Handbook of Cardiac Care Handbook of Cardiac Care K P Ball J Fleming T J Fowler I James G Maidment C Ward Published, in association with Hastings Hilton Publishers Limited, by MT PRESS LIMITED International Medical Publishers Published, in association with Hastings Hilton Publishers Limited, London, by MTP Press Limited International Medical Publishers Falcon House Lancaster, England Copyright © 1981 Update Books Ltd Softcover reprint of the hardcover 1s t edition 1981 First published 1981 as The Heart Patient All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission from the publishers ISBN-13: 978-94-011-7264-6 e-ISBN-13: 978-94-011-7262-2 DOl: 10.1007/978-94-011-7262-2 Contents Contributors VII 1 1 Is Heart Disease Preventable? K P Ball 31 2 Case Finding in General Practice K P Ball 37 3 The Unexpected Finding on Routine Examination C Ward and J Fleming 55 4 The Patient with Chest Pain J Fleming and C Ward 5 Hypertension 69 C Ward and J Fleming 87 6 Cardiac Arrhythmias C Ward and J Fleming 7 Myocardial Infarction 103 C Ward and J Fleming 8 Congenital Cardiac Disease 121 J Fleming and C Ward 135 9 Long-Term Problems J Fleming and C Ward v VI HANDBOOK OF CARDIAC CARE 10 Current Investigative Techniques 147 J Fleming and C Ward 1 1 Managing Strokes 163 T J Fowler 12 Systemic Disorders and the Heart 181 C Ward and J Fleming 13 Current Therapy 193 Geoffrey Maidment and Ian James 14 Future Prospects for the Treatment of Heart 219 Disease J Fleming Index 229 Contributors K P Ball, MD, FRCP Senior Lecturer in Preventive Medicine and Cardiology, Middlesex Hospital Medical School, London J Fleming MD, FRCP Consultant Physician, Cardiothoracic Unit, Northern General Hospital, Sheffield T J Fowler, DM, FRCP Consultant Neurologist for the South East Thames Region Ian James, MB, PhD, FRCP Senior Lecturer in Clinical Pharmacology, Academic Departments of Medicine and Pharmacology, Royal Free Hospital Medical School, London Geoffrey Maidment, MB, MRCP Senior Registrar, Norfolk & Norwich Hospital, St Stephen's Road, Norwich C Ward, MD, MRCP Consultant Cardiologist at the Regional Cardiothoracic Centre, Wythenshawe Hospital, Southmoor Road, Manchester VB 1 Is Heart Disease Preventable? K. P. BALL Great progress has been made in recent years in the treatment of heart disease as a result of the study of individual patients. It is a paradox that these advances have not prevented a steady increase in cardiovascular mortality, which now accounts for over half the deaths of middle-aged men and more than a quarter of those among middle-aged women. Most heart attacks and strokes occur suddenly in the apparently fit. Prediction can therefore come only from the study of healthy people in the community in order to obtain clues for prevention. Fortunately this epidemiological approach is already showing great promise and has done much to indicate how heart disease might be prevented. THE SIZE OF THE PROBLEM Cardiovascular disease is the cause of 52070 of the deaths of men aged 45 to 54 years, and 41070 of those aged 35 to 44 years. It kills men during their most productive years and in women of these ages it is exceeded only by deaths from cancer (Figure 1.1). Between 1950 and 1970, deaths from coronary heart disease (CHD) increased steadily, particularly in men, and also in women under the age of 45. In recent years there has been a tendency for this curve to flatten and it may be starting to fall, as has occurred already in the United States. Even if there is no further increase, the toll of preventable cardiovascular deaths is enormous. 1 2 HANDBOOK OF CARDIAC CA RE Ages 35-44 years 50 40 0) ro c 30 Q) u..... M 20 a.. F 10 Cardiovascular Cancers Accidents disease 60 MAges 45-54 years _ Stroke 50 F L-J Coronary Q) hea 40 0ro) disease c Q) 30 ~ Q) Q.. 20 10 Cardiovascular Cancers Accidents disease Figure 1.1 Causes of death in men and women aged 45 to 54 years and 35 to 44 years, in England and Wales, 1973. (From Journal of [he Royal College of Physicians, 1976.) INCIDENCE OF CARDIOVASCULAR DISEASE IN GENERAL PRACTICE The average general practitioner with 2,500 patients on his list will see about seven deaths from coronary heart disease each year of which two may affect patients under the age of 65. Since one in five men will develop a heart attack before retirement, he will have about 100 such men on his list. In addition, there will be approx imately four fatal strokes and one or two patients with lung cancer. However, the relative incidence of such conditions will depend very much on where he lives. Middle-class practices in the South of England have fewer patients with cardiovascular disease than do working class practices in the North, Ulster or Wales (Figure 1.2). Wherever his practice is the general practitioner will find that a heart attack is the single commonest cause of death. Two-thirds are sudden and take place in the home, at work or during leisure. In IS HEART DISEASE PREVENTABLE? 3 Men Women 100 c o c o a o ro Women Q) o b f'igure 1.2 Observed death rates per 100,000 (averaged over 1969-77) in six regions in the UK, for a) coronary heart disease (I CD 410-414), and b) cerebrovascular disease (lCD 430-438). (From Fulton et ai., British Heart Journal, 1978.) about a quarter of all patients sudden death is the first manifestation of coronary heart disease, and the patient may perish unaware that he had anything wrong with his heart. GENES VERSUS ENVIRONMENT IN CHD Although a positive family history is more frequent among patients with CHD, man's environment is certainly much more important than his genes. Familial hyperlipidemia occurs in only one out of 250 of the population and can therefore not account for the large majority of cases. The evidence for an environmental cause is as follows. (l) The wide variation in the incidence of CHD between different countries (Figure 1.3). Scotland and Finland have 4 HANDBOOK OF CARDIAC CARE I Fin land I Scotland I United States I New Zealand J Northern Ireland I Australia I England and Wales I Canada I Ireland J Norway J Netherlands I Israel I Denmark I Germany - Fed. Rep. J Sweden I Poland I Switzerland I Italy J Bulgaria J Greece J France J MexIco WJapan I I I I I 100 200 300 400 500 Deaths per 100,000 Figure 1.3 Mortality (deaths per 100,000) due to coronary heart disease in males aged 45 to 54 years, in 1971. (From World Health Statistics Annual, WHO, 1974.) the highest incidence of CHD in the world, and England and Wales are only a little lower down the list. By contrast, the incidence of coronary heart disease in middle-aged Japanese men is less than one-tenth of that in Finland. (2) The experience of migrants moving from low- to high-risk countries. Despite the low incidence of CHD in Japan, it is considerably higher in those Japanese who migrate to Hawaii, and second generation Japanese who have moved to California tend to resemble native Americans in their sus ceptibility to CHD (Figure 1.4). It is interesting that in those Japanese families which retain the traditional way of life there is no increased risk of CHD. (3) The steep rise in the incidence of CHD in many countries in