PREVENTION OF CORONARY HEART-DISEASE

1106 would do well to give a lead in this small way in over which they have full control. University Hospital of South Manchester Manchester M20 8LR.

a

sphere

JAMES T. LEEMING.

TREATMENT OF ACUTE MYOCARDIAL INFARCTION

SIR,-Both Dr Fearnley’s contribution1 and your leading article2 perpetuate ignorance about care of patients with acute myocardial infarction (A.M.I.). The coronaryunit (c.c.u.) is not simply " enormous quantities of resuscitation equipment ", but an area where patients, compassionately looked after with cardiac rhythm closely scrutinised, are prospectively treated to obviate the need for resuscitation. Nevertheless, it is prudent to question the value of the hospital c.c.u. to the community, for calculated maximal reduction of community coronary death by the hospital c.c.u. cannot exceed 3-5%. In Scotland and Virginia, community mortality from coronaryartery disease rose5 or did not change6 after establishment of the hospital c.c.u. We agree that " surely we should now be admitting those patients who are at greatest risk, concentrating all hospital resources on their management, and returning them home at the earliest possible time consistent with safety ". The middle phrase is the point of contention. Unless the hospital provides major resources outside hospital for care of A.M.I., the effect of the hospital c.c.u. will remain minimal,3,4 since 60% of coronary deaths occur outside hospital.’ Prehospital coronary care is not primarily a " domiciliary resuscitation service " although two-thirds of promptly resuscitated patients with prehospital cardiac arrest from A.M.I. survived long term 8-11 with 86% alive 2 years later."Prehospital removal of dysrhythmias and acute dysautonomia precisely when risk of sudden death is greatest at onset of A.M.I. prevents the need for " domiciliary resuscitation" and also reduces morbidity and mortality. 12,13 Moreover, 17 % of prehospital coronary deaths occur in ambulances 14 and are caused by preventable dysNor is prehospital coronary care only rhythmias.12,13 " feasible in an urban centre ". Pragmatic and inexpensive,12,14 mobile coronary care adapts easily to country and suburban settings 15-1and lowers hospital costs by shortening stay both in the c.c.u. and in hospital." In the Bristol survey,20 widely cited as arguing for care

1. Fearnley, G. R. Lancet, March 9, 1974, p. 417. 2. ibid. p. 395. 3. Lown, B., Klein, M., Hershburg, P. Am. J. Med. 1969, 46, 705. 4. Pantridge, J. F. Q. Jl. Med. 1970, 39, 621. 5. Oliver, M. F. Proc. R. Coll. Physns, 1968, 3, 47. 6. Stillerman, R., Aldrich, R. F., McCormack, R. C., Crampton, R. S. Circulation, 1970, 42 (suppl. III), 83. 7. Gordon, T., Kannel, W. B. J. Am. med. Ass. 1971, 215, 1617. 8. Adgey, A. A. J., Nelson, P. G., Scott, M. E., Geddes, J. S., Allen, J. D., Zaidi, S. A., Pantridge, J. F. Lancet, 1969, i, 1169. 9. Crampton, R. S., Aldrich, R. F., Stillerman, R., Gascho, J. New Engl. J. Med. 1972, 286, 1320. 10. Crampton, R. S. Virginina med. Mon. 1974, 102, 97. 11. Baum, R. S., Alvarez, H., Cobb, L. A. Circulation, 1973, 48 (suppl. IV), 40. 12. Pantridge, J. F. Chest, 1970, 58, 229. 13. Webb, S. W., Adgey, A. A. J., Pantridge, J. F. Br. med. J. 1972, iii, 89. 14. Crampton, R. S., Aldrich, R. F., Stillerman, R., Gascho, J. A., Miles, J. R., Jr. Para-med. J. 1974, 6, 13. 15. Kernohan, R. J., McGucken, R. B. Br. med. J. 1968, iii, 178. 16. Crampton, R. S., Stillerman, R., Gascho, J. A., Aldrich, R. F., Hunter, F. P., Jr., Harris, R. H., Jr., McCormack, R. C. Virginia Med. Mon. 1972, 99, 1191. 17. Marcus, H., Crampton, R. S. ibid. 1974, 101, 126. 18. Pantridge, J. F., Webb, S. W. Update Internal. 1974, 1, 11. 19. Boyle, D. McC., Barber, J. M. Walsh, M. J., Shivalingappa, G., Chatuverdi, N. C. Lancet, 1972, ii, 57. 20. Mather, H. G., Pearson, N. G., Read, K. L. Q., Shaw, D. B., Steed, G. R., Thorne, M. G., Jones, S., Guerrier, C. J., Erout, C. D., McHugh, P. M., Chowdhury, N. R., Jafary, M. H., Wallace, T. J. Br. med. J. 1971, iii, 334.

economy of management of A.M.I. and for safety of home treatment, 25-6% of patients with A.M.I. died after requesting help within 1 hour of onset of symptoms. Elsewhere

identical cohort receiving prehospital care before admission has an 8-6% mortality.44 Annually, rapid provision of prehospital care of A.M.I. saves 8-6 lives per 100,000 population. 21 In Charlottesville and Albemarle County, a community of 80,000 in 745 square miles including a city of 40,000, its suburbs, and surrounding villages and farms, prehospital coronary care with a median response of 15 minutes has been associated with statistically significant reduction of coronary deaths in the past 3 years. Mortality-rate in ambulances has dropped by 62%, in the prehospital phase of A.M.I. by 26%, and in the entire community by 15%.14 The hospital c.c.u. deaths for patients with A.M.I. treated outside hospital fell to 8’4%. We find it logical to extend coronary care beyond hospital in any community, urban, suburban, or rural, with partician

pation by family physicians,

community hospitals, general ambulance ser-

nurses,

mobile intensive-care units, and vices. Department of Medicine,

University of Virginia Medical Center, and CharlottesvilleAlbemarle Rescue

Squad, Charlottesville, Virginia 22901, U.S.A.

RICHARD S. CRAMPTON ROBERT F. ALDRICH JOSEPH A. GASCHO.

SIR,-Dr Todd (March 30, p. 559)

was

led astray in his

theory in medical practice by your editorial (March 9, p. 395). The empirical observations of Sir Clifford Allbutt led to the regimen of many weeks of bed rest for angina. S. A. Levine used this for worsening angina and later for similar cases, or acute indigestion ", with changes in the electrocardiogram diagnostic of infarction. Smith in Chicago, Wilson in St. Louis, Pardee in New York, as well as Levine, had noted these changes in Q-ST before they all went into service, 1917-19. Pardee published his cases,22 but Levine’s chief was unconvinced attack

on

"

until later, when Levine recommended weeks of bed rest.23 Herrick referred to Smith’s observation in 1918. Smith, Herrick, Wilson, and Pardee never put patients to bed if they felt well and had normal pulses and blood-pressures. Portable electrocardiographs made it possible and with " acute indigestion " to profitable to persuade men " the of heart attack ". The theoretical accept diagnosis basis for prolonged bed rest was provided 25 years after empirical use was initiated, and 5 years before that practice was vigorously attacked. Theory and practice are equally tricky guides. Hippocrates noted that " experience is fallacious; judgment difficult ". Pasteur had the last word: " Keep your enthusiasm but let strict verification be its constant companion ". New

145 East 16th Street, York, N.Y. 10003, U.S.A.

W. DOCK.

PREVENTION OF CORONARY HEART-DISEASE

SiR,—DrMann’s call (Jan. 12, p. 63) for a more " scientific approach" to the prevention of coronary heart-disease (C.H.D.) resembles academic foot-dragging when compared with his own vigorous studies in Masailand

ago.24 He did show thatph ysical fitness and heart-disease coexisted in both Masai warriors immunity and Olympic marathon runners. He suggested at that time that fitness may protect against C.H.D. Since that time the American Medical Joggers Association has been

just

ten

years to

21. Webb, S. W. Lancet, March 30, 1974, p. 559. 22. Med. Clins N. Am. 1921, 4, 1491. 23. ibid. 1925, 8, 1719. 24. Mann, G. V., Shaffer, R. D., Rich. A. Lancet,

1965, ii, 1308.

1107 some 5000 hobby marathoners in the United States and has been unable to document a single case of fatal C.H.D. in a marathon finisher of any age.25 Rehabilitation programmes in Honolulu and Toronto are now offering supervised distance running for cardiac patients. Several patients have raced at marathon distances after recovering from one or more myocardial infarctions.2s Hobby marathoning appears to be an effective way to prevent c.H.D. It is cheap and has few unpleasant sideeffects. Until Mann can contradict his own earlier work and show that it is possible for C.H.D. to coexist with the level of fitness seen in the marathon runner, I think he should soften his attack on Turner and Ball. 27

following

Centinela Valley Hospital, 555 East Hardy, Inglewood, California 90307, U.S.A.

called " Medicredit ", which reinforces a basic belief of the Association: that quality health care should be available to every American, regardless of his economic or social status. While there are a number of other health insurance plans currently before Congress, the AMA plan has, by far, the largest number of sponsors

(183).

National Health Insurance-like PSROs and HMOsare primary concerns of not only the physician population of the United States, but of the total population as well. That we are in " the thick of things " seems to me to negate both the import as well as the tone of your article. American Medical Association, 535 North Dearborn Street, JAMES H. SAMMONS, Executive Vice Presidenr Designate. Chicago, Illinois 60610.

THOMAS J. BASSLER. RELEVANCE OF THE RELEVANT IN TEACHING

AMERICAN MEDICAL ASSOCIATION SIR, The broadside against the American Medical Association in your Round the World Section on March 30 (p. 557) (" Struggles Ahead for the A.M.A.") is not only at variance with the facts in a number of areas; it also smacks of negativism in the extreme, which is not the general attitude at AMA. There are so many general unsupported statements that one wonders where to begin in refutation. You speak of an "immense drop" in membership during recent years, yet, in 1973, AMA showed an increase in membership. Agreed, this was the first yearly increase in three years, but the membership figures are still impressive : more than 54% of all American physicians are members of AMA. And, more importantly, of the 201,000plus physicians who are involved in office-based practice of medicine-the main form of health delivery in the United States-a very healthy 72% are members of AMA. It is also a matter of concern to AMA that its position be defined as having a " steadfast opposition to every organisational development to improve health care ..." One of these " examples " is given as Medicaid, yet the AMA’s policies on health care to the needy are strongly reflected in the Medicaid legislation which was finally enacted by Congress. Shortly after enactment of the program, the AMA strongly endorsed the program; and this support remains in effect. In turning to a discussion of the three " major issues " on which you believe AMA will go down to resounding defeat ", the record needs to be set straight once again. AMA is not " committed

to opposition " toward health mainorganisations (HMOs). In fact, AMA policy states that the Association " supports a pluralistic approach to health care delivery and has no objection in principle to contract practice (HMOs)." The AMA adds, only that the HMO is an experiment, and before HMOs are offered by the Federal government as a be-all and end-all to solve the nation’s health delivery problems, adequate evaluation be made through a limited experimental

tenance

program.

On the issue of PSROs, which, incidentally, are currently number 203, not 1600, the AMA has announced it will cooperate in the implementation of the law-although it will work for its change at the same time. There are, indeed, a number of " deleterious effects " which the PSRO law could bring about. While there is no intention to go into them here the AMA policy on PSROs is consistent with the concern felt about this program by thousands of physicians in this country. Not to take an active part in the public debate would be an abdication of responsibility. The tone of your article suggests that AMA opposes a national health insurance proposal, and that simply is not true. AMA, as a matter of fact, is sponsoring a national health insurance proposal set to

25. 26. 27.

Bassler, T. J. J. Am. med. Ass. 1973, 223, 1391. Bassler, T. J. Science, 1974, 183, 256. Turner, R., Ball, K. Lancet, 1973, ii, 1137.

SIR,-Much of the discussion on teaching hinges on the question of relevance; by relevance is meant a direct association of teaching material with the practical work of clinical medicine. I have noticed over the past few years an increasing preoccupation with relevance by medical students, many of whom are scarcely able to form a judgment on the matter. This has been associated with a swing towards soft-core subjects such as social psychology and community medicine, the popularity of the latter subjects being enhanced by the ease with which their content can be assimilated. An objective of some medical schools is to train students in the manipulation of facts in relation to the handling of patients. But surely the term education merits a deeper order of understanding-namely, an appreciation of how scientific inquiry has led to the production of facts ? Biochemistry has its own philosophy, its own attitudes and technical attributes. Many of the science laboratories which are breaching the frontiers of knowledge are not noticeably concerned with the application of discovery; if the student is to see through a window on to a new world then relevance ought to be a subsidiary matter. 27 Inverleith Terrace,

ANGUS STUART.

Edinburgh.

S.I. UNITS to conjure up a clinically useful of 5000 white cells in a cubic millimetre of blood. Can anv ordinarv doctor envisage 5-0 x 109/litre ?

SIR,-It is just possible

image

25 Catherine Road, Surbiton, Surrev.

CHARLES STEER.

SHOULDER-HAND SYNDROME

SIR, Your editorial (May 4, p. 850) is, I feel, misleading and incomplete. It is hard to understand how you can make general statements about this condition without considering the fundamental papers 1.2 by Erik Moberg of Sweden. These two papers clearly establish the vital importance of the venous pumping mechanism in the hand and axilla and show that its absence is a feature common to all the various conditions mentioned in your review. You comment that the syndrome " seems to have become steadily less common; indeed many physicians now rarely see it ". This is probably true in cardiac patients, because of the more recent insistence on general early motion, particularly in the left arm in which most of the cardiac pain presents. It is certainly not true in terms of the upper limbs following trauma, accident, and other 1. 2.

Moberg, E. Acta orthopœd. scand. 1955, 109, 285. Moberg, E. Surg. Clins N. Am. 1960, 40, 367.