I). Percentagewise, more females had their first attack after 60 years of age, while more males suffered an attack at an earlier age than their 49th year. Length of Survival Following First Attack of Infarction: Of the 183 males still living, 125 APRIL 1962
Ten Years
547
548
Sigler TABLE
Age
at First Attack
Age (v-s.)
I
TABLE
of Myocardial
Infarction
Males
Females
(226)
(29)
Present
Age
of the
I /O
Females
(183)
(29)
Ko.
4
20-29
13
5.8
2
7.2
30-39
88
38.9
4
14.3
40-49
50-59
91
40.3
16
55.2
so-59
1 l ~ 3:
60-69
95
70-79
‘g i ‘::I
1
60-69
28
12.1
6
21.3
70-79
2
1.0
1
3.0
51.5
55.2
yr.
80-89 Mean
yr,
Youngest
23 yr.
30 yr.
Oldest
72 yr.
74 yr.
infarction, only 2 died during the second infarc-
v>* Occupation and Postinfarction Status: The 29 females in this series were all housewives and TABLE
Length
Dead Patients Males (43)
%
Living
Group
(183)
Age
1
P.,’
20 8 51.9
3.4
2
6.9
14
48.4
11
37 9
1
11
25.6
1
2.3
3.4
63.8 yr.
67 I yr.
63.3 yr.
Youngest
39 yr.
43 yr.
47 yr.
Oldest
86 yr.
86 yr.
x3 yr.
Dead Group
II
of Survival
Males
T
(226)
Still Living*
Total
Still
Living
Females
Living
%
No.
No.
%
No.
(‘i
7.1 13.7 17.5 13.7 16.4 8.2 11.4 3.3 2.2 2.2 1.1
11
32 23 17 10 8 5 3
74.4 53.7 39.5 23.3 18.6 17.7 7.0
19 20
13 25 32 25 30 15 21 6 4 4 2
2
4.6
45 48 49 35 38 20 24 6 4 6 2
15.8 16.8 17.2 12.5 13.3 7.0 8.3 2.3 1.4 2.3 0.7
21
2
1.1
2
0.7
22
2
1.1
1
2.3
3
1.1
23
1
0.5
0
0.0
1
0.3
24
1
0.5
1
0.3
15 or more
58
30.7
11
31.6
69
26.1
20 or more
8
4.3
1
2.3
9
3.2
9 6 7 2 3 2
/C
Group
No.
0’
3 4 8 6 5 1
10.3 14.0 27.7 20.6 17.2 3.4
,o
3.4 3.4
25
* Represents
(29)
(29)
(43)
No. 10 11 12 13 14 15 16 17 18
at Death
all returned to their regular but supervised work, 2 to 5 months after recovery from infarction. Of the 226 males, 151 (66.8 per cent) were engaged in business, professional or clerical work, and 75 (33.2 per cent) in manual work. The business group of 106 (46.9 per cent)
tion. The rest are either still living or have died long after the second or third infarction (Table
Years After First Infarction
No.
%
30-39
Age
Age
1.9
40-49
Mean
and
h?ales
(yrs.1
C’
No.
III
Patients
Living Patients
kc
No.
Living
the remaining
living
patients
in the “Dead
Group”
at the respective THli
3 2
10.2
~
6.8
years after the first infarction.
AMERICAK
JOURSAL
OF CARDIOLOGY
Long TABLE
Survival
Following
Myocardial
Infarction
549
TABLE VI
IV
Number and Percentage of Cases in Given Areas of Infarction Location of Infarction (Left Ventricle)
Occupation
and Postinfarction 226 Males Returned
Status
to Work
%
Retired Occupations
Posterior wall
92
36.1
Anterior wall
72
28.2
Anteroseptal
65
25.5
Anterolateral
5
1.9
Upper lateral
2
0.8
19
7.5
More than one infarction
Regular
No.
No.
Modified
%
No.
70
___ Alloccupations
226
100.0
161
71.2
54
Business
106
46.9
86
81.2
18
16.9
Professional
31
13.7
21
67.7
10
32.3
Clerical
14
6.2
9
64.9
5
35.1
Ma”Ul workers
75
33.2
45
/
60.0
23.9
/ 21 ~28.0
TABLE v Patients with RecurrinP Infarction Agr at Onset in Years
Case
First Infarct
Angina
Second Infarct
Third Infarct
As
Age
Still Living
Dead
-l-
hi& D. L.
51
57
hf.
53
66
B. s.
51
58
R. R.
40
52
A. S.
59
73
s.
63’/r 66 61 54
57 83 75
s. D.
65
69
H. B.
55
55
H. G.
52
54
66
J. C.
48
54
60
s. s.
59
69
70
A. D.
62
65
75
I.. P.
49
58
72
39
41
52
55
56
67
28
35
J. S. F. %.
49
J. P.
25
i
H. R.
I
44
.I. L.
(
43
j
::
61
65
49
~
58
58
and designers, maintenance workers, printers and chauffeurs. Most of the patients were engaged in these pursuits for many years before the first attack of infarction. About 2 to 6 months after the attack, 161 (71.2 per cent) returned to their regular work and continued working for years; in 54 (23.9 per cent) a change of work was necessary, and 11 (4.9 per cent) were obliged to give up their work after the first attack. Several patients voluntarily retired after the age of 65. The percentage of patients who returned to work varied in different groups (Table VI). As many as 86 (81.2 per cent) of the business group but only 45 (60 per cent) of the manual workers continued their regular occupations. Of the 11 patients who had to give up their work, 9 were manual workers and 2 were businessmen. None of the professional nor clerical workers had to give up his work. However, the number of patients in these two groups is too small for comparison.
Female A. D. L. H.
ILLUSTRATIVE
:: -
Average duration betwren first and second infarct 6.5 yr.; first and third infarct 10 y-r,; first infarct and present age 14.7 y’.; second infarct and present age 8.8 y’.; first infarct and death 13.7 y’.; second infarct and death 6.6 y’.
patients consisted of shopkeepers and salesman, insurance brokers or agents, manufacturers, realtors, bank managers, organizers and other enterprises of a similar nature. The professional of 31 patients included physicians, group pharmacists, accountants, teachers and lawyers. The 14 clerical workers were shipping clerks, auditors, cashiers and proofreaders. The 75 manual workers were mechanics, machinists, electricians, clothing operators, cutters, pressers APRIL
1962
CASES
The following four cases illustrate some of the features observed in this series of 255 cases. Inasmuch as the cases cover long periods of observation, the histories are of necessity greatly abbreviated. CASE 1. M. O., male, owner of a wholesale drygoods business for many years, was seen for the first time on April 1, 1944 at 56 years of age. The day before he suddenly developed severe constricting pain in the anterior chest radiating to the left arm, lasting two hours, associated with cold, clammy perspiration, and requiring morphine for relief. An electrocardiogram (Fig. 1A) showed an early phase of acute posterior wall infarction with subendocardial myocardial ischemia of the anterior wall. He made a good clinical recovery after six weeks.
aVL
aVF
FIG. 1. Case 1. A, April 1,1944, early phase, acute posterior infarction and subendocardial ischemia of anterior wall. B, June 17, 1944, late phase of posterior infarction. C, February 2, 1952, residual changes of old posterior wall infarction. (Figure retouched for clarity.)
FIG. 2. Case 2. A, December 25, 1937, anterior wall infarction. Old lead IVF used in those days yields a reversed polarity so that the tall R and T waves are equivalent to a deep Q and inverted T. B, November 13,1958, C, May 10, 1951, posterior wall infarction. tracing within normal limits. D, August 15, 1951, remains of posterior wall infarction and subendocardial ischemia of anterolateral wall. E, August 15, 1955. residual changes. F, January 7, 1961, residual changes still present, but less marked.
Long Survival
Following
Examination on June 17, 1944 revealed a heart rate of 80, normal heart sounds, blood pressure 170/110 and some congestion at the bases of the Subjectively, he was well and could walk lungs. six to ten blocks without discomfort. An electrocardiogram (Fig. 1B) showed the remains of the posterior wall infarction. Subsequent examinations showed the same findings. His blood pressure varied between 130/85 and 170/110. He was practically symptom-free except for occasional palpitation and slight pain in the left arm. On February 2, 1952 he had an episode of pain in the right lower anterior part of the chest radiating to the interscapular region lasting 20 to 25 minutes, but there were no changes in the physical findings. The electrocardiogram (Fig. 1C) remained the same as before. On May 14, 1953 he had an upper respiratory infection for which he was given penicillin and which was followed by a severe rash. Antihistamines gave relief, but were followed by constricting chest pain which lasted on and off for one day without demonstrable acute changes in the heart. At the present writing (May 10, 1961) about 17 years after the attack and at 73 years of age, he is still alive and well, directing his business in an active manner. CASE 2. A. S., male, was first seen on December 22, 1937 when he was 59 years old. He has been in the retail jewelry business since 20 years of age. He visits boats on their arrival in New York ports and sells his wares to foreign sailors. He has to do considerable walking and stair climbing. He gave a history of lues which he contracted at 28 years of age and received antiluetic treatment for several years. Aside from that he was always well. For five weeks he experienced left precordial pain radiating to the left arm on exertion. The night before the examination he was awakened from sleep at 12:30 A.M. by severe anterior chest pain with cold sweat, marked pallor and fainting sensation. He required 30 mg. of morphine for relief. Examination revealed a tall, well preserved individual, height 73 inches, weight 175 pounds. His temperature during the first four days ranged between lOlo and 102OF., pulse 95-100, the leukocyte count was 15,500, with 79 per cent polymorphonuclears. The sedimentation rate was 32 mm. in 1 hour. An electrocardiogram (Fig. 2A) 3 days after the onset showed acute anterior wall inNo unipolar extremity and precordial farction. leads were in use at that time, except for a lead IV obtained by placing the right arm electrode at the apex coupled to the left leg electrode, giving a polarity opposite to that obtained by later methods. In other words, the low voltage notched R wave in the lead IV of Figure 2A was really a Q wave and the positive T wave would be negative in present day electrocardiograms. He recovered after six weeks of bed rest and returned to his usual work three months later, which he continued without interruption. APRIL 1962
Myocardial
Infarction
On January 16,1946 he had an episode of momentary unconsciousness with nausea and pain in the right scapular region, but there was no demonstrable evidence of recurring acute myocardial damage. He was symptom-free thereafter. An electrocardiogram obtained on November 13, 1948 (Fig. 2B), 11 years after the infarction, showed no gross abnormalities. On April 3, 1951 he again began to experience midsternal pressure and some pain radiating to the upper part of the left arm on walking against the wind, and 22 days later, he had another severe spontaneous attack of pressure pain in the anterior chest radiating to the left arm and interscapular region lasting 2 hours and relieved by morphine. This was followed by other clinical findings of acute infarction, shown by an electrocardiogram (Fig. 2C) to involve the posterior wall. He again made a good clinical recovery. He became, however, greatly depressed and worried when his family physician told him he would have to retire from his business because of his heart condition. However, with my assurance that he would be able to resume his business activities An electrocardiogram (Fig. 2D) after a short rest. taken 2 months after the second infarction showed residual findings of the infarct and subendocardial ischemia of the anterolateral wall. He was observed thereafter for 3 months at which time he showed progressive
improvement
He was then allowed continued
working
in
to return
his
cardiac
to his business
full time, feeling
reserve. and he
well for the next
five years. From time to time he was subject to the angina1 syndrome m a mild form on excessive strain or when worried. His blood pressure ranged between 125/70 and 160/100. An electrocardiogram obtained on October 15, 1955 (Fig. 2E) still indicated the remains of the posterior wall infarction with a greater degree of ischemia in the anterolateral wall. In view of his age of approximately 77 years at that time, he was advised to continue his work on a three to four hour a day basis and to rest on the days when he was subject to the angina1 pain. This he has done for the last six years. In February of 1960 he had an episode of bronchopneumonia which confined him to bed for five weeks. At the height of the disease, when the temperature was 104’F., he was delirious for 2 days and received massive doses of antibiotics. He made a good recovery. Examination on January 7, 1961, at 83 years of age and 24 years after his first myocardial infarction, revealed him to be in relatively good condition. The electrocardiogram (Fig. 2F) still showed the remains of his posterior wall infarction, but the ischemic pattern in the anterolateral wall was diminished. An interesting feature in this case is that the tests of his blood serology obtained on several occasions over the years of observation were all strongly positive for lues without any detectable clinical manifestations of the disease. Another important observation is that he felt best when no drugs were used. Reas-
552
Fig. 3.
Sigler
Case 3.
‘4, June 7, 1949, anterior
infarction
with septal involvement
June 2, 1949, later phase. C-D, October 24, 1951 and March 16, 1956, exaggeration of QRS complex and high R-T take-off in leads Vz through tember 25, 1959, 4 davs before death. Marked chanzxs in the ventricular to 0.17 second. ’
surance, relaxation from the occasional
CASE 3.
and careful chest pain.
dieting
gave
relief
S. N., male, a machine operator on embroidery for many years, was seen for the first time on June 10, 1949 when he was 64 years old. Ten days previously, after each meal he began to feel uncomfortable. On June 7, 1949 he had an attack of severe pressure in his chest radiating to the left arm and sweating. Assuming that he had indigestion, he took citrocarbonate and lemonade which made him vomit. He felt somewhat better, but the pain continued in milder form throughout the night and the following day. When first seen, he was acutely ill. He had an ashen pallor and was dyspneic. The heart was moderately enlarged, rate 110, regular rhythm. The first sound was greatly diminished in intensity, the second sound accentuated and split at the pulmonic area. There was a proto-
and right bundle branch block. B, respectively, showing persistent changes with VS due to left ventricular aneurysm. E, Sepcomplexes with delay in the QRS conduction
diastolic gallop rhythm and a grinding friction rub. The lungs showed massive edema. therapy
He
improved
with
but his condition
the following
10 days.
oxygen
continued
and
for about
to normal
by the end of 15 days.
5 days,
gradually
digitalis
to be critical
His temperature
to 104OF.
pericardial pulmonary for
was 102.5’ coming
down
He had a leukocytosis of 19,500 with a polymorphonucleosis of 80 per cent. An electrocardiogram obtained on the third day of his illness (Fig. 3A) showed acute anterior wall infarction with extensive septal involvement and right bundle branch block. Two weeks later another tracing (Fig. 3B) showed a later phase of the infarction. He gradually improved enough to be discharged from the hospital in six weeks. After several months he was practically symptom-free except for some left precordial pain and dyspnea on exertion. His blood pressure varied between 120/75 TIIE
AMERICAN
JOURNAL
OF CARDIOLOGY
Long Survival A
B
C
D
E
Following F
G
Myocardial A
Infarction B
C
553 D
E
F
G
August 20, 1949, acute anterior wall infarction. B, September 14, 1949. C-D, May 25, 1957, respectively, showing persistence of the changes with a greater degree of ischemia in the 1958, early stage of posterior wall infarction and remains of previous anterior infarction. F, of anterior and posterior wall infarction. G, August 17, 1960, same as F, plus left ventricular hypertrophy and greater ischemia of anterolateral wall. H, November 22, 1960, complete A-V block and idioventricuProlonged ventricular asystole in lead VI. lar rhythm of left ventricular origin.
FIG. 4. Case 4. A, 1955, and October 29, latter, E, March 21, June 18, 1958, remains
and 170/90. His heart rate was 96 on discharge from the hospital and dropped to levels of 58 to 65 later. With diuretic therapy, his lungs remained clear.
Six
months
after
his work on a gradually ill effects. ual terior
features
attack
The electrocardiograms of right
wall infarction,
ventricular
the
aneurysm
he returned
increasing bundle
showed
branch
with changes (Fig.
schedule
to
without the resid-
block indicative
and anof left
3C and D).
He continued working until the early part of 1957, at about 72 years of age and 8 years after the onset He then began to develop severe of infarction. progressive heart failure. There was increase in liver enlargement and pulmonary congestion which responded fairly well to treatment until the early part of 1959. This soon became more severe and he developed massive ascites which required frequent abdominal paracentesis. He died on September 29, 1959, at about 74 years of age and more than 10 years after the onset of the massive infarction. An electrocardiogram obtained 4 days before death APRIL 1962
(Fig. 3E) showed marked changes in the ventricular complexes with suggestion of fresh infarction in the anterolateral wall of the left ventricle. CASE 4. H. K., male, owner of a photoengraving business for many years, was seen for the first time on August 20,1949 when he was 63 years old. He was a mild diabetic for a number of years and a frequent devotee of “wine, women and song,” living a rather merry life. About 20 years before, he had had an attack which a doctor told him was a “mild coronary” and which debilitated him for several weeks. Since 1947 he was subject to some retrosternal pain on exertion. On August 19, 1949, at 4 P.M. after partaking of a heavy meal, he developed severe burning and pressure sensation in the retrosternal region lasting several hours and which recurred in milder form throughout the night. The following day he appeared acutely ill. There was marked congestion at the bases of the lungs. The blood pressure was 95/70. An electrocardiogram (Fig. 4A) revealed an early phase of
554
Sigler
anterior wall infarction. His clinical course was rather stormy, with periods of mental confusion and disorientation. An electrocardiogram on September 14, 1949 (Fig. 4B) showed a later stage of the infarction. He finally made a good recovery after six weeks in bed and resumed his business activities 2 months later. He felt well for several years except for occasional headaches and some precordial discomfort, especially when indulging in excesses. An electrocardiogram obtained on May 25, 1955 about six years later (Fig. 4C) still showed some remains of the infarction. On October 28, 1957 he had another episode of severe anterior chest pain lasting a half-hour after an exciting argument. An electrocardiogram the following day (Fig. 4D) revealed ischemia in the area of the previous infarction. He was asymptomatic, however, and returned to his activities a few days later. On April 10, 1958 he suddenly experienced severe pain in the interscapular region radiating to the epigastrium, with marked dizziness, fainting sensation and vomiting. The pain continued for several hours. His blood pressure dropped to 90/60 from the usual levels of 130/75 to 150/l 10. An electrocardiogram (Fig. 4E) revealed an early stage of acute posterior wall infarction in addition to the remains of the previous anterior wall infarction. The leukocyte count was 11,000 on the second day and 17,000 on the fourth day. The transaminase was 75 units on the second day, and the blood sugar varied between 156 He ran a typical clinical and 262 mg. per cent. course of infarction from which he recovered after 5 He again returned to his business activities weeks. 2 months later and he was symptom-free except for dizziness and at times mild mental confusion. An electrocardiogram (Fig. 4F) showed the remains of his posterior and the previous anterior infarction. He continued feeling well for two and a half years. In May, 1960, more than 2 years after the second myocardial infarction, he suddenly developed a cerebral vascular accident with partial left hemiplegia, loss of power to articulate, some dysphasia and marked After 2 weeks in the confusion and disorientation. hospital, his condition greatly improved and he regained most of the cerebral functions. His cardiac status remained the same except for increased cardiac An electrocardiogram (Fig. 4G) on enlargement. August 17, 1960, about two and a half years after the second infarction, showed evidence of left ventricular hypertrophy and extensive myocardial ischemia of the anterior and posterior walls of the left ventricle at the sites of the previous infarctions. On November 4, 1960, more than 11 years after his first infarction, he suddenly developed recurring lapses into within
unconsciousness 2 hours,
and
without
An electrocardiogram
convulsions
responding
obtained
and
during
these attacks,
parts of which are shown in Figure 4H, indicated plete pulses
atrioventricular originating
block
with
died
to any therapy.
idioventricular
in the left ventricle,
comim-
terminating
in complete ventricular asystole, with atria1 contractions continuing. If it is true that he had an attack of myocardial infarction 20 years before when he was first seen, it would place the onset of the first manifestations of coronary disease at upward of 31 years before his death.
DISCUSSION Immediate Mortality: These observations indicate that the prognosis of myocardial infarction is far better than it was hitherto considered to be. embracing relatively small Other reports4-” numbers of patients seem to corroborate this impression. This report, however, is not offered to show the average prognosis of myocardial infarction, but rather the great longevity of many of these patients. To determine the average prognosis, we must include patients who die during the acute phase or during convalescence, those who die one or more years later, those who die suddenly with no history of an attack and autospy findings of acute coronary occlusion, and those with asymptomatic infarction who recovered without medical attention only to be discovered later by a chance electrocardiographic examination. Such average prognosis has been included in previous reports. It is also understandable that no real average prognosis can be obtained unless many series of observations by different authors are combined. Each author presents his own personal experiIn addition, the years covered by any ences. given report is a factor in the study of the average Thus, in my experience dating back prognosis. to the early 1920’s, I found that up to about 1930 the immediate mortality rate was as high as 15 to 20 per cent. As the years rolled by, the immediate death rates have progressively diminished and the average longevity has increased, so that in the years between 1941 and 1950 the immediate mortality rates were about 7 to 8 per cent, which correspond to those Since 1950 the of Beer and co-workers.12 immediate average yearly mortality rate seldom surpassed 5 per cent, and it is usually less. The recent progressive decrease in the immediate mortality rates is attributed to early diagnosis and treatment of the disease, less delay on the part of the patient in seeking proper therapy, the proper use of digitalis and the newer diuretics when called for, proper rest, carefully regulated food intake during the acute phase, a better psychological approach to the patient, the effective employment of anticoagulant therapy and better therapy upon the early manifestations THE AMERICAN
JOURNAL
OF
CARDIOLOGY
Long Survival
Following
of shock. The high mortality rates reported from some hospitals, especially to 1940 or even to 1950, running in some cases as high as 50 per cent, are very unusual and are not observed in private practice. They are due probably to admissions of neglected and moribund cases, and possibly also to insufficient private medical and nursing care. Lang Term Prognosis: Perhaps a fair average longevity following myocardial infarction for those patients who survived and lived 3 months or longer is given by Waldron and Constable.r3 These authors analyzed 1,551 case reports of myocardial infarction from the files of the Mutual Life Insurance Company, comprising persons who claimed disability. The average life expectancy was found to vary with the age of onset of the disease. Thus, the average longevity in individuals who developed the disease between 30 and 39 years of age was 11.5 years against a normal expectancy of 33.4 years; in individuals who developed the disease between 40 and 49 years of age the longevity was 10.5 years against a normal expectancy of 25.2 years ; and in those who developed the disease between 50 and 60 years of age, the average longevity was 8.5 y-ears against a normal expectancy of 17.8 years. These, of course, are not true figures of the average prognosis of myocardial infarction as they do not include the immediate mortalities mentioned above. The observations reported in this paper may have some bearing on the prognosis. Percentagewise, more females than males reach an older age after infarction. This appears to be due mainly to the older age at which infarction However, the ratio of develops in females. males to females who live longer after infarction is greater than the ratio of those who develop disease generally. An infarction of coronary abrupt onset and without antecedent angina pectoris over a long period of time seems to have a better prognosis, unlike the observations of Boas’” in a small number of cases of short longevity. The probable explanation is that some individuals without antecedent angina pectoris have a lesser degree of coronary atheromatosis leading to infarction. A person with infarction occurring earlier in life appears to have a chance for longer survival. The location of infarction seems to have no definite prognostic significance, although in our group there was a relatively greater percentage of cases with posterior wall infarction than infarction of the entire anterior wall of the left APRIL
1962
Myocardial
Infarction
555
ventricle as compared with a group of cases of a short survival. More than one infarction occurring after long intervals did not seem to influence the longevity in this series, unlike the observations of Honey and Truelove.15 However, recurrence after short intervals definitely decreases longevity. My findings confirm those of other authors6J6-ig that return to work after recovery from infarction does not affect and may even improve the prognosis. In this series of 255 cases, the percentage of patients who returned to work was greater than in most other reports. This is probably due to the fact that this is a select group and that most of the patients were self-employed in business or professions where activities could be more easily regulated. Factors Determining Longevity: On the basis of these observations, the most important factor which determines the longevity following myocardial infarction is the inherent hereditary constitutional state of the individual and his reaction to the cardiac injury as well as to other diseased bodily states, as in Case 2. There are marked differences in the constitutional and psychological make-up of the patient and his reactivity to intrinsic and extrinsic environmental conditions. Early death in some and great longevity in others following infarction cannot be explained by local structural cardiac pathology alone. In this series of cases there were individuals with massive structural myocardial damage who underwent considerable strain over several years with no apparent ill effects, as illustrated by Case 3, while other patients with relatively little cardiac damage succumbed early to the disease or were more or less completely disabled. The variations in the reactivity of the heart itself to injury also appears to depend mainly upon the constitutional and psychic state of the individual from time to time. This is demonstrated by the changing character in the manifestations of existing coronary disease and organized myocardial infarction with changes in the general condition of the patient and his environment. It is my belief that the cardiac and constitutional reactions to intrinsic and extrinsic environmental conditions cannot be studied in the laboratory alone but require long term clinical observation and recording on a statistical basis. There is need for such enterprise by the clinician in private practice who is in direct contact with each patient for years. The study should include the hereditary background, which appears
to be most important, the environment of the patient, emotional strains to which he is exposed, psychic make-up of the individual, his occupational pursuits and efforts applied to them, climatic conditions, infections, intoxications, various organic diseases or disturbances outside the heart, and other factors that may affect the general health of the individual and predispose him to early death from coronary disease. Medical schools would do well to prepare graduates for such an undertaking and future statistics should be gathered from such sources, and not from death certificates or from hospital records.
Two hundred and fifty-five patients are reported who have lived or are still living 10 years or longer following acute myocardial infarction. They are part of a series of 1,700 patients observed over a period of thirty-four years, preThe male to female ratio in viously reported. these 255 cases was 7.8 : 1 as compared to 3.2 : 1 in the entire series. The onset of acute infarction was abrupt, without antecedent angina, in 81.2 per cent of the cases while in the original series it was 52.4 per cent. The age at onset of the first attack of infarction corresponded to that of the entire series, the usual age being between 50 to 69 years. About 68.4 per cent males and 89.8 per cent females still living have already lived 10 to 14 years or longer after their first infarction attack; 27.3 per cent males, 15 to 19 years; and 4.3 per cent, 20 years or longer; of the females, one is alive 15 years, one 23 years and one 25 years or longer. Of the 43 males who have died, 74.4 per cent lived 10 years or longer, 31.6 per cent 15 years or longer and 2.3 per cent 22 years or longer. A large percentage of patients have surpassed the average life exPercentagewise, relatively more pectancy. females than males have reached an older age. Anterior wall infarction occurred in 55.6 per cent of the patients; posterior wall infarction in upper lateral infarction in 1.9 36.1 per cent; per cent and multiple infarction at different times in 7.5 per cent. Only two patients died during a second infarction ; the rest are either still alive or died long after a second or third infarction. Of the males, 66.8 per cent were in profesand business enterprises and sional, clerical 33.2 per cent were manual workers. Of these only 4.9 per cent had to give up work because of The others resumed their the heart disease.
regular or modified work. A greater percentage of businessmen than other workers returned to their regular work. Retirement because of illness was most frequent in manual workers. Of the females, all returned to their housework. Our observations in this group indicate that more females than males reach an older age probably because infarction on the average occurs later in females. The ratio of males to females who live longer after infarction is greater than the ratio developing coronary disease generally. Infarction developing without antecedent angina pectoris seems to have a better prognosis. The location of infarction seems to have no prognostic significance, although infarction of the posterior wall appears to hav-e a better prognosis than of the entire anterior wall. Return to work after infarction does not affect and may even improve the prognosis. Based on our findings the most important factor which determines longevity following myocardial infarction is the inherent hereditary constitutional state of the individual and his reaction to cardiac injury as well as to other diseased bodily states. Intrinsic and extrinsic environmental conditions are also operative factors. REFERENCES 1. SIGLER, L. H. Prognosis of angina pcctoris and coronary occlusion. Follow-up of 1,700 cases. J.A.M.A., 146: 998, 1951. 2. SIGLER, L. H. Prognosis of angina pcctoris and myocardial infarction, further report. Am. J. Cardiol., 6: 252, 1960. 3. Statistical Bulletin, Metropolitan Life Insurance co., vol. 40, July 1959. 4. MASTER, A. M. and JAFFE, H. L. Complete functional recovery after coronary occlusion and insufficiency. J.A.AM.A., 147: 1721, 1951. 5. MASTER, A. M., JAEFE, H. L., TEICH, E. M. and BRINBERG, L. Survival and rehabilitation aftw coronary occlusion. J.A.lM.A., 156: 1552, 1954. 6. BIORCK, G., BLOMQWST, G. and SIEVERS, .I. Myocardial infarction. Acta med. scandinav., 162: 81, 1958. 7. COLE, D. R., SINGIAN, E. B. and KATZ, L. N. Long term prognosis following myocardial infarction and some factors which affect it. Circulation,9 : 321, 1954. 8. LINDEN, L. Prognostic aspect of myocardial infarction. Acta med. scandinau., 143: 464, 1952. 3. SMITH, C. farction.
Length of survival after myocardial J.A.M.A., 151: 167, 1953.
in-
10. BREGANI,P., SELVINI,A. and PAVESI, V. The long term prognosis following myocardial infarction : clinical control of 180 patients after 1 to 18 years. :Minerua med.. 50: 2343, 1959. 11. WHITE, P. D.; BLAND, ‘E. F. and LEVINE, S. A. THE AMERICANJOURNAL OF CARDIOLOGY
Long Survival Following
12.
13.
14.
15.
Further observations concerning the prognosis of myocardial infarction due to coronary thrombosis. Ann. Znt. Med., 48: 39, 1958. BEER, S., HEINE, W. I. and KRASNOFF, S. 0. The mortality of acute myocardial infarction in private practice. Am. J. M. SC., 222: 500, 1951. WALDRON, F. A. and CONSTABLE,N. P. Myocardial infarction, a mortality study. Tr. A. Life Znsur. M. Dir. America, 34: 69, 1950. BOAS, E. P. Natural history of coronary artery disease of long duration. Am. Heart J., 41: 323, 1951. HONEY,G. E. and TRUELOVE, S. C. Prognostic factors in myocardial infarction. Lancet, 1 : 1209, 1957.
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16. CRAIN, R. B. and MISSAL, M. E. Industrial cmployee with myocardial infarction and his ability to return to work: follow up report. New York J. Med., 56: 2238, 1956. 17. IISALO, E., KALLIOLA, A., KASANEN,A. and LINKO, E. Prognosis and work capacity after cardiac infarction. Nerd. med., 59: 264, 1958. 18. WEISS, M. M., SR. and WEISS, M. M., JR. Fiveyear follow-up study of men who returned to work after a myocardial infarction. J.A.M.A., 168: 17, 1958. 19. MORRIS, J. N., HEADY, J. A., RAFFLE, P. A. B., ROBERTS, C. G. and PARRES, J. W. Coronary heart disease and physical activity of work. Lnncet, 6795: 1053, 1953; 6796: 1111, 1953.