- Email: [email protected]
To each according to his desert
Annotations
It is our proposal that the observed reaction of dispersal followed by aggregation is a function of the surface active properties of the heparin, coumadin, etc., molecules acting on the surfaces of cells and the surfaces of other particles present in the blood. Heparin or other surfactant molecules accummulating at the cell surfaces form films; adjacent films then adhere to each other causing aggregation to occur. Albumin and fragments of cells are also capable of layering out on surfaces, to form films and in a manner similar to that exerted by high concentrations of heparin, to produce aggregation. The point to be emphasized is that to prevent particle aggregation, an optimal concentration of the anticoagulating or antiaggregating agent must be present in the circulating blood during the bypass procedures. Optimal is used to mean
To each aocording
April,
Bernard Ecanow, Ph.D. Bernard H. Gold, Ph.D. University of Illinois at the Medical Center Chicago, Ill. Max Sadove, M.D. Rush Medical Center Chicago, Ill.
to his desert
Sed rest is one measure which is generally used in the management of a patient with acute myocardial infarction. The length of bed rest of such patients varied a great deal with .the passage of time. According to Lewis’ “. . rest in bed should be continued for at least eight weeks, even in the milder cases, to ensure firm cicatrisation of the ventricular wall. . . . A number of patients have lost their lives, and especially those who have early recovered from symptoms, by neglect of these precautions.“’ Most authors recommended a bed rest of six weeks duration. This is a far cry from the few days of bed rest advocated lately. The long bed rest in general use was influenced by a few experimental studies performed by pathologists. As early as 1916 Karsner and Dwyer’ had found necrotic tissue in the myocardium 60 days after ligation of a coronary artery in dogs. More than two decades later Mallory White, and Salcedo-Salza?, in their classical paper, showed that it took five weeks for the removal of necrotic material after an infarction. While small infarctions in dogs healed in about five weeks, large ones healed completely in two months. Therefore, to every clinician the long bed rest for patients with acute myocardial infarction seemed to be absolutely necessary. This viewpoint found support in a study’ which revealed a higher incidence of rupture of the myocardium in mental patients with acute myocardial infarction who were ambulatory; 73 per cent of patients with an acute myocardial infarction died from cardiac rupture and tamponade. Furthermore, experiments on dogs5 showed that, after ligation of the ramus descendens anterior, rest led to healing of the infarction with production of a small tirm scar without thinning of the ventricular wall, while early exercise (within three days after the operation) resulted in thin scars with aneurysmal bulging. The often quoted experiments by Thomas and Harrison” are not pertinent because the myocardium was only slightly damaged by burning; the authors themselves caution not to draw conclusions concerning patients. For many years now, perhaps, influenced by statements pointing out the harm done by prolonged bed rest,‘. ” patients
536
that concentration of drug at which dispersion has fully occurred and beyond which aggregation will be initiated. This concentration can be quickly and empirically determined through microscopic examination of blood samples which are routinely drawn during bypass surgery.
1978, Vol. 95, No. 4
with acute myocardial infarction were asked to be out of bed early and were discharged early from the hospital. Already in 1959 Brummer and colleagueas questioned the need for long bed rest in the management of acute myocardial infarction. Groden and associateaX did not find any significant difference in mortality rate, development of hypotension, shock or heart failure, further episodes of cheat pain, incidence of arrhythmias in two groups of patients with acute myocardial infarction when mobilized early or late and discharged from the hospital early or late. The authors also state that there was no difference in the long-term incidence of ventricular aneurysms in the two groups. One of their groups stayed in the hospital three weeks and the other five weeks. In addition to venous thrombosis and pulmonary embolism, muscular atrophy, economic and psychologic effects were mentioned as arguments against prolonged bed rest, thus completely disregarding the findings of pathologists mentioned above. It is also significant, with today’s reliance on instrumental findings, that, in more recent studies, the presence or absence of gallop rhythm, distant, muffled heart sounds, tiles over the bases of the lungs, often even the level of blood pressure, are not considered in a decision of the duration of bed rest. In numerous recent studies more authors tried to demonstrate that still earlier ambulation and earlier discharge from the hospital did not increase mortality and morbidity, and did not lead to the formation of a cardiac aneurysm. “-I4 a”d menY0thers Some authors discharge patients with acute myocardial infarction even after 7 or 10 days if no complications have been observed, and some went even so far as to find bed rest unnecessary.‘5 Shah,‘” while concluding that “physical activity after myocardial infarction was associated with reduced mortality,” noted that there was also association with “increasing effort intolerance between 18 months and two years after the acute attack.” This delayed disability of those patients who did not follow the conventional bed rest was not explained by the author. Abraham and co-workers,‘” in a prospective randomized study, came to the unusual conclusion that “early mobilization is beneficial irrespective of
ooO2-8703/78/0495-0536%00.20/O
0 1978 The
C. V. Mosby
Co.
Annotations
complications on admission” in patients with acute myocardial infarction. Hurst,” on the other hand, in an Editorial in the same issue, scrutinizes the article by Abraham and colleagues and finds certain deficiencies in the type of investigation these authors followed in their study and concludes that “common sense dictates that patient management should be individualized” and that “this matter is under active study by many people.” Mather and associates18. 2’ even considered home care preferable for many patients, particularly older ones and-strangely enough-for those with initial hypotension. Wingo and Lope~‘~ found early ambulation even beneficial in patients admitted with complications. Collins’” maintams that the decision whether hospital or home care is desirable depends on the status of the patient two hours after the start of symptoms. Some other investigators arrive also at remarkable conclusions. Wilson and Pantridge*’ base the early discharge from the hospital of their patients on the degree of the RS-T segment displacement. Earlier studies, however, have demonstrated in experiments on dogs that very small and superficial lesions of the heart, for instance brushing a 10 per cent solution of sodium chloride on an area as large as one square centimenter or mechanical lesion of such an area, may cause a marked displacement of the RS-T segment.?? Chaturvedi and colleaguesz3 discharged from the hospital 68 per cent of their patients with acute myocardial infarction by the seventh day. However, persistence of RS-T elevation of more than two millimeters six days after the onset of the infarction argues against an early discharge. In an Editorial?’ it is stated that, in a majority of uncomplicated infarctions, immobilization for more than seven days is not justified. Hayes and co-worker@ removed from the coronary care unit after 48 hours patients when they were free of pain, heart failure, and arrhythmias. These patients were discharged from the hospital nine days after the onset of the infarction. However, such patients not rarely develop later transmural infarctions.‘” Despite the numerous studies mentioned above we are convinced that early mobilization and discharge from the hospital of patients with acute myocardial infarction is associated with more frequent complications, particularly congestive heart failure and ventricular aneurysm. It is established that the amount of circulating blood increases when patients change from complete bed rest to even slight physical activity, due to sudden mobilization of blood from the depots; this increased circulating blood volume returns to the heart and bulging of the damaged portion of the myocardium is understandable. This would not occur in small subendocardial infarctions, but in transmural infarctions, readily recognized in the electrocardiogram, the situation is different. The point must be stressed that the clinical diagnosis of cardiac aneurysms, even with the aid of the X-ray studies, is very difficult and often missed (unless one uses invasive procedure). In addition, sudden dilatation of the heart may lead to congestive heart failure. Because of the many papers of recent vintage recommending a short stay in the hospital of patients with acute myocardial infarction , Utilization and Peer Review Committees insist on quick discharge of such patients. The decision is often made within the first hours after admission of the patient without regard to later developments. Repeatedly we observed patients with acute myocardial infarction who, after discharge from the hospital, developed
American
Heart
Journal
gallop rhythm, distant, impure heart sounds, and pulmonary congestion. These patients improved markedly when, in addition to medication, rest (nor absolute bed rest) was recommended for several weeks or even months. Some of these patients remained symptom-free for years afterward. It must be stressed that not every clinician finds an early mobilization of patients with acute myocardial infarction justifiable. Thus, Blumgart and Zoll*” sound a warning directed toward the advocates of early mobilization and “emphasize the importance of rest and reduced activity for many weeks after acute myocardial infarction.” Weingarten and colleagues*’ observed 35 patients with acute myocardial infarction for 4 to 14 months after early discharge from the hospital. All had been mobilized by the sixth day and were discharged after up to 15 days after hospitalization. Two of these patients were readmitted because of a new infarction, two developed congestive heart failure, and one of these died. In another study the recurrence of myocardial infarction, within months after dismissal from the hospital of patients who were ambulated early, was very high.9 In a recent Editorial, Mille?O takes a compromise attitude when he assumes that “around three weeks of hospitalization. . . offers a reasonable middle route to follow” and emphasizes that “It remains to be established whether there is any value to early mobilization.. . other than the psychological benefit.” Generalizations on this subject are not justified. Sensible individualization is necessary and every patient has to be evaluated according to the clinical findings. Our tentative suggestions are as follows: For small, “intramural” or subendocardial infarctions, without complications, we recommend one week of bed rest and discharge from the hospital after 14 to 20 days. In larger and especially transmural infarctions, without complications, we advise bed rest of three to four weeks and discharge in four to five weeks. Any significant complication will cause lengthening of the time of bed rest and hospital stay; it is well recognized that complications may arise suddenly and unexpectedly even in the “mildest” case, namely in patients with a “small” infarction.
David Scherf, M.D. 55 E. 86th Street New York, N. Y. 10028 Jules Cohen, M.D. Department of Medicine New York Medical College New York, N. Y. REFERENCES 1.
2.
3. 4. 5. 6.
Lewis, T.: Diseases of the heart, 2nd edition, London, 1937, MacMillan and Co., p. 49. Karsner, H. T., and Dwyer, J. E., Jr.: Studies in infarction. IV. Experimental bland infarction of the myocardium, myocardial regeneration and cicatrization. J. Med. Res. 34:21, 1916. Mallory, G. K., White, P. D., and Salcedo-Salzar, J.: The speed of healing of myocardial infarction, AM. HEART J. 18:647, 1939. Jetter, W. W., and White, P. D.: Rupture of the heart in patients in mental institutions, Ann. Intern. Med. 21:783,1944. Sutton, D. C., and Davies, M. D.: Effects of exercise on experimental myocardial infarction, Arch. Intern. Med. 48:111&3, 1931. Thomas, W. C., and Harrison, T. R.: The effects of
537
Annotations
7. 8. 9.
artificial restriction of activity in the recovery of rats from experimental injury, Am. J. Med. 208:436, 1944. Scherf, D., and Boyd, J. J.: Cardiovascular Diseases, J. B. Lippincott, Philadelphia, 1947, p. 68. Dock. W.: The evil sequelae of complete bed rest, J.A.M.A. 125:1083, 1944. Brummer, P., Linko, E., and Kasanen, A.: Myocardial infarction treated by early ambulation, AM. HEART J.
52:269, 1956. 10. Groden, B. M., Allison, 11. 12.
13.
19. 20.
21.
22. A., and infarction,
Shaw, Scot.
G. B.: ManageMed. J. 12:435,
ment of myocardial 1967. Adgey, A. A. J.: Prognosis after early discharge from hospital of patients with acute myocardial infarction, Br. Heart J. 31:750, 1969. Harpur, J. E., Kellett, R. J., Conner, W. T., et al.: Controlled trial of early mobilisation and discharge from hospital in uncomplicated myocardial infarction, Lancet 2: 1331, 1971. Duke, M.: Bed rest in acute myocardial infarction, AM.
23.
24. 25.
26.
HEART J. 82:486, 1971. 14.
15. 16.
17. 18.
Irvin, C. W., and Burgess, A. M.: The abuse of bed rest in the treatment of myocardial infarction, N. Engl. J. Med. 243:486, 1950. Shah, J. R.: Letter-Early mobilisation after mvocardial infarction, Lancet 1:534,-1972. Abraham. A. S.. Sever. Y.. Weinstein. M.. Dallbern. M.. and Menczel, J.: Value of early ambulation in patients with and without complication after acute myocardial infarction, N Engl. J. Med. 292:719, 1975. Hurst, J. W.: Editorial-“Ambulation” after myocardial infarction, N. Engl. J. Med. 292:746, 1975. Mather, H. G., Morgan, D. C., Pearson, N. G., and al.: Myocardial infarction: A comparison between home and hospital care for patients, Br. Med. J. 1:925, 1976. I
Statistics,
I
,
marathoning
April,
1978, Vol. 95, No. 4
28.
II
29.
30.
HEART J. 92:547, 1976.
and CWO
Many reports have appeared in the last decade that describe epidemiological studies of the relationship between physical activity and mortality, especially mortality from coronary heart disease. The methodological and epidemiological problems encountered by these studies are extreme, and valid conclusions are notoriously difficult to achieve.‘m3 Yet Bassler’ has written that “a search of the literature failed to document a single death due to coronary arteriosclerosis among marathon finishers,” and, in a subsequent letter, he concludes that “when the level of vigorous exercise is raised high enough, the protection appears to be absolute. The American Medical Joggers Association has been unable to document a single death resulting from coronary heart disease among marathon finishers of any age.‘r5 We do not know what signitlcance we are to place upon Bassler’s communications: we do not know how many deaths of marathonem-from all cause+was revealed by the search of the literature conducted by 3assler, ,nor do we know the number of autopsies performed or reviewed by the A.M.J.A., both crucial facts for establishing the statistical significance of his findings.
53%
27.
Wingo, C. S., and Lopez, A.: Ambulation after myocardial infarction, N. Engl. J. Med. 294:341, 1976. Collins, A.: Home or hospital care after myocardial infarction: Is this the right question? Br. Med. J. 1:559, 1974. Wilson, C., and Pantridge, J. F.: ST segment displacement and early hospital discharge in acute myocardial infarction, Lancet 2:1284, 1973. Boyd, L. J., and Scherf, D.: The electrocardiogram in experimental pericardial (epicardial) injury, Bull. N. Y. Med. Coll. 2:168, 1939. Chaturvedi, N. E., Walsh, M. J., Evans, A., et al.: Selection of patients for early discharge after acute myocardial infarction, Br. Heart J. 36:533, 1974. Editorial: Myocardial infarction then and now, Lancet 1:395, 1974. Hayes, M. J., Morris, G. K., and Hampton, J. R.: Comparison of mobilisation after 2 and 9 days in uncomplicated myocardial infarction, Br. Med. J. 3:10, 1974. Madigan, N. P., Rutherford, B. D., and Frye, R. L.: The clinical course, early prognosis and coronary anatomy of subendocardial infarction, Am. J. Med. 601634, 1976. Mater. H. G.. Pearson. N. G.. Read. K. L. G., et al.: Acute myocardial infarction; Home and hospital treatment, Br. Med. J. 3:334, 1971. Blumgart, H. L., and Zoll, P. M.: Clinical pathologic correlations in coronary artery disease, Circulation 47:1139, 1973. Weingarten, M. A. Pinkhas, J., and de Vries, A.: Early discharge after mvocardial infarction. Folia Clin. Int. (Barc.)>5:271, 1975. Miller, A. J.: Editorial-Rehabilitation and length of hospitalization after acute myocardial infarction, AM.
I have made some calculations which bear on this. In 1975, 10,482 men and women completed a marathon road race.G Approximately 5 per cent of these runners were women, leaving 9,958 male marathonem. I have estimated the number of men expected to die from ischemic and related heart disease in a cohort of 9,958 white American males whose age distribution is the same as these marathoners, but whose relative weight, level of exercise, and smoking habits are the same as the general American insured male population. However, marathoners, almost to a man (or to a woman), are invariably quite thin and not addicted to smoking. After applying appropriate weight and smoking r&k factor corrections to the estimated mortality rate for these men, we may obtain an estimate of the number of men that would be expected to die per year in this non-running, non-smoking, non-average weighted group of men. This estimate, then, is independent of any postulated “protection” that marathoning might afford. Table I, columns 1 and 2, show the age distribution of the marathoners, column 3 the annual mortality rate per lo5 for each age interval for white insured U.S. males,’ and column 4
0002-8703/78/0495-0538$00.20/O
0 1978 The
C. V. Mosby
Co.
It is our proposal that the observed reaction of dispersal followed by aggregation is a function of the surface active properties of the heparin, coumadin, etc., molecules acting on the surfaces of cells and the surfaces of other particles present in the blood. Heparin or other surfactant molecules accummulating at the cell surfaces form films; adjacent films then adhere to each other causing aggregation to occur. Albumin and fragments of cells are also capable of layering out on surfaces, to form films and in a manner similar to that exerted by high concentrations of heparin, to produce aggregation. The point to be emphasized is that to prevent particle aggregation, an optimal concentration of the anticoagulating or antiaggregating agent must be present in the circulating blood during the bypass procedures. Optimal is used to mean
To each aocording
April,
Bernard Ecanow, Ph.D. Bernard H. Gold, Ph.D. University of Illinois at the Medical Center Chicago, Ill. Max Sadove, M.D. Rush Medical Center Chicago, Ill.
to his desert
Sed rest is one measure which is generally used in the management of a patient with acute myocardial infarction. The length of bed rest of such patients varied a great deal with .the passage of time. According to Lewis’ “. . rest in bed should be continued for at least eight weeks, even in the milder cases, to ensure firm cicatrisation of the ventricular wall. . . . A number of patients have lost their lives, and especially those who have early recovered from symptoms, by neglect of these precautions.“’ Most authors recommended a bed rest of six weeks duration. This is a far cry from the few days of bed rest advocated lately. The long bed rest in general use was influenced by a few experimental studies performed by pathologists. As early as 1916 Karsner and Dwyer’ had found necrotic tissue in the myocardium 60 days after ligation of a coronary artery in dogs. More than two decades later Mallory White, and Salcedo-Salza?, in their classical paper, showed that it took five weeks for the removal of necrotic material after an infarction. While small infarctions in dogs healed in about five weeks, large ones healed completely in two months. Therefore, to every clinician the long bed rest for patients with acute myocardial infarction seemed to be absolutely necessary. This viewpoint found support in a study’ which revealed a higher incidence of rupture of the myocardium in mental patients with acute myocardial infarction who were ambulatory; 73 per cent of patients with an acute myocardial infarction died from cardiac rupture and tamponade. Furthermore, experiments on dogs5 showed that, after ligation of the ramus descendens anterior, rest led to healing of the infarction with production of a small tirm scar without thinning of the ventricular wall, while early exercise (within three days after the operation) resulted in thin scars with aneurysmal bulging. The often quoted experiments by Thomas and Harrison” are not pertinent because the myocardium was only slightly damaged by burning; the authors themselves caution not to draw conclusions concerning patients. For many years now, perhaps, influenced by statements pointing out the harm done by prolonged bed rest,‘. ” patients
536
that concentration of drug at which dispersion has fully occurred and beyond which aggregation will be initiated. This concentration can be quickly and empirically determined through microscopic examination of blood samples which are routinely drawn during bypass surgery.
1978, Vol. 95, No. 4
with acute myocardial infarction were asked to be out of bed early and were discharged early from the hospital. Already in 1959 Brummer and colleagueas questioned the need for long bed rest in the management of acute myocardial infarction. Groden and associateaX did not find any significant difference in mortality rate, development of hypotension, shock or heart failure, further episodes of cheat pain, incidence of arrhythmias in two groups of patients with acute myocardial infarction when mobilized early or late and discharged from the hospital early or late. The authors also state that there was no difference in the long-term incidence of ventricular aneurysms in the two groups. One of their groups stayed in the hospital three weeks and the other five weeks. In addition to venous thrombosis and pulmonary embolism, muscular atrophy, economic and psychologic effects were mentioned as arguments against prolonged bed rest, thus completely disregarding the findings of pathologists mentioned above. It is also significant, with today’s reliance on instrumental findings, that, in more recent studies, the presence or absence of gallop rhythm, distant, muffled heart sounds, tiles over the bases of the lungs, often even the level of blood pressure, are not considered in a decision of the duration of bed rest. In numerous recent studies more authors tried to demonstrate that still earlier ambulation and earlier discharge from the hospital did not increase mortality and morbidity, and did not lead to the formation of a cardiac aneurysm. “-I4 a”d menY0thers Some authors discharge patients with acute myocardial infarction even after 7 or 10 days if no complications have been observed, and some went even so far as to find bed rest unnecessary.‘5 Shah,‘” while concluding that “physical activity after myocardial infarction was associated with reduced mortality,” noted that there was also association with “increasing effort intolerance between 18 months and two years after the acute attack.” This delayed disability of those patients who did not follow the conventional bed rest was not explained by the author. Abraham and co-workers,‘” in a prospective randomized study, came to the unusual conclusion that “early mobilization is beneficial irrespective of
ooO2-8703/78/0495-0536%00.20/O
0 1978 The
C. V. Mosby
Co.
Annotations
complications on admission” in patients with acute myocardial infarction. Hurst,” on the other hand, in an Editorial in the same issue, scrutinizes the article by Abraham and colleagues and finds certain deficiencies in the type of investigation these authors followed in their study and concludes that “common sense dictates that patient management should be individualized” and that “this matter is under active study by many people.” Mather and associates18. 2’ even considered home care preferable for many patients, particularly older ones and-strangely enough-for those with initial hypotension. Wingo and Lope~‘~ found early ambulation even beneficial in patients admitted with complications. Collins’” maintams that the decision whether hospital or home care is desirable depends on the status of the patient two hours after the start of symptoms. Some other investigators arrive also at remarkable conclusions. Wilson and Pantridge*’ base the early discharge from the hospital of their patients on the degree of the RS-T segment displacement. Earlier studies, however, have demonstrated in experiments on dogs that very small and superficial lesions of the heart, for instance brushing a 10 per cent solution of sodium chloride on an area as large as one square centimenter or mechanical lesion of such an area, may cause a marked displacement of the RS-T segment.?? Chaturvedi and colleaguesz3 discharged from the hospital 68 per cent of their patients with acute myocardial infarction by the seventh day. However, persistence of RS-T elevation of more than two millimeters six days after the onset of the infarction argues against an early discharge. In an Editorial?’ it is stated that, in a majority of uncomplicated infarctions, immobilization for more than seven days is not justified. Hayes and co-worker@ removed from the coronary care unit after 48 hours patients when they were free of pain, heart failure, and arrhythmias. These patients were discharged from the hospital nine days after the onset of the infarction. However, such patients not rarely develop later transmural infarctions.‘” Despite the numerous studies mentioned above we are convinced that early mobilization and discharge from the hospital of patients with acute myocardial infarction is associated with more frequent complications, particularly congestive heart failure and ventricular aneurysm. It is established that the amount of circulating blood increases when patients change from complete bed rest to even slight physical activity, due to sudden mobilization of blood from the depots; this increased circulating blood volume returns to the heart and bulging of the damaged portion of the myocardium is understandable. This would not occur in small subendocardial infarctions, but in transmural infarctions, readily recognized in the electrocardiogram, the situation is different. The point must be stressed that the clinical diagnosis of cardiac aneurysms, even with the aid of the X-ray studies, is very difficult and often missed (unless one uses invasive procedure). In addition, sudden dilatation of the heart may lead to congestive heart failure. Because of the many papers of recent vintage recommending a short stay in the hospital of patients with acute myocardial infarction , Utilization and Peer Review Committees insist on quick discharge of such patients. The decision is often made within the first hours after admission of the patient without regard to later developments. Repeatedly we observed patients with acute myocardial infarction who, after discharge from the hospital, developed
American
Heart
Journal
gallop rhythm, distant, impure heart sounds, and pulmonary congestion. These patients improved markedly when, in addition to medication, rest (nor absolute bed rest) was recommended for several weeks or even months. Some of these patients remained symptom-free for years afterward. It must be stressed that not every clinician finds an early mobilization of patients with acute myocardial infarction justifiable. Thus, Blumgart and Zoll*” sound a warning directed toward the advocates of early mobilization and “emphasize the importance of rest and reduced activity for many weeks after acute myocardial infarction.” Weingarten and colleagues*’ observed 35 patients with acute myocardial infarction for 4 to 14 months after early discharge from the hospital. All had been mobilized by the sixth day and were discharged after up to 15 days after hospitalization. Two of these patients were readmitted because of a new infarction, two developed congestive heart failure, and one of these died. In another study the recurrence of myocardial infarction, within months after dismissal from the hospital of patients who were ambulated early, was very high.9 In a recent Editorial, Mille?O takes a compromise attitude when he assumes that “around three weeks of hospitalization. . . offers a reasonable middle route to follow” and emphasizes that “It remains to be established whether there is any value to early mobilization.. . other than the psychological benefit.” Generalizations on this subject are not justified. Sensible individualization is necessary and every patient has to be evaluated according to the clinical findings. Our tentative suggestions are as follows: For small, “intramural” or subendocardial infarctions, without complications, we recommend one week of bed rest and discharge from the hospital after 14 to 20 days. In larger and especially transmural infarctions, without complications, we advise bed rest of three to four weeks and discharge in four to five weeks. Any significant complication will cause lengthening of the time of bed rest and hospital stay; it is well recognized that complications may arise suddenly and unexpectedly even in the “mildest” case, namely in patients with a “small” infarction.
David Scherf, M.D. 55 E. 86th Street New York, N. Y. 10028 Jules Cohen, M.D. Department of Medicine New York Medical College New York, N. Y. REFERENCES 1.
2.
3. 4. 5. 6.
Lewis, T.: Diseases of the heart, 2nd edition, London, 1937, MacMillan and Co., p. 49. Karsner, H. T., and Dwyer, J. E., Jr.: Studies in infarction. IV. Experimental bland infarction of the myocardium, myocardial regeneration and cicatrization. J. Med. Res. 34:21, 1916. Mallory, G. K., White, P. D., and Salcedo-Salzar, J.: The speed of healing of myocardial infarction, AM. HEART J. 18:647, 1939. Jetter, W. W., and White, P. D.: Rupture of the heart in patients in mental institutions, Ann. Intern. Med. 21:783,1944. Sutton, D. C., and Davies, M. D.: Effects of exercise on experimental myocardial infarction, Arch. Intern. Med. 48:111&3, 1931. Thomas, W. C., and Harrison, T. R.: The effects of
537
Annotations
7. 8. 9.
artificial restriction of activity in the recovery of rats from experimental injury, Am. J. Med. 208:436, 1944. Scherf, D., and Boyd, J. J.: Cardiovascular Diseases, J. B. Lippincott, Philadelphia, 1947, p. 68. Dock. W.: The evil sequelae of complete bed rest, J.A.M.A. 125:1083, 1944. Brummer, P., Linko, E., and Kasanen, A.: Myocardial infarction treated by early ambulation, AM. HEART J.
52:269, 1956. 10. Groden, B. M., Allison, 11. 12.
13.
19. 20.
21.
22. A., and infarction,
Shaw, Scot.
G. B.: ManageMed. J. 12:435,
ment of myocardial 1967. Adgey, A. A. J.: Prognosis after early discharge from hospital of patients with acute myocardial infarction, Br. Heart J. 31:750, 1969. Harpur, J. E., Kellett, R. J., Conner, W. T., et al.: Controlled trial of early mobilisation and discharge from hospital in uncomplicated myocardial infarction, Lancet 2: 1331, 1971. Duke, M.: Bed rest in acute myocardial infarction, AM.
23.
24. 25.
26.
HEART J. 82:486, 1971. 14.
15. 16.
17. 18.
Irvin, C. W., and Burgess, A. M.: The abuse of bed rest in the treatment of myocardial infarction, N. Engl. J. Med. 243:486, 1950. Shah, J. R.: Letter-Early mobilisation after mvocardial infarction, Lancet 1:534,-1972. Abraham. A. S.. Sever. Y.. Weinstein. M.. Dallbern. M.. and Menczel, J.: Value of early ambulation in patients with and without complication after acute myocardial infarction, N Engl. J. Med. 292:719, 1975. Hurst, J. W.: Editorial-“Ambulation” after myocardial infarction, N. Engl. J. Med. 292:746, 1975. Mather, H. G., Morgan, D. C., Pearson, N. G., and al.: Myocardial infarction: A comparison between home and hospital care for patients, Br. Med. J. 1:925, 1976. I
Statistics,
I
,
marathoning
April,
1978, Vol. 95, No. 4
28.
II
29.
30.
HEART J. 92:547, 1976.
and CWO
Many reports have appeared in the last decade that describe epidemiological studies of the relationship between physical activity and mortality, especially mortality from coronary heart disease. The methodological and epidemiological problems encountered by these studies are extreme, and valid conclusions are notoriously difficult to achieve.‘m3 Yet Bassler’ has written that “a search of the literature failed to document a single death due to coronary arteriosclerosis among marathon finishers,” and, in a subsequent letter, he concludes that “when the level of vigorous exercise is raised high enough, the protection appears to be absolute. The American Medical Joggers Association has been unable to document a single death resulting from coronary heart disease among marathon finishers of any age.‘r5 We do not know what signitlcance we are to place upon Bassler’s communications: we do not know how many deaths of marathonem-from all cause+was revealed by the search of the literature conducted by 3assler, ,nor do we know the number of autopsies performed or reviewed by the A.M.J.A., both crucial facts for establishing the statistical significance of his findings.
53%
27.
Wingo, C. S., and Lopez, A.: Ambulation after myocardial infarction, N. Engl. J. Med. 294:341, 1976. Collins, A.: Home or hospital care after myocardial infarction: Is this the right question? Br. Med. J. 1:559, 1974. Wilson, C., and Pantridge, J. F.: ST segment displacement and early hospital discharge in acute myocardial infarction, Lancet 2:1284, 1973. Boyd, L. J., and Scherf, D.: The electrocardiogram in experimental pericardial (epicardial) injury, Bull. N. Y. Med. Coll. 2:168, 1939. Chaturvedi, N. E., Walsh, M. J., Evans, A., et al.: Selection of patients for early discharge after acute myocardial infarction, Br. Heart J. 36:533, 1974. Editorial: Myocardial infarction then and now, Lancet 1:395, 1974. Hayes, M. J., Morris, G. K., and Hampton, J. R.: Comparison of mobilisation after 2 and 9 days in uncomplicated myocardial infarction, Br. Med. J. 3:10, 1974. Madigan, N. P., Rutherford, B. D., and Frye, R. L.: The clinical course, early prognosis and coronary anatomy of subendocardial infarction, Am. J. Med. 601634, 1976. Mater. H. G.. Pearson. N. G.. Read. K. L. G., et al.: Acute myocardial infarction; Home and hospital treatment, Br. Med. J. 3:334, 1971. Blumgart, H. L., and Zoll, P. M.: Clinical pathologic correlations in coronary artery disease, Circulation 47:1139, 1973. Weingarten, M. A. Pinkhas, J., and de Vries, A.: Early discharge after mvocardial infarction. Folia Clin. Int. (Barc.)>5:271, 1975. Miller, A. J.: Editorial-Rehabilitation and length of hospitalization after acute myocardial infarction, AM.
I have made some calculations which bear on this. In 1975, 10,482 men and women completed a marathon road race.G Approximately 5 per cent of these runners were women, leaving 9,958 male marathonem. I have estimated the number of men expected to die from ischemic and related heart disease in a cohort of 9,958 white American males whose age distribution is the same as these marathoners, but whose relative weight, level of exercise, and smoking habits are the same as the general American insured male population. However, marathoners, almost to a man (or to a woman), are invariably quite thin and not addicted to smoking. After applying appropriate weight and smoking r&k factor corrections to the estimated mortality rate for these men, we may obtain an estimate of the number of men that would be expected to die per year in this non-running, non-smoking, non-average weighted group of men. This estimate, then, is independent of any postulated “protection” that marathoning might afford. Table I, columns 1 and 2, show the age distribution of the marathoners, column 3 the annual mortality rate per lo5 for each age interval for white insured U.S. males,’ and column 4
0002-8703/78/0495-0538$00.20/O
0 1978 The
C. V. Mosby
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