Cardiac strain and trauma

Cardiac

Strain

Trauma

and

EUGENE L. COODLEY, M.I). Los

T

HE sig;nificance is assuming

realize

that

with

over

some

strain

when

of heart

people

are affected

disease,

of all deaths

each

we

our

terms,

(a) penetrating

duce

lesions

hemorrhage,

contusion

Because

tamponade,

embolism,

or auricular

(b) nonpenetrating

indirect

contusion

from

tion

of trauma

to heart

; (c ) strain,

mation rupture,

sufflcienc). between

The

ensuing

s! mptoms

of cardiac

stitutes

a difficult

problem

mrtlical

in

stress

of strain,

both

in industry

of the need

tIecause

capabilit!.

limitations, ployer.

the

during

of an the

prognosis

elnplo)-ment,

of a minor

constitute

in-

in legal

danxcr

to frllow

and men-

to

assumed

by

of his cardiac

disease, employes

cent

of \\orkers

in

occlusion

his

heart

the

em-

60 per

Among

men

insured

cent

disabilit)-

those

arteriosclerotic

with rhosr

survi\.e

Lvho qualified

permanent

benefits,

xvith coronary

heart

to

in deter-

and

to

better

trauma.

ten

occlusion,

strain

of

disease,

relationship.

cardiac

changes

He

strain

secondcould

but ernphasizcd

or strain

follohved

within the

lcad

that

of laborator\

presence

period

of no prior

was sufficient,

of pre-csisting of a recent

the

t))- continu-

a reasonat)lc

this xequencc

presence

I))

dysfunction

\vith the appearance

the

has

insufficient)-

or ph>-sical

In

Sigler’ followed

cardiac

for causal

changes

a necessity.

In

and

half

of in-

survived

a later

infarction, the clinical of coronary

)ears.

disease,

Strain:

coronary

nwrosis,

of efrort

“ml-ocardial

live

for total atwut

KEL.\UON

while

disease,

acute

must

1~ dc-

nature

monstrable.

a previous to work

in

of

of sudden

with

acute

ous symptoms

lvork,

the problems

continue

trauma,

moderate

criteria

that

ary to emotional

was

condition

t))- virtue

industry \vho

five ) ra’rs, and

cludinq

noted

on

change in cardiac function during employment. Insurance statistics have shown that 80 per coronar\-

to aid

of cardiac

symptoms

confirmatory

of aggra\.ation

and

case,

and limi-

of early or minimal

Emotional

that

to myocardial

for decisions

the question

cardiac

after

or

out

con-

importance

individual

liability

in industr)-, of diagnosis

rewlts

Physiccil continuous

often

ph)xical

is of particular

in a given possibilities

01: TRAI-MA TO HEART DISEASE

sequence

The relation

work

rela-

so as to better

CRI,~ERIA FOR EXTARLISHING Cncs.4~

and

nonindustrial

tal, to hearL disease

disease

factors

damage

pointed

situations.

the

cardiac

in-

relation

opinion and

for

methods

valve

dysfunction

and

tations mining

it is impor-

the cause-effect

employment

prognosticate

for-

coronary

Lvhich

industrial

contributing

help evaluate

and

producing

industrial

testimony

I)oth

valvu-

fibrillation;

cause-effect

trauma,

dispute,

pro-

muscle,

and

accidents,

volves

may

arrhythmia,

necrosis,

patterns.

in-

or aneurysm

producing

m)-ocardial

trauma

disabled,

after 15 years.

considerations,

result

injuries,

or rupture,

of these

to evaluate

pericarditis,

of heart

becoming

\\-ere living

to attempt

which

and infarction

lar rupture, cardiac

cardiac

after

a third

tant assess

defining

cludes:

than

over

disease.

In

more

that

and year

California

10 )-ears or longrr

and trauma

importance

ten million

type

SO per cent this

of cardiac

increasing

Angeles,

to

coronar)-

publication, ischemia,

Siglcr”

ischcmic

stated

that

necrosis.

a nd

kvhich are the underlying manifestations

of the

artc‘ry disease. thrombosis.

cauws

acute

of

phase

are not due solely The),

ma)’

result

from other acute occlusive processes or from acute functional disparit), brt\vcen the demand and the supply of the blood to the heart muscle. Emotional and ‘or ph+cal strain are potent factors

in the production

of the acute phase of

Cardiac

612 the disease. . . . be unusual

The strain must not necessarily

provided

been undertaken disease.

The

it is great enough

at a vulnerable symptoms

must not necessarily must be continuous If

disease, must

there

tate

strable

ciency

after

may

injury

the

strain. un-

occlusion

functional

at

Delayed

death

insuffi-

atheromatosis

of several

cardiac

insult

if autopsy

autopsy,

myocardial

coronary

where coronary

an acute

years

may be due

insult

extension

at the original site of injury, and there acute

findings

pathologic

reveal

findings

an

to ac-

for death.”

Weiss3

and

physiologic

felt that cardiac

tion of the resiliency force

others changes

the etiology

have

shown

occur

that

with

many

emotional

may

the same mitral

disease

He pointed

rupture

heart may

valves

relation

betlveen

and stated (a)

that

increase

mia,

Studies

in

and

capillaries,

permeability rises

of patients

output,

in

of pulmonary

serum

suffering

as exemplified

by teeth

tion while at apparent

grinding,

tension

stress precipitating

This

occur

or an acute

cardiac

in conjunction

dent of minor extent otherwise,

with

rhythm,

(d) pericardial

trauma

damage reported

with signs of failure,

secondary

per cent developed arrhythmias and two-thirds Arenof these developed permanent changes. bergy5 in analyzing 28 cases of traumatic heart

following

in 24 to 48 hours.

direct

trauma

ventricular tusion,

asystole

laceration,

valve

contusion

sulting

in hypotension,

pressure

cardiac

changes

cardiac

rupture,

trauma

He

con-

or coronary

coronary

infarction.

that

shock with

with posttraumatic

shock re-

ischemia

and

explained

the

such as stress as being

changes

with development

insufficiency Ejort

the pathologic

or fibrillation,

artery

com-

to the sinoauricular

and stress has indicated

may produce

nonthrombotic

explained

following

nodes.

in analyzing trauma

or strain,

or onset of oc-

as the result of contusion

and auriculoventricular Moritzl?

mitral

(f) heart

Osborn7

of the right auricle extending

following

or

trauma

of arrhythmias

pressive chest trauma

plaques

to nonpenetrating

diastolic

onset of angina,

due to physiologic

up to 1953 and stated that 15

aortic

immediately

unex(c) ab-

rub or evidence

systolic murmur

an acci-

350 cases

(b)

of the heart,

(e)

effects of indirect

stress while at a work not physi-

symptoms

changes,

normal

damage.

or in association

cally involving unusual exertion. Cardiac Trauma: Taylor4 reviewed of heart

dysfunc-

rest does not invalidate

of preceding

with emotional

nightmares,

of cardiac

emotional may

increasing

may also be present in sleep,

etc., so that the occurrence the concept

oc-

of 49 per cent

tension of a gradually

Tension

nature.

cholesterol.

from coronary

clusions have shown an incidence with preceding

arrhyth-

arrhythmia. for providing

of tamponade,

(g) immediate

may

at least one must be present:

acute enlargement

the development

and adrenalin

with

and heart

plained

clusion

time,

fever,

by direct irrita-

criteria

electrocardiographic

failure

may

by- muscular

fumes or gases, re-

necrosis trauma

fibrilla-

trauma

rheumatic

the following

in pulse rate,

output,

in auricular

or may,

while

of rheumatic

or chordae

reactivate

in myocardial

He cited

aneurysm

out that remote

tion such as from inhaling sult

type of disease,

an

may result

that

will vary with

in the presence

tion.

clotting

blood viscosity

rupture

strain

blood

cardiac

emphasized

of the underlying

strain

stress and strain such as changes pressure,

Sprague6

the results of any type of injury i.e.,

of cardiac

injury- was a func-

of the chest wall and the

of the blow.

result in arrhythmias,

to such

count

injury-he

the se\,erity.

and the incidence

effort,

to an acute

between

injury

soon after

to

are no other

found no relation

of thoracic

of demon-

coronary

is marked.

myocardial

disease,

occur

especially

following

cardiac

or upset may precipi-

Death

due

myocardial

and Trauma

and in the absence

is to be attributable ischemia

but

work if performed

excitement

acute

after,

pre-existing soon

non-strenuous

strain,

strain

of structural

of fresh

an attack.

a given

the

following

was

be demonstrable

der emotional

of the

and followed within a reason-

evidence

Physically

and has

phase

be severe soon

able time by evidence damage.

Strain

or hemorrhage

of pulse and blood of relative

coronary

into atheromatous

with swelling and lumen obstruction. In assessing and Coronary Insuj’kienq:

the role of effort,

Yater8

reported

topsy cases of all forms of coronary

on 950 ausclerosis in

the Armed Forces, and in the younger age group the terminal cardiac episode occurred during strenuous activity in 32 per cent. French

and Dock,!’

in a similar

c:orrelation

l)et\veen activity

so d es. Sigler,

found and

t)e sudden

pathologic

In each instance heart failure. cipitated I))- a period of acute Lvhich has followed

strain in the presence circulation.

is rarely

protractecl

factors. how

He

sitlting from phy-sical or mental for 30 minutesor He indicated common

morc,or

to strain

after effort

that

but that

inadequate

are

stated

that

distress

re-

several times.

insufficiency

was as

to one-half.

that occlusion

of the time needed for a thrombus

rion.

coronary

make<

the

He

I))- the finding

of an organizing

thrombus

\vith effort as compared

of those in \vhich patients

MEDICOIJXAL A

many

revealed imous

out in 38 as-

to 11 per cent

died in bed.

cian,

intimal

rupture

of intramural

hema-

of atheromatous

dur-

material

Strain:

In

that se\‘ere strain cardiac

insult,

unusual

qf Cardiac Disability

cardiac ma)

the

criteria

disability:

Due to

whereby

it is apparent

be followed

by signs of

has already

in

cvith

A study’”

Industry

Heart

Mhen five expert

Clam-

Association

physicians

an-

and

\vhen the

same

case

a second time by the .same physi80

per

cent

confirmed

they had rendered.

tion.

In cases involving \vere made

the

first

LVhen compared Accident

reached

a

unusual

in almost

Tu-o-thirds

Com-

under

the

the

the

cent

of

classed as moderate

and 50 per cent of the patients age

of the labor

presumption

exertion.

90 per

of the cases of heart disease

\vere reported in occupations or mild exertion,

of

55.

code,

that

In

California,

in effect,

in

any

establish

cast

of heart

disease arising from police or firemen’s

activities

during

and that this strain need not be

if the patient

Cardiacs

to the alyards of the Industrial

statutes

evaluating

strain induces

on heart

exertion,

disagreeing.

California

a‘greement,

opinion

vverc

to form a clot. .S’unlmar_~ n/ Cdrrici

and

mission, there was roughly a 70 per cent correla-

toma, cha nqes in viscosity and permeabilitying stress, :~nd rcleaw

that

only

cases.

formation

experts

the

was analyzed

possible

included

to stress

by the of

IN CARI)I.XC 7‘RAT!hl.4

exists in legal decisions

secondary medical

awards

and hemorrhage,

peak. and

symptoms.

I-'ROBLEW

paradox

disease

Kapp, I1 in ii re\iw of 42 cases of coronary thrombosis following trauma or effort, stated that mechanisms

in

alyzed 319 cases. only 14 per cent were in unan-

obstruc-

this is borne

per cent of ca‘;cs of fatal coronary- occlusion wciatrd

of occurrence

in cool vvcather, in late after-

usuatly~ with premonitory

mittee

circulation

of partial

to hIaster”’

These same studies have incidence

noon \\:hen acti\ it)- was at its highest

initiated

occurred

to form, and

collateral

in the presence

According

have revealed

among people in managerial

sho\vn an incrwsed patients

fields of

Studies of series

in \.aried occupations

or skilled labor fields. younger

Although OCto the devclop-

related

heart disease, certain

a greater incidence

in only 2. per cent of cases because

n~rrely

is not causally

of patients

and in 100 cases found a

in one-third

cupation

stress persisting

recurring

that coronary

as occlusion,

also was of the opinion

effort

is-

or mental

subjective

or

is acute

disease.

endea\,or show a predilection.

physical

or asystole, cause

Occupation and Coronary Attacks: ment of coronary

the result of strain,

should

coronary

these are pre-

was of the opinion

pathogenic

the histor).

relation

or

episodes of coronary- insufficiency

common

fibrillation precipitating

myocardial

of an abnormal

Master”’

occlusion

as a

or asystole,

failure---the

myocardial ischemia, which has followed physical or mental sti.ain in the presence of acl\,anced

disease may findings

of \-entricular. fibrillation

chemia

heart

epi-

has indicated

with coronary

Mithout

t)e due to ventricular

a similar

terminal

in nuinerous publications.

his belief that death result

study,

hours of employment,

a causal

relation

exists. The entitled

courts

have

ruled

to compensation

that

an employe

whenever

is

his condi-

\.ulnerablc phase of coronary disease. The symptoms following strain should be continu-

tion is aggravated by the employment, or if the employment hastened death or disability. The

ous and followed in a reasonable

question

development

of lahoratory

of damage

Death

from coronary

be sudden brithout pathologic MAY.

1959

period

or clinical

by the

evidence

disease may

findings and may

of whether

the employment

precipi-

tated the collapse of a diseased heart prior to the time when the normal progress of the disease Ivould have

Ibrought on such a collapse

is one

614

C:ardiac

of fact.

The court also stated:

strain

is a usual or unusual

the facts involved.

evidence that

only

One

the

thus helping

Of

the injury or death

if there is competent

substantial

to show the causal connection

strain

and ‘Traunla

If there was a strain usual

to that type of employnent, is compensable

“M:hether

one is

Strain

and

the

collapse.”

serum that

in a study of 250 cases of nonpenetrating

chest

this is more

helpful

LaDue’”

has pointed

glutamic

occur

days.

He also indicated

damage

muscles during

Having between

considered effort

mechanisms

to moderate

cardiac

and

review

trauma.

value

heart

damage,

the modes

Man)-

and

in acute

emphasize

of the

synptoms

cardiac

enlargement,

Of

murmurs,

frequently

laboratory changes come

of

popular

in the diagnosis

cast, particularly betlveen

transaminase cardial

infarction

SGO-T

for cardiac

of the 72 per cent

scribed

only

of cardiac

dis-

about

cardiac

an elevation

out considerable

studpiG of the

damage. of patients

showing

had

demonhas

as unusual in trauma

muscle

age, and has indicated

necrosis

dewith-

of as little

as 10 per cent of the total myocardium would give rise to an elevation. He also pointed out a few instances

of a rise in the enzyme level Macassociated with an arrh!-thmia alone. Donald et ~1.‘~ have studied the level of serum lactic

dehydrogenase

found the of longer addition, between

in myocardial

protein

universally

without

infarction.

The

test ma)

disease and

technique to be simpler and the changes duration (up to six to eight days). In the level tends to vary significantly acute ischemia and actual infarction,

cardiac

the enzyme

X change

tests

in C-rcac-

ti\-e protein from positive to negati\,c can be expected after t\vo to three weeks in the presence of cardiac

damage,

so this ma>- more

reliabl)

the course of the disease than the sedi-

mentation

rate, which tends to be elevated despite

the absence

for

of other signs

disease. ILLLXTRATIVE CASE HISTORIES

To illustrate

some of the problems

in assessing the relationship subsequent tories

cardiac

seen b)-

me

Commission

have

medicolegal

files.

or liver dam-

that infarction

almost

since, in this instance,

of the

but this In that

Chinsky17

C-reactilre

he

will tend to be negative.

in a large percent-

one-fourth

damage.

to

be useful \vhen the patient is first seen and tested

indicate

that elevation

was not specific elevation,

be-

trauma,

skeletal

tmt tends to be negati\-e in coronar)’

insufficiency

of active

bodily

to

positive after the third day in acute transmural infarction,

oxalacetic

after

strable

the

and

and this is

injur)-

The

reported

with myo-

revealed

mechanical hotPin:

been

glutamic

age of patients study,

C-React& has

associated

acti\-ity \vas present

SGP-T,

muscle.

long periods

serum

in conditions

in SGO-T,

for one to six days,

of

to skeletal

t)!. minimal

trauma,

recently

.A recent

is followed

more than four days after the suspected

on an acute basis.

Serum Transaminase: relation

of

tests shelving

have

true

that trauma

surgery

signs of

Among

available,

enzymes

also

skeletal

rhythms

rubs,

significance.

modalities in serum

the

findings

heart failure, and presence of abnormal arc

par-

course,

and/or

of the

changes,15

situations.

pattern

the

activit)

after

and ma)- persist four to seven

increase

SLD

let us

of diagnosis

authors

of electrocardiographic

ticularly

for relation

by \\-hich this may operate,

briefly

now

the evidence

than

out that rises in strum

transaminase

injuries, felt that the ma,jority of cases of cardiac

DIAGNOSIS OF C.4RDIrZC:TRAUUA

in liver disease

dysfunction.

trauma,

or diagnosed.

Studies on the transaminase suggest

p).ruvic

muscle

were not recognized

these entities when the

is indefinite.

glutamic

cardiac

between

.4renberg,‘-’

to separate

electrocardiogram

CASE 1.

Acute

employed was

planks

the

task

three

more

appeared

:

prior any

chest

shown

severe,

and

history

demise.

.\t

hours.

became

he

of heart

He this

\vho had

for thr long

died

twenty was

symptoms

present

prior

A physical

check-up

one

any

While

physical

to

abnormalities,

‘1Ht .4MERICAN

IOLJRNAL

thr

OF

pres-

sweating later.

No

nor

were

day

hefor? but

4

discomfort

obtained. year

x

however,

excessive minutes

2

and

chest

with been

engaged

to work.

the and

the

ten years, of

of heaviness

time,

disease

past

sections

continued

nausea

from

.Issoriated

carpenter

his-

-Accident

carpenter,

them up a stairway.

area.

case

Insufficiency

he complained

sure in the chest

several

abstracted

of lifting

and carrying

in this function, for

been

Coronary

as a general

given

damage,

effort and

for the Industrial

A 55-yrar-old

Physical Stmitr:

invol\-ed

between

his

of

his

had not rlrctro-

CARI)IOI.OCY

01 5

Coottley cardiogram revealed

at the time

of his check-up

low- ‘I’ waves

preted

as showing

Postmortem weighing

g

cardium,

myocardial

vessels,

lnterpreta/io~~

that

was

insufficiYnry

as a rrsult

of unusual

inadcquatc

coronary

Commenf:

Death

coronary

by persistent findings

no

that

i< made regardless

when

complained

He

togethrr

with

work.

That which

evening,

at a liqhter drveloped

job

and

cardiogram ST

drpression

infarction

in leads

‘l’here

that

abdominal

distress

walking,

relieved

Comment: coronaryin

history

he had

by sitting

While

recom-

waves

and with

protein

was 94 (normal myocardial

begun. disease, episodes with

but

his

of upper

will

the history

cause

infarction

of some

dis-

comfort \vith heavy meals or walking, relieved by rest, indicated pre-existing coronary artery disease. distress 36

Following appeared

hours.

tory findings

the

acute

intermittently

Electrocardiographic confirmed

trauma, for and

the diagnosis

‘T\vo day5

chest

the

and

still elevated

next

laboraof acute

forrman.

‘l’he Nv,rt

but

home

to 75 and T

wave

\‘s was noted,

and

to 64 while

thr

taken

tracinq

the

protein

of vasodilators heparin.

of his history

revealed

uwc

available

hypertension existingbeen

a chronic

and

heart

quarrel,

symptoms

tha

prcvncr c.lt.ctro-

presumed

.An episode

of acute

and myocardial

diastolic

of dyspnca,

was

necrosis

caronar)a \.iolent

suhsrqllc~ntl)

Tht, time sequence

coincidental

heart attack \vas unlikel).

\~as such that a The lag

of electrocardiographic

have confused

prc-

to ha\-e

during

de\.eloped.

might

suh-

hypc,rtcnrion

and

of chronic

was precipitated

in development

dailv

for comparison.

disease

present.

insufficient!-

was two

No previous

In the presence

C’orn~~:

the picture,

changes

but the lab-

orator\- data pro\-ed helpful in evaluation. award

\\as made

trauma C&b

4.

pain

white during

stop working da);. but

This

th?

which

for five d‘tys’ persisted at

leads No

2. Q

elevated

that

for time

3 and wa\‘cs to

with

several with

\vcxc noted. ‘I%

prrsistrd

for one morning chest

ST

of pain

srqmcnts

depression

Serum

following

day,

I~lrctrocardioqr~~m

elevated slight

to the

Hv stopped

pressing

hours.

had

during

and on thr

scvcre,

of right

and

in nature.

vacation,

revealed

a\‘F

95.

of swrrping.

pain

t7 .Sl~nrn:

complained

for a few minutes

chest

the fifth day awakcncd taken

OccluJiu~2 .Yo/ Due

was transient

i\n

of industrial

damace.

janitor

course

times

recurrc’nt

basis

cardiac

male

several

c&ach vpisodc

working

the

.-lcillc~ Coronary

4--year-old

chest

on

precipitating

1, \\a~

and gradually and

years.

dyspnea.

\I~S

transaminasv

concentrated

rsrrtional

trans-

in Icads

C-reactivr

for several

f~~llow-

but srrum

inversion

\\ith the, usr

165:‘105

without

tht

fr\cr

cutaneous Rcvie\v

lattar

a low-grade

improved

averaging

hours

.\ physician

Hr was kept in bed for two weeks.

plus.

to a nvxby

srveral

limits,

dc-

Iowan

hc \\as rlnablc

present.

A rrpcat

later.

~nan arca.

to be helped

still

d

an hour.

and an electrocardiogram

noted.

as b~arnc*

maintvnancp

normal

a

bhltrwri/

male

in the chest

and went

wns clcvated

aVIA. V:

to

the

recvded.

discomfort

aminase

A

rarely

had

ing day was still within

considerable

with myocardial

heart,

A

still for a f&v minutes.

trauma

occlusion

a normal

or

horn?

Electro-

Q

posterior

of heart

meals

was

C-reactive

had frequent

afttr

way

and

any abnormality.

cardiog-rams

chest

3 together

transaminasr

finding

with

pain

gr,tdllally

chest

Ih

employment Negro

the

pressing

working,

dull

area

sweating.

deep

2 and

to continue

quarrel

argument,

pain

of

off and on for almost

profusc,ly.

of occasional

He w-orked

the

the

The

with

hour.

dull

of

s~\cating

to develop

heart damage.

a 59-year-old

persisted

and

at light

taken.

and anticoagulants

was no prior

wife> stated

were

of acute

an

with

on

1 and Vs.

A diagnoses was made,

over

profuse

showed

plus and serum

50).

but

m leads

suspended chest

hours.

with

Chst

ground,

hospitalization

admission

be

continued

twice

day,

summoned.

of ST

was three

awoke

pain

segments

for

and

for several

next

chest

the

man,

course

inter\.al

interpretation

( oron~zry Insuffliczmcy tier

\-eloped an acute sofa.

inducing

in a violent

thca tmd

was struck

in the

breath

electrocardiograms on

rlevatrd

hc

the

was

mended,

worker to

better

persisted

severe

physician

of

he felt

can

to

steel beam

discomfort

shortness

in thy day,

aching,

Srcondnry

knocked

of throbbing

in

heart disease.

construction was

law

effort, a full award

area by a swinging

a crane.

death

lculf

was summoned

insuffi-

industrial

Infarctkn

A 62-year-old

7‘rWTUl:

dis-

infarction the

of pre-existin?

.Ilyocardiul

in thP mid-chest

to

with that required

During

arqummt

time

and the medicolegal

CZ.4sE 3.

\:

The

infarction.

was that of trauma

involved

acute myocardial

The

follow-.

provides

2.

prrsencr

well-recognized

suffjciently,

thrombosis,

maintrnancc

with autopsy

\Vhen

sho\vn to be due to industrial (:ASP.

in thr

in an already

is a

phenomena.

California

effort

coronary

myocardial

occlusion,

may

acutr

together

recent

ciency is prolonged necrosis

of

14th

was consistent

Strr.!

effort or strain, followed

chest pain,

of

physiologic.

below

and

occlusion

of the myo-

circulation.

insufficiency

coronar)-

Later

heart

in this case was ascribed

Unusual

eased heart.

from

enlarged narrowing

thickening

of ,rn already

or

an

and areas of fib]-osis of the myocardium.

.\ledicoleqnl

acute

damage).

considerable

of tllca coronary

had

Va and VS (inter-

revealed

with

examination

1, aVL,

nonsprcific

examination

400

sclerosis

in lead

day,

in Irat

transaminasc deep

($

in 1. was

waves

616

(Iardiac

Strain

appexcd in lcacls 2, 3, and aVF’ and early -1’ wave inversion was noted. Pain had suhsid(sd Ixlt hc was kept at lid rest, and a diagnosis of acute post&or myocardial infarction was made. Past history rcvealcd no prior hthart disease, hrart symptoms: or the presence of hypcrtcnsion or diabetes. Work history rcvealrd no unusual physical or emotional strain. ;\ physical chrck-up six months before had hrcn normal. as was the clrctloc;ll.dioaram at that time.

Although

Comment: episode had

of coronary

precipitated WC felt

tenable

in this cast.

unusual

insufflcienc)-

that

pre-existing

chest

work

was

pain

the

disease

was

pain,

fifth

tertninating

with

in an

electrocardiographic

relatively

changes

short duration.

for industrial

trauma

acute

cardiac

entirely

consistent.

\vas argued

no

to

be

occlusion

The final diagnosis coronary insufficiency

cardial

necrosis

sclerotic

heart

The

pattern

associated

secondary disease

with

a

damage.

of severe,

temporally

in this case Gth myo-

to chronic angina

continuous

arteriopectoris.

chest

moderately

pain

with heav).. unusual work

and

effort

and

While

it

se\:ere pre-exist-

ing disease at this age would have predisposed this

worker

through

to

a

coincidental

the natural

heart disease,

heart

development

attack

of coronary

this episode was considered

the direct result of effort.

to be

It is well-recognized

that less effort will be required

to produce

in a heart with extensive

car-

coronary

prior disease.

of death in this case was similar

to that of case 1. SUMMARY (1)

ful

The importance

appraisal

cardiac

CASE 5. Acil~e -tfyocnrduzl Infmctim .4.r.rocinted with Unu.c~ml Work: A 68-yrar-old carpenter, \vho had been doing part-time light carpentry, began working fulltime building stages on a moving-picturr srt. The work thc.m several involvrd lifting htxavy planks, carryiq hundred feet, removing rusty nails with one hand while bracing the planks with the other hand, and then piling He comthem on a stack of lumber about 3 feet high. plaincd of chest discomfort after srvcral hours on the second day of work. After resting, hch workrd intermittently the rest of the day, but in the late aftrmoon, dcvclopcd very srverr, crushing chest pain toqcther with profuse sweating and slight dyspnea. ‘I’hv chest pain was still present during the evening at home, and the He administcrrd an opiate family physician was called. after noting findings of a rapid, irrcqular heart beat. sweating, basal lung r&s, and evidence of grneralized sclerosis. Blood pressure was 105j70 at thr time of his examination. Thr patient died around midnight. but no postmortem examination could bc obtainrd. Past history revealed the presence of long-standing coronary heart disease with mild chronic angina, and two prior episodes of cardiac decompcnsation. No had occurred. Mild hypertension prior occlusions had bren present for four yrars averaging- 1 SO/l 00. Comment: was acute

that

The mechanism

no

of only

heart

dama,qe

disease than in one with minimal

No award was made

causing

this diagnosis

industrial

not

and the acute episode I)(‘gan on the

day,

made

between

prcscnt ; there was no pain during the fi\-c days of vacation,

in death,

the relationship

diac damasc

and

known

culminating

oc-

initially

and did not persist;

preceded

heart

an

coronary

hypothesis

The

localized,

exertion

the

that

during

the subsequent

clusion,

was poorly

it was argued

and Trauma

of

trauma,

of an accurate

cause-effect both

direct

and care-

relationship

in

and indirect,

has

been emphasized. (2)

The physiologic

of the pathogenesis ary to trauma (3) strain

and strain,

Evidence may

or laboratory

indicates

that

second-

trauma

significant

sequence

of cardiac

criteria

of diagnosis

minimal

cardiac

changes

including

electrocardiographic

and

if asso-

with clinical and/

evidence

Varied

description

damage,

has been reviewed.

be considered

ciated in a temporal (4)

and clinical

of cardiac

damage. of early or

have been reviewed, patterns,

changes

in serum enzymes, and clinical abnormalities. (5)

Illustrative

demonstrate an evaluation

case histories are included

the application of effort

of these criteria

or strain

in relation

to in to

cardiac dama,ge. 6010 Wilshire Blvd. Los Angeles 36, Calif. REFERENCES 1. SIGLER, L. H. : Cardiac disability and death caused by strain; problem in workmen’s compensation. J.A.M.A. 154: 294, 1954. 2. SIGLER, L. H. : Evaluation of claims for workmen’s compensation in cardiac disability and death. Zndust. Med. 25: 10, 1956. 3. WEISS, E. : Emotional factors in coronary occlusion. Am. Pratt. t? Digest Treat. 8: 1776, 1357. 4. TAYLOR, H. B.: Transient cardiac arrhythmias induced by non-penetrating trauma to the chest. Am. Heart J. 46: 557, 1953. 5. ARENBERG, H.: Traumatic heart disease. Anti. Znt. Med. 19: 326, 1943. ‘THE AMERICANJOURNAL OF CARDIOLOGY

617

Coodley 6. SPRAGUP,

H. B.

production

aggravation

of

heart

disease.

Bull. .Yezu Ihrh- Acczd.Med. 23: 631, 1947. 7. 0s~op.x. G. R.: Findings in 262 fatal accidents. l,n,lcPt 2: 277, 1943. 8. Y.UER, \\‘. M., Wtxsn, P. P., STAPLETON, J. F., and (:L~RIC, M. I,. : Comparison of clinical and Pathologic aspectsof coronary artery disease in men of various age qoups. -4r~z. Z~tl. ‘ifeed. 34: 352, 1951. 7. FRENCII, X. J. and DOCK, W.: Fatal coronary arteriosclerosis in young soldiers. J..4.M..4. 124: 1233.1944. IO. MASTER. A. M. and JAFFE, H. L.: Factors in the onset of coronary occlusion and coronary insufficiency. J.A..V.A. 148: 794, 1952. 11. KAPP, I.. X.: ‘I’muma in relation to coronary thrombosis: A clinical study of 42 cases of coronary throbomsis following trauma or unusual effort. .4nn. Int. bled. 38: 327, 1953. 12. MORITZ, .4. R.: Trauma, stress and coronary thrombosis. J.A.M.A. 156: 1306, 1954. 13. BE..XRD. R. K., Bnes~ow, L., THOMAS, W. H.,

MAY, 1959

G.+RDIPEE, C. I%.> BUECHLEI, K. \\:.. and MULLIN, X’. \V.: Heart disease claims under- the

: EfTect of trauma and strain on the

and

California 14.

15.

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17. 18.

19.

workmen’s compensation

art.

C~rruln-

ticitl 8 : 448. 1056. .‘IRENBERG, H.: ‘Traumatic heart disease, a clinical study of 250 cases of non-penetrating chest injuries Ann. Int. idled. 19: 326, 1943. BURGH, G. I<. : Significance of certain early changes in the ‘I wave in coronary disease. .1.:1..11..4. 165: 1781, 1957. I.IEBERMAN. .I.. IASKY, I., DULKIN, S. I., and LOBSTEIN, 0. E. : Serum glutamic-oxalacetic transaminase activity in conditions associated with myocardial infarction: I. Bodily trauma. 4nn. Inl. Med. 46: 485,1957. GHIVSKY, M. and SHERRY, S. : Serum transaminase as a diagnosttc aid. Arch. Znt. Med. 99: 556, 1957. ~IACT~ONALD,R. P., SIMPSON, .J. R., and Noss~r., E.: Serum lactic dehydrogenasc-a diagnostic aid in myocardial infarction. J.:l.ni.rl. 165: 35: 1957. LADUE, J. S.: Laboratory aids in the diagnosis of myocarrlial infarction. .J.A..11._1. 165 : 1776, 1957.