Article

Survival after Resuscitation from Out-of-Hospital Ventricular Fibrillation

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Abstract

During the first three years in operating a comprehensive system for the management of out-of-hospital medical emergencies, 146 patients were resuscitated from ventricular fibrillation, hospitalized, and discharged home. The diagnosis of acute transmural myocardial infarction associated with the episode of ventricular fibrillation was confirmed in only 17% of the patients. The presence of myocardial necrosis, based on either evidence of new transmural infarction or LDH-isoenzyme criteria was established in 49.5% of the patients. During the follow-up period, averaging 418 days, 43 of the 146 patients died. Thirty-four of the 43 deaths occurred suddenly outside the hospital. Patients whose aborted sudden cardiac death was associated with acute transmural infarction had a mortality rate of 14% after two years of follow-up. In contrast, patients without evidence of acute myocardial necrosis had a high mortality rate — 47% at two years. It is concluded that: 1) out-of-hospital ventricular fibrillation is common and treatable; 2) the phenomenon of sudden cardiac death should not be equated with acute myocardial infarction; 3) patients resuscitated from ventricular fibrillation without associated acute myocardial infarction are prone to sudden death — most likely from ventricular fibrillation.

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... Gerade die externe Defibrillation erhielt durch die Entwicklung der Coronary Care Units (CCU) in den frühen 60er Jahren immer mehr Einzug in die Krankenhäuser [44]. Mitte der 70er Jahre erkannten Cobb et al., dass Kammerflimmern und nicht etwa der akute Myokardinfarkt selbst die Hauptursache für plötzlichen Herztod darstelle und durch eine zeitnahe Defibrillation eine gute Wiederbelebungsrate erzielt werden könne [34], [9], [15], [43]. "How could we have prevented Heller's death at that time; keep him forever in the CCU, or follow him around with a defibrillator? ...
... Danach wurde der Einfluss der jeweiligen Indikation auf die Schockeffektivität mit Hilfe des Chi²-Tests nach Pearson untersucht. (3,9) 12 (3,9) 8 (2,6) 6 (1,9) ...
... Danach wurde der Einfluss der jeweiligen Indikation auf die Schockeffektivität mit Hilfe des Chi²-Tests nach Pearson untersucht. (3,9) 12 (3,9) 8 (2,6) 6 (1,9) ...
Thesis
Untersuchungen zum Einfluss der intraoperativen Schocktestung und weiterer Variablen auf die Schockeffektivität von implantierbaren Kardioverter Defibrillatoren. Studienkollektiv n=309, Datenerhebungszeitraum 2000 bis 2013, Vergleich einer ineffektiven und effektiven Schockgruppe hinsichtlich verschiedener Variablen.
... ICD significantly reduced the rate of SCD (HR 0.55), similar to DEFINITE trial. Since ventricular arrhythmias are the most common cause of SCD [59,60] these studies have proven useful from this point of view, even though their results are cited as evidence against early ICD prevention after MI. ...
Article
Full-text available
Implantable cardioverter defibrillators (ICDs) are the cornerstone of primary and secondary prevention of sudden cardiac death (SCD) all around the globe. In almost 40 years of technological advances and multiple clinical trials, there has been a continuous increase in the implantation rate. The purpose of this review is to highlight the grey areas related to actual ICD recommendations, focusing specifically on the primary prevention of SCD. We will discuss the still-existing controversies strongly reflected in the differences between the international guidelines regarding ICD indication class in non-ischemic cardiomyopathy, and also address the question of early implantation after myocardial infarction in the absence of clear protocols for patients at high risk of life-threatening arrhythmias. Correlating the insufficient data in the literature for 40-day waiting times with the increased risk of SCD in the first month after myocardial infarction, we review the pros and cons of early ICD implantation.
... Recurrent cardiac arrhythmias comprise of just 5%-10% of in-hospital deaths after out-of-hospital resuscitation. 18,27 Patients with recurrent cardiac arrest have been found to have a high incidence of new or preexisting abnormality of the AV or intraventricular conducting systems. 28 The clinical presentation of survivors of OHCA is linked to the type and extent of the underlying disease. ...
... Combining SCD with non-SCD the investigators obtained a HR of 1.04 with respect to all-cause mortality, but regarding the type of death, the ICD significantly reduced the rate of SCD (HR 0.55), the true purpose of implantation. Since VAs are the most common cause of SCD these studies have proven useful in this regard [23,24]. ...
Article
Full-text available
Background: Prevention of sudden cardiac death (SCD) early after acute myocardial infarction (AMI) is still a challenge, without clear recommendations in spite of the high incidence of life-threatening ventricular arrhythmias, as implantable cardiac defibrillator (ICD) placement is not indicated in the first 40 days after an AMI; this timing is aleatory and it is owed to fact that the two pivotal studies for evaluation of ICDs in primary prevention, MADIT and MADIT II, excluded the patients within three, respectively four weeks after AMI. Methods: We conducted a retrospective, single-center study that included 77 patients with AMI. All patients were monitored by continuous ECG in the first week after the event. Transthoracic echocardiography was performed at discharge and 40 days after the event. Patients with ejection fraction of 35% or less as assessed by 2D echocardiography 40 days after the MI, which received an ICD for the primary prevention of SCD, were included in the study. The subjects were followed for a median of 38 months, by means of device interrogation and echocardiography. Results: We divided our patients into two groups: in the first group, with left ventricular ejection fraction (LVEF) under 30% after MI, all patients remained in the reduced ejection fraction heart failure category, with an increase from an initial mean of 18.93 ± 4.99% to a mean of 22.18 ± 4.53% after a period of 40 days; we obtained a positive and statistically significant correlation (p < 0.001 and r – 0.547), and all patients presented indication of ICD implant 40 day after MI. In the second group with LVEF between 30% and 35% after MI, the mean LVEF increased from an initial mean of 31.73 ± 1.33% to a mean of 32.33 ± 1.49% after a period of 40 days. A statistically significant correlation (p – 0.02 and r – 0.78) was obtained, although 3 patients presented a LVEF over 35% at 40 days post-MI. Most of the ICD therapies (14.54%) appeared in patients with LVEF 0.05. The majority of the ICD therapies (11.9% from 13.4%) appeared in patients with NSVT at initial ECG monitoring; also, these presented an increased number of NSVT at ICD interrogation (77.6% vs. 6%) when compared to patients without VT detection at the initial ECG monitoring. Still, statistical significance was not reached – p > 0.15. Conclusions: The patients could benefit from ICD implant earlier than stated in the actual guidelines, since there are insufficient data in the literature for the waiting time of 40 days. Correlated with the increased risk of SCD in the first months post myocardial infarction, the present study proves the benefit of early ICD implantation considering that all our patients with a low ejection fraction immediately after infarction remained in the same category and the great majority (96.1%) required the implantation of an ICD after 40 days. Thus, we could avoid exposing our patients at risk of SCD for an unnecessary prolonged period, and choose early ICD implantation.
... 27,28 Platelet emboli are postulated to cause sudden death. [29][30][31] It is certainly possible that a shower of disintegrating platelets may not only block small arteries but their "pharmacological" contents could provoke intense spasm more distally. 32,33 There is some evidence suggesting that right coronary artery occlusions are more often associated with sudden death. ...
... The response to cardiac arrest, as first conceptualized 60 years ago for acute myocardial infarction and for sudden, unexpected OHCA with shockable rhythms, no longer applies universally. 16,17 The role of health status and survival probability (ie, very healthy vs frail older adults), individual choice, and racial or cultural differences are all key considerations for determining the appropriateness of resuscitation in older adults with OHCA. The current default setting for OHCA resuscitation risks violating the principles of autonomy and "first do no harm" for a large and growing subset of the most vulnerable older adults in our communities. ...
... Even with the most sensitive techniques a period of approximately six hours must elapse before death for changes of acute infarction to be recognisable (Davies 1992). In studies of the survivors of out-of-hospital sudden cardiac death, convincing clinical evidence of acute myocardial infarction has been found in a minority of subjects: (17%: Baum et al. 1974; 39%: Liberthson et al. 1974). ...
Thesis
Experimental studies have shown that when pathological processes disrupt the normal orderly sequence of electrical recovery following activation, the conditions favouring the development of reentrant arrhythmias are created. Comparatively little is known about the role of so-called increased dispersion of repolarisation in human arrhythmias, due in part to the difficulty in measuring this process. QT dispersion, defined as the difference between the longest and shortest QT intervals measured from the surface electrocardiogram, has been proposed as just such a measure. A fundamental assumption in the use of QT dispersion is that interlead variations in QT dispersion do indeed reflect regional variations in ventricular repolarisation time. Comparatively few data exist to support this hypothesis and the relationship is explored in this thesis. The last decade has seen a proliferation of studies testing the association between increased QT dispersion and the development of life threatening arrhythmias or sudden death in a variety of cardiac and noncardiac disease states. In the largest group of patients at risk of such events - those with ischaemic heart disease - these studies have so far failed to demonstrate the predictive value of QT dispersion. This may in part be explained by the way in which the methodology has been applied. Dispersion of repolarisation is a dynamic process that may change on a beat to beat basis. A single measure of QT dispersion from a resting electrocardiogram may therefore fail to reflect an individual's capacity to develop the substrate for life threatening arrhythmias. This thesis concerns an exploration of the factors contributing to increased QT dispersion in individuals with heart disease. In particular the influence of acute ischaemia and premature beats, separately and in combination, have been studied as conditions predisposing to arrhythmia development and associated in experimental studies with increased dispersion of repolarisation.
... Recurrent cardiac arrhythmias comprise of just 5%-10% of in-hospital deaths after out-of-hospital resuscitation. 18,27 Patients with recurrent cardiac arrest have been found to have a high incidence of new or preexisting abnormality of the AV or intraventricular conducting systems. 28 The clinical presentation of survivors of OHCA is linked to the type and extent of the underlying disease. ...
... Наиболее высокий риск ВСС отмечался среди людей, ранее перенесших внезапную остановку сердца. В случае, если перенесенная остановка сердца не была связана с транзиторными состояниями, такими как ишемия или некроз миокарда, риск повторной ВСС был особенно высок и достигал 47% в течение двух лет после первого эпизода [17]. При развитии фатальной тахиаритмии необходимо купировать ее как можно быстрей. ...
Article
The implantable cardioverter defibrillators (ICDs) currently play, along with drug therapy, one of the leading roles in the prevention of sudden cardiac death. Efficacy and safety of ICD in different groups of patients have been proven in a number of large randomized trials. Taking into account the high proportion of sudden cardiac death in the structure of total mortality, ICDs allow saving thousands of lives annually. Rapid scientific and technical progress, currently observed in all spheres of human activity, allows assuming with high probability a significant increase of reliability and therapeutic opportunities of ICDs in the nearest future. Due to the ever growing number of ICD implantations across the world, we consider important objective to increase interest in implantable antiarrhythmic devices among physicians of different specialties. This paper briefly describes the history of the ICD from the formation of the concept in the late 60-ies of XX century, to current multifunctional implantable antiarrhythmic devices. The ICD example shows the impact of the development of microelectronics and computer technology at the end of XX - the beginning of XI century on the current medicine.
Chapter
This chapter reviews some of the current therapeutic concepts and delivery systems of prevention, recognition, and management of ventricular dysrhythmias, both prior to hospital admission and in the hospital.
Chapter
Emerging pathological and clinical data has allowed us to formulate an evolving concept regarding thrombosis and sudden death. Several fundamental relevant issues need to be addressed before we go on. First, cardiac death is always sudden since it is generally the result of an abrupt electrical phenomenon. The question is when it occurs in term of timing. Four different stages of sudden death can be identified. Second, emphasis on the pathogenic mechanism of sudden death has always been placed on the primary electrical component of the heart related to ventricular function (substrate), accumulating evidence suggests that acute thrombosis and ischemia (isichemia) may also play an important role in sudden death; depending on the stages of sudden death, one or both of these pathogenic mechanisms predominate. Third, in most antithrombotic trials, sudden cardiac death is not properly defined in terms of timing nor in terms of mechanisms. Nevertheless, there is enough information to provide us with the relevant hypothesis. With this background, we will discuss the four different stages of sudden death, the pathogenic mechanisms, and the role of antithrombotic therapy in each stage of sudden death (Table 1).
Chapter
Tachyarrhythmias are common during the first few days following acute myocardial infarction, reflecting the unstable electrical properties of ischemic cardiac cells. In the conventional coronary care unit the control of these tachyarrhythmias by electrical means has usually involved emergency countershock for life-threatening episodes or the occasional use of overdrive pacing. The last decade has seen the emergence and refinement of electrophysiologic techniques allowing intracardiac recording and stimulation including the delivery of intravascular counter-shock. These more invasive techniques have not been widely applied in the setting of acute infarction, but the question arises as to their potential role. This chapter reviews the types of tachyarrhythmias observed in patients during acute myocardial infarction (AMI), and the electrical techniques available for diagnosis and management. The potential usefulness of newer approaches is discussed in the context of evidence from Duke University Medical Center regarding the spectrum of tachyarrhythmias detected in the coronary care unit of the 1980s.
Chapter
Initially, the idea of having an implanted device that would automatically deliver an electrical shock was considered unconventional, too extreme and undesirable. The concept was looked upon with some degree of disbelieve and its future was greatly doubted. In spite of such skepticism, the implantable defibrillator found a definite role in medicine, although its application was initially limited to those patients with recurrent cardiac arrest that are refractory to other forms of therapy. In such patients, the physician would have no choice because other forms of treatment have been exhausted. Undoubtedly, in following such algorithm, some patients would have died from their arrhythmia and never benefited from the device therapy. In that respect, sudden death from ventricular arrhythmia was common and, to some degree, an acceptable outcome.
Chapter
In recent years, prompt and accurate therapy of life–threatening arrhythmias has considerably improved by patients information, continuing education, general practicioners and development of emergency rooms, intensive care units (ICU) and emergency rescue systems. This leaves us with a growing group of patients at risk of recurrence of disabling arrhythmias after the initial episode, especially in the case of survivors of sudden death.
Chapter
Electrophysiology studies (EPS) began in the late 1960s in the dog laboratory where recording of the His bundle electrogram was accomplished.1 The first recordings in the human heart occurred in a patient with atrial septal defect2; whereas in 1969, Scherlag et al3 were the first investigators to percutaneously, by right heart cardiac catheterization, record a His bundle in humans by safely placing an electrode catheter across the tricuspid valve.
Chapter
In den vorangegangenen Referaten wurden bereits Zahlen über die Prognose des frischen Herzinfarktes sowie ihre Beeinflussung durch die Therapie genannt. Hieraus und aus den zahlreichen Mitteilungen der Literatur zu diesem Thema ergeben sich vorab zwei gravierende Feststellungen: 1. nahezu zwei Drittel aller einem Infarkt erliegenden Patienten sterben bereits vor der Aufnahme in ein Krankenhaus. 2. Die Hospitals-Letalität des frischen Herzinfarktes betrug früher 30% und mehr; sie konnte durch Einrichtung von Intensivstationen auf etwa 20% gesenkt werden.
Chapter
Sowohl der Pathologie als auch der Pathophysiologie der koronaren Herzkrankheit im allgemeinen, als auch den entsprechenden Ver?nderungen beim akuten Herzmuskelinfarkt sind in diesem Buch ausf?hrliche Darstellungen gewidmet (s. Kap. 2 und Kap. 3). An dieser Stelle soll nur kurz auf einige Aspekte eingegangen werden, die f?r die Diagnostik, den Verlauf der akuten Erkrankung oder das therapeutische Vorgehen im klinischen Alltag von Bedeutung sind.
Chapter
Therapeutic effectiveness of antiarrhythmic agents, defined as the prevention of lethal or potentially lethal arrhythmias, must incorporate considerations of 3 elements: 1. the forms and/or frequency of chronic ventricular arrhythmias, as well as the characteristics of arrhythmias labeled as ‘potentially lethal’; 2. the clinical settings in which various forms of ventricular arrhythmias occur; and 3. the validity of end-points used to guide antiarrhythmic therapy.
Chapter
Unter plötzlichem Herztod verstehen wir den natürlichen Tod aus kardialer Ursache, der unerwartet und plötzlich eintritt. Er betrifft zumeist Patienten mit zugrundeliegender Herzerkrankung, obwohl diese zuvor weder zu Symptomen noch klinischen Zeichen einer Herzerkrankung geführt haben muß. Bezüglich der Zeitspanne zwischen Beginn der Symptome und Eintritt des Todes für die Bezeichnung „plötzlich“ werden in der Literatur bis zu 24h angegeben (s. Beitrag Janssen: „Der Sekundenherztod aus morphologischer Sicht“, S. 27). Unter Zugrundelegung eines Zeitintervalls von lh gehen vorsichtige Schätzungen davon aus, daß allein in der ehemaligen Bundesrepublik Deutschland etwa 70000 (Statistisches Jahrbuch) und in den USA 300000 Menschen jährlich den plötzlichen Herztod erleiden [19].
Chapter
Although many workers contributed to the development of the automatic implantable cardioverter defibrillator (AICD), Dr. Michel Mirowski (see Fig. 1) is widely acknowledged as the father of the device now implanted in man; his single-minded perseverance, in the face of great technological and other obstacles, continued long after the AICD’s clinical introduction in 1980, and is largely responsible for the present degree of worldwide acceptance of this therapy, now being used to protect thousands of patients from sudden death. So his passing from among us, just a few months ago, adds particular significance to this review of the historical evolution of the AICD.
Chapter
Sudden cardiac death occurs in approximately 400000 individuals in the USA each year1–4. Most out of hospital resuscitation studies have shown that the majority of patients who have sudden cardiac death have coronary artery disease, a recent or old myocardial infarction and significant left ventricular dysfunction. Although other cardiac entities such as cardiomyopathy, valvular heart disease, acute myocarditis, the idiopathic long QT syndrome and WPW syndromes can result in sudden cardiac death, these entities are present in a much smaller percentage of patients (25%). Out of hospital resuscitation studies have also shown that in the majority of patients sudden cardiac death is due to a malignant ventricular tachycardia (VT) that degenerates into ventricular fibrillation (VF)5–11. Bradycardia seems to be much less often the cause of sudden cardiac death. In recent years significant advances have been made in understanding the substrate of sustained ventricular tachycardia particularly in patients with coronary artery disease12–14.
Chapter
Since its inception, investigators have been eager to explore the question “What is the impact of the automatic implanted cardioverter defibrillator, (ICD), on the management of patients with life threatening ventricular arrhythmias?” Several questions have been posed including: 1) Does the device reduce the incidence of sudden out-of-hospital death? 2) Does the device improve survival? 3) How does it compare to pharmacologic, ablative, and other surgical therapies?
Chapter
The automatic implantable cardioverter-defibrillator (AICD) is a battery-powered, implantable device intended to prevent the sudden cardiac death (SCD) syndrome. Fully two-thirds of coronary artery disease mortality occurs by means of this mechanism. It also occurs in heart disease of other etiologies as well. The problem is of epidemic proportions in the developed countries of the world, and claims nearly half a million victims per year in the United States alone, nearly one death per minute [1]. The figures on the Continent are estimated to be similar. All told, there are more victims in any given two-week period from SCD than from the entire acquired immune deficiency epidemic to date.
Chapter
Herz-Kreislauferkrankungen stehen unter den Todesursachen bei uns an erster Stelle. Soweit Angaben des Statistischen Bundesamtes über die exakte Todesursache überhaupt etwas aussagen können, starben 1976 138 900 Menschen an coronarer Herzkrankheit; 77 700 davon an einem Herzinfarkt. Auf die Problematik solcher Angaben kann hier nicht näher eingegangen werden. Es gehört aber sicher zu den dringlichsten Aufgaben der Inneren Medizin, Prophylaxe, Frühdiagnostik und Soforttherapie dieser Krankheitsgruppe zu verbessern. Bei der Behandlung des akuten Myocardinfarkts konnten in den letzten 10 Jahren durch die Einrichtung coronarer Wachstationen Fortschritte erzielt und die Hospitalletalität auf 10–15% gesenkt werden. Dennoch liegt die Gesamtsterblichkeit bei rund 40%. Wenn man bedenkt, daß sich etwa zwei Drittel der Infarkttodesfälle ereignen, bevor die Patienten die Klinik erreichen (43, 57, 59, 65, 75, 81, 84) so wird deutlich, daß die Ansätze für eine Lösung des Problems nur in der vorklinischen Phase des Myokardinfarkts zu suchen sind. Dies führte zum Konzept der „Precoronary care“, das die Verbesserung der Sofortversorgung des Infakrtpatienten in der Praehospitalphase zum Ziel hat (50).
Chapter
The mechanism of arrhythmias following acute infarction, whether enhanced auto-maticity or re-entry or both, appears to vary depending on the time after coronary occlusion. Early after myocardial infarction, ventricular fibrillation may result from re-entrant excitation. During the later stages of infarction enhanced automaticity may precipitate ventricular fibrillation. Janse et al. have suggested that, within the first 15 minutes following experimental coronary occlusion, the premature beat is initiated by injury currents [1]. By its prematurity this beat increases the differences in conduction velocity and refractory periods of ischemic and non-ischemic tissue in the border zone and creates the conditions where micro re-entry can exist. It is probable that minute differences in the way the premature beat is conducted may decide whether or not re-entry succeeds.
Chapter
John Hunter, apart from his other contributions to medical science, has left a vivid description of his heart condition. His angina pectoria was brought on by “agitation of the mind … principally anxiety or anger … the most tender passions of the mind did not produce it”. (Home 1794). His life was said to be in the hands of any rascal who cared to provoke him. Apparently his sudden death was brought on by a particularly irritating Hospital Board Meeting. The post-mortem appearance of his coronary arteries were described by his brother-in-law as being “in the state of bony tubes” (Home 1794).
Chapter
Sudden cardiac death is one of the unsolved problems in clinical cardiology. This syndrome has been reported to be associated in most cases (more than 80%) with underlying coronary heart disease, and in the remaining cases with cardiomyopathies, aortic stenosis, mitral valve prolapse, QT syndrome and WPW syndrome. From the experiences in the literature patients with severe coronary heart disease and with poor left ventricular function and complex ventricular arrhythmias carry a particularly high risk of sudden cardiac death. In addition, from recent studies the detection of (abnormal) ventricular late potentials within the ST segment of the high gain amplified, signal averaged surface ECG seems to provide a new marker of increased left ventricular irritability in CHD patients. One of the most important diagnostic goals in sudden death candidates is the assessment of ventricular vulnerability. This may be achieved by recording of complex ventricular arrhythmias, by detection of ventricular diastolic potentials within the ST segment, and by provocation of repetitive ventricular response with programmed ventricular stimulation. The identification and characterization of the risk of successfully resuscitated pre-hospital cardiac arrest victims to develop a new fatal event constitutes a major clinical problem. Based on the experiences from the literature and our own studies a high risk profile of those SD candidates to develop a new fatal event may be outlined as follows: Bradycardia ofless than 60 bpm after successful resuscitation, atrio- or intraventricular block, severe coronary heart disease with triple vessel disease, low left ventricular ejection fraction and severe contraction abnormalities, complex ventricular arrhythmias, presence of ventricular late potentials, and inducibility of repetitive ventricular response.
Chapter
During the 16 years since the inception of prehospital coronary care in Belfast, Northern Ireland [1, 2], the lives of thousands of acutely ill cardiac patients have been saved and their quality of life has been improved by a lowered morbidity. Nowhere has this been more apparent than in the United States where Pantridge’s concept of mobile coronary care revolutionized emergency medical services. The ease of detection of prefatal and fatal arrhythmias in acute ischemic heart disease and the portability of the relevant instruments and drugs to monitor, defibrillate and treat the coronary patient, expedited experimental emergency care systems staffed first by physicians and then by nurses, paramedics and emergency medical technicians (EMTs). Since costs, benefits and outcomes were easily assessed, innovative improvements attended rapid feedback of favorable results. This chapter will discuss the adaptation of mobile coronary care in the Virginia Piedmont, the United States, Canada and Europe, the influence of cardiopulmonary resuscitation (CPR) by the citizen, the noncontroversy about mobile coronary care, the financial burden and benefit to the community, and the important role of the physician who is responsible for medical control of prehospital coronary care.
Chapter
Endothelial injury with subsequent platelet deposition at injured sites plays a pivotal role in acute and chronic vascular diseases and their thromboembolic sequelae. The major risk factors in human coronary atherosclerosis — (i) hyperlipidemia, (ii) hypertension, and (iii) smoking — have been related experimentally to endothelial injury (1–4).
Chapter
Am Anfang dieses Abschnitts soll mit einem etwas vereinfachenden Schema eine Abgrenzung des morphologischen, funktionellen und klinischen Bereichs der Coronarerkrankungen erfolgen (Abb. 45.1).
Article
Advances in resuscitation following out-of-hospital cardiac arrest (OHCA) provide an opportunity to improve public health. This review reflects on past developments, present status, and future possibilities using the science-education-implementation framework of the Utstein Formula and the clinical framework of the links in the chain of survival. With the discovery of CPR and defibrillation in the mid 20th century, resuscitation developed a scientific construct for progress. Systems of emergency community response provided operational efficiency to treat OHCA. Contemporary resuscitation involves integrated interventions in the chain of survival: early recognition, early CPR, early defibrillation, expert and timely advanced life support and hospital care, and multidimensional rehabilitation. Implementation of scientific advances is especially challenging given the unexpected nature of OHCA, the need for time-sensitive interventions, and the substantial collective of stakeholders involved in the chain of survival. Systematic measurement provides the foundation to evaluate performance and guide implementation initiatives. For many systems, telecommunicator CPR and high-performance CPR by emergency professionals are accessible, near-term programs to improve OHCA outcome. Smart technologies that activate, coordinate, and/or coach community “volunteers” to accelerate early CPR and defibrillation have conceptual promise, though robust implementation has been achieved by only a handful of systems. Longer-term strategies may leverage technology to develop a high-fidelity “life-detector” or engineer and disseminate a specialized consumer defibrillator designed to bridge care until arrival of professional response.
Thesis
The Implantable Cardioverter Defibrillator (ICD) offers an alternative to drug therapy, surgery or catheter ablation for the treatment of patients with life threatening ventricular tachyarrhythmias. This thesis reviews the development and current status of this therapy with reference to the first 48 patients to receive an ICD at St. George's Hospital. Data from these patients has been used to analyse the factors affecting success or failure of ICD implantation using a transvenous lead system, the patterns of ICD therapy delivery, long-term device performance and occurrence of complications. Using novel techniques for assessment of psychomotor performance and cerebral blood flow the impact of continuing transient episodes of arrhythmia on motor performance was studied. Risk analysis techniques have been applied to examine whether ICD recipients should be allowed to drive a motor vehicle and a flexible model has been developed by the author to enable the assessment of the cost-efficacy of ICD use in its present and potential future applications. The study concludes that smaller heart size on the chest radiograph is the best predictor of successful ICD implantation using a transvenous lead system and that low left ventricular ejection fraction is the best predictor of appropriate ICD therapy delivery. The psychomotor studies show that even transient hypotensive symptoms during an arrhythmia are associated with marked impairment of psychomotor performance. Risk analysis shows that ICD patients who have not received a therapy within the two years after ICD implant might safely be allowed to drive a private motor vehicle. Modelling techniques show that the current use of the ICD in high-risk cardiac arrest survivors is comparable in cost-efficacy to other invasive medical therapies. Relative reductions in equipment cost, increasing ICD life and reduced implant mortality could result in a fourfold improvement in cost-efficacy over the next decade. Prophylactic use of the ICD may prove cost-effective in the light of these changes but has major implications for health care expenditure because of the large numbers of ICD implants required.
Article
Objectives: The study sought to assess the prognostic impact of COPD in patients presenting with ventricular tachyarrhythmias and sudden cardiac arrest (SCA) on admission. Background: Data regarding the outcome of patients with COPD presenting with ventricular tachyarrhythmias and SCA is limited. Methods: A large retrospective registry was used including all consecutive patients presenting with ventricular tachycardia (VT), fibrillation (VF) and SCA from 2002 to 2016. Patients with COPD were compared to patients without COPD applying multivariable Cox regression models and propensity-score matching for evaluation of the primary prognostic endpoint defined as long-term all-cause mortality at 2 years. Secondary endpoints were all-cause mortality at index, at 30 days and after discharge, cardiac death at 24 h, rehospitalization related to cardiac causes and the composite endpoint of cardiac death at 24 h, recurrences of ventricular tachyarrhythmias and appropriate ICD therapies at 2 years. Results: In 2813 unmatched high-risk patients with ventricular tachyarrhythmias and SCA, COPD was present in 9%. VF was less common in COPD (28% versus 39%; p = 0.001). Multivariable Cox regression models revealed that COPD was associated with the primary endpoint of long-term all-cause mortality (HR = 1.245; 95% CI 1.001-1.549; p = 0.001), which was also proven after propensity score matching (log rank p = 0.001). The secondary endpoints of all-cause mortality at index, at 30 days, after discharge, cardiac death at 24 h, as well as the composite endpoint of cardiac death at 24 h, recurrences of ventricular tachyarrhythmias and appropriate ICD therapies were higher in COPD (p < 0.033). Conclusion: In high-risk patients presenting with ventricular tachyarrhythmias and SCA, COPD was associated with higher long-term all-cause mortality, cardiac death at 24 h and higher rates of the composite endpoint of cardiac death at 24 h, recurrences of ventricular tachyarrhythmias and appropriate ICD therapies at 2 years.
Chapter
Wie häufig ventrikuläre Herzrhythmusstörungen beobachtet werden, wird im wesentlichen durch die Dauer und Art der EKG-Registrierung bestimmt.
Chapter
Sudden death (SD) is a natural phenomenon interrupting life instantaneously. The widely accepted definition is a death occurring unexpectedly, within 1 h from the onset of symptoms, in healthy even vigorous people or in people whose preexisting morbid conditions did not foresee such an abrupt outcome [1–18]. This temporal definition refers to witnessed SD, whereas it should be extended to 24 h for unwitnessed SD victims known to be alive and healthy one day prior to being found dead [3–7]. Since up to one third of SDs are unwitnessed, exclusion of these SDs would seriously bias a study by underrepresenting this quote. In nearly two third of cases, SD is the first cardiac event, whereas in one third it is predictable because the patient is at high risk. SD which takes place in the hospital has to be excluded, whereas that occurring in the emergency room is included.
Chapter
Bereits im Altertum finden sich erste Beschreibungen des plötzlichen Herztodes. Hippokrates beobachtete vor über 2000 Jahren den Zusammenhang zwischen Thoraxschmerzen und einem kurz darauf folgenden plötzlichen Tod. Zu Beginn des 18. Jahrhunderts wurde von Lancisi erstmals eine Monographie über den plötzlichen Herztod veröffentlicht, wobei er sich auf eine große Zahl obduzierter Patienten nach plötzlichem Tod stützte. Schon damals wurden erste Hinweise auf die Bedeutung der Coronararterioskle-rose bei plötzlich Verstorbenen erbracht (Lancisi 1706). Hering (1917) war Anfang dieses Jahrhunderts einer der ersten, der Kammerflimmern als Ursache für den „Sekundenherztod“ annahm. Es dauerte jedoch bis in die 50er Jahre, daß erstmals die Möglichkeit, durch elektrische Defibril- lation Herzflimmern zu beheben, durch ZOLL in Boston erprobt und dadurch das sonst fast immer letale Kammer-flimmern potentiell beherrschbar wurde (Zoll et al. 1956). Die Einführung der extrathorakalen Herzmassage durch Kouwenhoven et al. (1960) ermöglichte es dann, die Zeit zwischen Herz-Kreislauf-Stillstand und Defibrillation zu überbrücken. Damit war der plötzliche Herztod kein schicksalhaftes, unabwendbares Ereignis mehr. Folgerichtig hat sich seitdem das ärztliche Interesse zunehmend diesem Problem zugewandt.
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Unexpected cardiac arrest in an out-of-hospital environment is a worldwide problem of enormous magnitude. Estimates for the United States alone suggest that 300,000 to 600,000 sudden deaths occur each year, with the broad range of estimates reflecting various definitions of “sudden death” (1). Until recently, studies of the nature and characteristics of sudden death victims remained entirely in the realm of epidemiologists and pathologists, since prehospital cardiac arrest was virtually 100% fatal. The clinical characteristics of patients dying suddenly and unexpectedly in the community were derived retrospectively from pathologic data, and the electrophysiologic characteristics were speculated upon from other clinical settings. The development of community-based emergency medical systems during the past decade, however, has led to the survival of a significant percentage of prehospital cardiac arrest victims; and, at the same time, has provided clinical investigators with the ability to study the clinical and electrophysiologic characteristics of individuals who have survived an unexpected, out-of-hospital cardiac arrest (2–4). Moreover, since survivors of prehospital cardiac arrest are at high risk for a recurrent cardiac arrest (approximately 30%) in the first year after the initial event (3, 4), it is also possible to study the characteristics of patients at risk for a future event.
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It is well known that patients with ischemic heart disease are prone to ventricular tachyarrhythmias and to sudden death.
Chapter
Myocardial infarction (MI) is the result of a low process of narrowing of the coronary vessels and an acute thrombotic event. The most rational approach to MI prevention should, therefore, be the prevention of coronary atheroma. However, although experimental data exist which indicate that antiaggregants are effective in preventing the formation of atherosclerotic lesions, and although a clinical study with a 5-year follow-up is presently being performed on the use of antiaggregants in inhibiting the angiographic progression of coronary scl erosis (1), at the present time the prevention of coronary atheroma does not seem to be clinically realistic. For this reason, research has been directed towards prevention of thromboocclusive events in the coronary vessels.
Chapter
Ca. jeder fünfte Todesfall in den westlichen Industriestaaten ist unter die Rubrik „plötzlicher Herztod“ einzuordnen. Betrachtet man die erwachsene Bevölkerung insgesamt, so besteht eine Inzidenz von ca. 0,1 bis 0,2% pro Jahr, Unverändert ist die koronare Herzerkrankung die wichtigste und quantitativ bei weitem führende Erkrankung, die mit Auftreten des plötzlichen Herztodes verknüpft ist. Beim Großteil der Betroffenen ist der akute Herz-Kreislauf-Stillstand die Erstmanifestation der Erkrankung. Die Prophylaxe des plötzlichen Herztodes ist immer auch eine Prävention der koronaren Herzerkrankung. Seit 1980 ist insbesondere in den Vereinigten Staaten eine Trendwende bei der Prävalenz der koronaren Herzerkrankung zu verzeichnen. Dies macht verständlich, daß z. B. in Seattle (USA-Staat Washington) im gleichen Zeitraum ein kontinuierlicher Rückgang an Kammerflimmern außerhalb des Krankenhauses zu verzeichnen ist. Das folgende Kapitel soll zum einen Krankheitsbilder neben der Koronararteriosklerose beschreiben, die in einem höheren Ausmaß mit dem Auftreten plötzlicher Todesfälle verknüpft sind und insbesondere bei jüngeren Betroffenen in die Differentialdiagnose miteinbezogen werden müssen. Ferner soll das therapeutische Vorgehen nach erfolgreicher Reanimation bei „Überlebenden des plötzlichen Herztodes“ zusammenhängend dargestellt werden.
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The successful outcome of any person who has either a respiratory or cardiac arrest will depend on the combined efforts of well-trained emergency medical technicians, paramedics, nurses, physicians, and the public bystander trained in cardiopulmonary resuscitation (CPR) (1–3). The important aspect to remember is that Basic Life Support is afirst aid procedure that can be done by anyone, while Advanced Life Support techniques are, in fact, the practice of medicine and, therefore, must be under the direct or indirect supervision of a physician. Ideally, the physician who acts as Medical Director of any Advanced Life Support program or Paramedic program should fulfill the following requirements:
Chapter
Despite tremendous strides in the diagnosis and management over recent years, coronary heart disease remains the leading cause of death in the industrialised world. In the UK about 459 people die of a heart attack every day — over 170 000 people every year1. One in three men and one in four women in the UK die from coronary heart disease. Death rates from coronary heart disease in the UK remain among the highest in the world’. In the United States nearly 1.5 million patients suffer from acute myocardial infarction annually2. The major cause of death is ventricular arrhythmias and sudden death.
Chapter
When in 1963 Day launched his concept (1) for intensive coronary care, he probably was unaware that this was the only moment at which a prospective comparative trial with random allocation to the ‘new’ treatment and the ‘old’ could have been carried out with full justification. It is sad that no one designed such a trial, but not surprising, given the similar history of other medical innovations. Yet the results of such a study might have prevented the current unrest about the usefulness of the coronary care unit (CCU).
Chapter
Most of what is known of the natural history of coronary disease has been learnt in the short space of 20 years. Community studies made in this period have shown that approximately half of all deaths from acute events occur within an hour of the onset of any symptoms [1, 2]. The recognition of the fact that most early deaths were due to ventricular fibrillation and therefore potentially reversible led to the concept of coronary care units [3, 4], though the results were disappointing because few patients were admitted to hospital during the period of greatest risk [1]. Later evidence showed that many early deaths were instantaneous due to ventricular fibrillation without recent infarction, so that victims have no opportunity to seek help before the onset of circulatory arrest [5, 6].
Chapter
For many centuries, sudden death unrelated to trauma has been recognised as a clinical entity. In the first century A.D. Pliny the Elder studied many citizens of Rome — physicians, senators, and businessmen — who had dropped dead. With no post-mortems, these deaths were usually attributed to ‘an act of the gods’. Frequent records of sudden death were made throughout the Middle Ages and in the seventeenth and eighteenth centuries. In 1560 Lusitanus wrote: ‘A reverend abbot from the Isle of Croma, one or two miles distant from Ragusa, when he was in good health and talking to several persons, said that he suddenly felt pain in his heart and with his hand moved rapidly toward the region of the heart, he fell, though slowly, to the earth and rapidly lost all his animal faculties. When called in I said he was dead. Not only was the pulse at the metacarpium and the temples missing, but even no motion upon the heart could be perceived. In order to satisfy the assistants I brought to the nostrils a burning candle whose flame did not move at all. Also a bright mirror was advanced near the mouth and nothing of respiratory contraction was seen on it. We then applied a glass vessel filled with water upon the thorax but the water was unmoved’. Lancisi [1] performed post-mortems on the citizens of Rome who died suddenly during 1705–1706, and found a natural cause for death in every case and he referred particularly to diseases of the blood vessels with ‘obstruction therefrom of the free flow of blood’.
Article
Ninety-four patients with ventricular tachycardia (VT), 49 with sustained and 45 with nonsustained VT, who had been refractory to or intolerant of other antiarrhythmic agents were treated in a multicenter, open-label study with flecainide acetate. Most had serious cardiac disorders associated with their arrhythmia: 49 patients (52%) had 1 or more conduction disorders on electrocardiography; 43 (46%) had congestive heart failure; 30 (33%) had left ventricular ejection fractions of 30% or less. Patients were initially treated orally in the hospital with 100 mg twice daily; dosage was titrated upward as needed at 4-day intervals to a maximal dose of 200 mg twice daily. Flecainide plasma level monitoring was performed to ensure plasma levels remained in the therapeutic range of 0.2 to 1.0 μg/ml. Patients were discharged with flecainide therapy if investigators judged it to be safe and effective. Minimum efficacy requirements included elimination of sustained VT and reduction of other ventricular arrhythmias as determined by 1 or more of the following: 24-hour electrocardiographic monitoring, programmed electrical stimulation, exercise testing and in-hospital monitoring. Sixty-eight patients (72%) were discharged with flecainide therapy. After a mean follow-up of 8 months, 45 patients (48%) were still taking flecainide, including 22 of 49 (45%) with sustained and 23 of 45 (51%) with nonsustained VT. Nine patients with sustained VT and 1 patient with nonsustained VT had aggravation of arrhythmia. Two patients had third-degree heart block. Nine patients died after discharge from the hospital: 6 from out-of-hospital sudden death and 3 from acute myocardial infarctions. Flecainide is an effective antiarrhythmic agent when used for the short- and long-term control of resistant VT.
Article
We have illustrated the life table method for computing survival rates with 5-year survival data for cancer patients, emphasizing the advantage gained by including survival information on cases which entered the series too late to have had the opportunity to survive a full 5 years. The advantage is measured in terms of reduction in standard error of the survival rate. For the five series of patients in this paper, the reduction in standard error ranged from one-third to two-thirds.
Article
Sudden cardiac death (SCD) continues unabated. Coronary care units, while effective in lowering hospital mortality, cannot significantly reduce SCD which occurs primarily outside the hospital and accounts for the majority of deaths from coronary heart disease (CHD). In view of the frequent precipitous nature of SCD, only a program which identifies and protects the victim prior to the event can hope to be successful in preventing the majority of SCD. Since it is likely that SCD is due to an arrhythmia, drug prophylaxis might prove effective. In view of the toxicity of currently available agents, it is mandatory to preselect a population at highest risk before embarking on a drug trial. Ventricular premature beats (VPB) may identify subjects susceptible to SCD. Epidemiologic and physiologic information on VPB is reviewed, and proposals are made for studies designed to establish the usefulness of VPB as a risk factor for SCD.
Article
55 of 126 patients with cardiac arrest outside hospital had resuscitative measures initiated within 4 minutes of the onset of arrest. 48 of the 55 had ventricular fibrillation. 39 of the 48 survived. Resuscitative measures were initiated by members of a mobile coronary-care team in 14 patients and by other individuals in 25. 27 left hospital alive and most of these patients were well at follow-up. 24 of the 27 had acute myocardial infarction, 2 had myocarditis, and 1 had been electrocuted. In 19 of the patients with myocardial infarction the coronary attack was clinically mild. These findings indicate the value of the training of medical and lay personnel in resuscitation methods provided a mobile coronary-care unit is available.
Article
53 patients leaving hospital after an episode of ventricular fibrillation (V.F.) complicating acute myocardial infraction have been followed up for six months and 41 of them have been followed up for over one year. The mortality-rate, work record, and clinical status of these patients indicate that the episode of V.F. did not adversely affect the long-term prognosis. Patients surviving primary V.F. did especially well. The first-year mortality-rate for this group was 7%. After one year 92% of male patients surviving primary V.F. were able to return to work and 67% had returned to the same job.
Article
In order to better understand the problem of prehospital sudden cardiac death (SCD) two groups of individuals were studied. One group was monitored by rescue squads during attempted rescue. These subjects were defibrillated from prehospital ventricular fibrillation (VF) and hospitalized if they survived or autopsied if they could not be resuscitated. The second group were SCDs which were witnessed and described by observers. Detailed past histories of both groups were collected, and either clinical or autopsy diagnoses were obtained. On the day of death or VF, one quarter reported new symptoms (primarily chest pain and dyspnea) preceding collapse by more than 30 minutes, one quarter reported symptoms lasting from 1 to 30 minutes, and one half collapsed instantaneously or within 1 minute of acute symptoms. A history of old myocardial infarction (MI) was present in 41% and of angina pectoris in 54%, and 27% reported new or changing symptoms within four weeks. In defibrillated survivors, "would-be SCDs," electrocardiographic (ECG) changes of acute myocardial infarction (AMI) or ischemia were nearly three times more frequent than changes detected histologically in SCDs, and in the former involved predominantly the anterior wall in contrast to the inferior wall in most autopsied deaths. This disparity implicates acute myocardial lesions, particularly of the anterior wall, in the majority of SCDs. Acute coronary lesions were found in 58% of SCDs autopsied. Most of these were ruptured plaques although almost one fifth of all autopsied SCDs had thromboses without intimal rupture. Severe chronic multivessel stenosis was present in most subjects, although 15% had only disease of a single vessel and in these, the left anterior descending (LAD) or left main coronary artery were involved in three quarters. The SCD population may be subgrouped into those with recent MI, those with only myocardial ischemia, and those with no detectable myocardial change. When rescuers were able to monitor prehospital SCDs, VF was found in the majority; however, 28% did have other terminal rhythms.
Article
All the deaths attributed to coronary artery disease and occurring in Belfast during one year were studied.The frequency distributions of the cases by interval of time between onset of the last attack and death are given for those not admitted to hospital, for those admitted to hospital, and for those already in hospital for some other cause of illness.Sixty per cent. of all the deaths occurred outside hospital. This indicates that the problem of cardiac resuscitation in coronary artery disease is to a considerable extent an extra-hospital one.Twenty-seven per cent. of the men and 22% of the women died within 15 minutes, but the median period of survival was 3 hours 30 minutes for men and 6 hours 18 minutes for women.The median time interval from the onset of the attack to sending for medical aid was 1 hour 17 minutes for men and 1 hour 6 minutes for women, and from summoning medical aid to sending for the ambulance 59 minutes for men and 1 hour 26 minutes for women. Ninety-six per cent. of the ambulance journeys to the patient were accomplished in less than 20 minutes.It was found among men, but not among women, that the duration of survival tended to be longer in older patients and in second or subsequent attacks.Of the 596 who did not gain admission to hospital 229 (23% of all the 998 patients) were known to have survived for more than half an hour after the onset of the fatal attack; 182 (18%) survived for more than one hour; and 143 (14%) survived for more than two hours. It is among these that there would appear to be special scope for the cardiac ambulance, providing that medical aid is sought and the ambulance is summoned without delay.
Article
A study of sudden unexpected nontraumatic deaths was begun on June 1, 1964. A sample of all nontraumatic deaths in Baltimore residents between the ages of 20 and 64 from June 15, 1964, to June 14, 1965, was obtained. The deaths were then studied by reviewing all available medical information in order to determine: (1) whether the death was possibly sudden or not and (2) the accuracy of the diagnosis reported on the death certificate. The next of kin or other relative or friend of each deceased person who died suddenly was then interviewed. For comparison, information was obtained on (1) a probability sample of the Baltimore population, and (2) deaths due to arteriosclerotic heart disease (ASHD deaths) that were found to be "not-sudden." There were 1,857 deaths in the original sample, of which 589 were sudden according to the definition of sudden death. After adjustment for sampling, it was estimated that 1,178 (32%) of the total 3,648 deaths in Baltimore were sudden. Arteriosclerotic heart disease (ASHD) accounted for 58% and the cardiovascular group together for 69% of the sudden deaths. Sixty per cent of all ASHD deaths were sudden. Of the 1,030 ASHD deaths in Baltimore City between the ages of 40 and 64, 20.6% occurred outside of a hospital and 46.2% represented deaths on arrival at a hospital. Only 18.9% of all ASHD deaths occurred after the first 24 hours of hospitalization. By use of data provided in several crosssectional and prospective studies, it was estimated that 22% of new coronary events were sudden deaths and that the case-fatality rate was 31%. In approximately half of the ASHD sudden deaths the deceased had a history of heart disease prior to death and in 24% the deceased had seen a physician within the week prior to death. Unfortunately we were not able to determine the reasons for these visits. In considering the implications of these findings with regard to the prevention of ASHD deaths, it would appear that prevention of only a comparatively small percentage (8.2%) of ASHD deaths is completely dependent on primary prevention. For the remaining ASHD deaths a combination of both primary and secondary prevention may be effective. Because of the rapidity of death and the high frequency of these deaths either occurring outside of a hospital or being called deaths on arrival, hospital treatment may well have little effect on reducing the ASHD mortality, while, on the other hand, the combination of better and earlier diagnosis and intensive treatment in a hospital could conceivably re- duce the mortality.
Article
The high rate of necropsy in deaths among permanent residents of Rochester, Minnesota, provided a unique opportunity to study the prevalence of coronary heart disease and the frequency and mode of death resulting from this disease. In this community of approximately 30,000 population, necropsy was done in 73 per cent of all resident deaths during the years 1947 through 1952. Included in this group were 691 necropsies that represented 67 per cent of the 1,026 deaths of persons 20 years of age or older. Coronary heart disease caused death in 221 patients (23 per cent of all necropsies and 32 per cent of all necropsies on adults). These 221 coronary deaths in adults represented 41 per cent of the men and 22 per cent of the women. The coronary deaths were attributed to acute coronary failure (sudden death) in 94 patients (43 per cent), acute myocardial infarction in 87 patients (39 per cent), congestive heart failure in 32 patients (14 per cent) and thromboembolism in eight patients (4 per cent). The 87 patients dying during acute myocardial infarction died of congestive heart failure (30 per cent), myocardial rupture (24 per cent), acute coronary failure (23 per cent), and thromboembolism (14 per cent), with the remaining 9 per cent dying of a combination of acute myocardial infarction and additional serious systemic disease. The greatest number of deaths from coronary heart disease occurred during the seventh decade of life in men and the eighth decade in women. At least one coronary artery exhibited from 25 to 100 per cent obstruction from atherosclerosis in 513 hearts (74 per cent of the adult necropsies). These necropsies, representing two thirds of all deaths in adults in this community, disclosed that significant coronary-artery disease was present in three of four adults and was the cause of death in four of 10 men and two of 10 women.
Article
This article has no abstract; the first 100 words appear below. THIS study was undertaken to describe, epidemiologically, fatal coronary heart disease in persons fifty years of age and younger during a one-year period in an urban-suburban community of approximately 1,000,000 persons. The Seattle–King County Department of Public Health served as the operational base of this investigation. The trend of occurrence of coronary heart disease in relation to total mortality in this community is shown in Table 1. The data for this table were compiled by Ravenholt,¹ who recoded original certificates of death for the years shown to fit as closely as possible the 1955 International List of Diseases and Causes of . . . *From the Seattle–King County Department of Public Health, Seattle, Washington. Supported in part by the Washington State Department of Health and the Heart Disease Control Program, Public Health Service, United States Department of Health, Education, and Welfare. Source Information SEATTLE, WASHINGTON †On active duty, Heart Disease Control Program, United States Public Health Service, assigned to Seattle–King County Department of Public Health. ‡Director, Division of Epidemiology and Communicable Disease Control, Seattle–King County Department of Public Health.
Premature mortality from coronary heart disease. The Framingham Study STANNARO) M, SLONIAN-G: Ventricular fibrillation in acute myocardial infarction: Prognosis following successful resuscitation
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GoRD)oN-T, KANNEL WB: Premature mortality from coronary heart disease. The Framingham Study. JAMA 215: 1617, 11. STANNARO) M, SLONIAN-G: Ventricular fibrillation in acute myocardial infarction: Prognosis following successful resuscitation. Am Heart J 77: 573, 1969