Cigarette smoking and employment status.

The smoking habits and health knowledge of the unemployed and the full-time workers were investigated in a cross-sectional study of over 10,000 men and women throughout Scotland. For both sexes (age range 40-59 years), the proportion of current smokers and ever smokers was found to be considerably higher among the unemployed. Only a small part of the difference could be explained by standardisation for social class. The unemployed smokers had began to smoke at an earlier age, with significantly more smoking whilst still at school. Amongst current smokers, the unemployed males reported smoking fewer cigarettes a day, whereas unemployed women smoked more than their full-time counterparts. The reported levels were confirmed by the biochemical measures of smoking; serum thiocyanate and expired air carbon monoxide levels. In contrast to their differences in smoking habit, the two groups were very similar in their knowledge of the hazards of smoking. Smoking habits among the unemployed reflect a complex interaction of financial and both current and previous social factors. Such relationships present a particular challenge to health promotion campaigns.

Unemployment, socioenvironmental factors, and coronary heart disease in Scotland.

Scotland, which has one of the highest death rates in the world from coronary heart disease, also has considerable regional variation in mortality from this cause. The relation between standardised mortality ratios for coronary deaths (1979-83) for 56 local government districts and a range of socioeconomic factors from the 1981 Census as well as climatic factors and water hardness were investigated. Strong associations were seen with several measures of social disadvantage, the strongest being with percentage of male unemployment. A fitted multiple regression model with mortality from coronary heart disease in men found independent effects of two social variables (percentage male unemployment and percentage social class III-V) and one climatic factor (rainfall). The model explained much (73%) of the geographical variation in mortality from coronary heart disease, but part of the geographical pattern, in particular some of the east-west gradient in mortality, remained unexplained by it. Explanations for the geographical variation and the association with economic factors are currently being sought in terms of individual risk factors in a large screening study, the Scottish Heart Health Study.

Urinary electrolyte excretion, alcohol consumption, and blood pressure in the Scottish heart health study.

As part of a study of risk factors for coronary heart disease 24 hour urine collections were obtained from 7354 men and women aged 40-59 selected at random from 22 districts throughout Scotland (Scottish heart health study). The mean of two standardised measurements of blood pressure was related to the reported consumption of alcohol and measurements of height, weight, pulse rate, and electrolyte excretion. Several significant correlations were found with both systolic and diastolic pressure, but only the coefficients for age, body mass index, and pulse rate were greater than 0.1. Alcohol consumption showed a weak positive correlation with blood pressure in men. Sodium excretion showed a weak positive correlation with blood pressure in both sexes, and potassium excretion showed weak negative correlations. In multiple regression analysis age, pulse rate, body mass index, alcohol consumption, and potassium excretion had significant independent effects but sodium excretion did not. Although measuring blood pressure twice on one occasion and 24 hour urinary sodium excretion only once may have weakened any potential correlation, the most likely explantation of these results is that the relation between sodium and blood pressure in the population is weak and that potassium and alcohol are of greater importance.

Cardiovascular risk factor profile and mortality in two Scottish cities.

Edinburgh and Glasgow are the two largest cities in Scotland, which has one of the highest coronary heart disease mortality rates in the world. Within Scotland, there is a geographical variation in these rates and Glasgow has a higher mortality rate than Edinburgh. However, the cities also differ socially and economically. Population surveys have been conducted in centres in both Edinburgh and North Glasgow using the MONICA project methods. These surveys were performed simultaneously in 1986 in men and women aged 25-64 years. Preliminary analysis shows that the differences in cigarette smoking, blood pressure and body mass index in men and women between the two centres are consistent with the difference in cardiovascular mortality. However there is no difference between the centres in reported exercise levels, and the difference in mean serum total cholesterol between the centres is in the opposite direction to that expected. Possible explanations of these differences are discussed.

How well can we predict coronary heart disease? Findings in the United Kingdom Heart Disease Prevention Project.

The probability of myocardial infarction developing over five years in a group of middle aged men was predicted with knowledge of their ages, blood pressures, cholesterol concentrations, and smoking habits as recorded in an initial screening examination. Although the top 15% of the risk distribution predicted 115 (32%) of the subsequent cases of myocardial infarction, there was a considerable overlap in predicted risk between those subjects who did and those who did not go on to develop a myocardial infarction. Of the subjects in the top 15% of risk, only 72 (7%) of those initially free of coronary heart disease and 43 (22%) of those initially with coronary heart disease actually developed a myocardial infarction over the subsequent five years. Thus, although a group of subjects at high risk can be identified, among whom will be a high proportion of potential victims of heart attack, many subjects will be wrongly classified. These findings may explain part of the difficulty in persuading patients of the potential benefits of reducing risks and highlight the need for research to improve the prediction of the development of coronary heart disease.

UK heart disease prevention project: incidence and mortality results.

Results are presented for the UK centre of the WHO European Collaborative Trial in the Multifactorial Prevention of Coronary Heart Disease (CHD). 18 210 men took part, aged 40 to 59; they were employed in 24 factories, which formed the allocation units for a randomised controlled trial lasting 5-6 years. Intervention comprised advice on cholesterol-lowering diet, smoking cessation, weight control, exercise, and treatment of hypertension. Advice was given mainly through factory medical departments, the staff being supplemented a little by a visiting central team. Self-reported cigarette smoking was moderately reduced, but changes in other risk factors were small and not well sustained. There was no clear effect on hard CHD end-points (coronary deaths and myocardial infarction) or on all-causes mortality. However, there was a 36% reduction in the rate at which intervention subjects reported ill with other CHD (principally angina) during the study, and at the end fewer intervention men gave positive responses to a self-administered questionnaire on angina and chest pain. These apparent benefits were not substantiated by electrocardiographic evidence, suggesting that participation in a heart disease prevention campaign may bias reporting of symptoms. Experience in other centres of the Collaborative Trial, however, suggests that more effective risk factor control does reduce CHD incidence and mortality. This implies that for the UK the problem is to find means of enhancing the acceptance of health advice.

Blood pressure measurement in the United Kingdom Heart Disease Prevention Project.

A blood pressure measurement was part of a cardiovascular screening examination of 8397 middle-aged men taking part in the intervention section of the United Kingdom Heart Disease Prevention Project. Standardised training techniques reduced observer bias to acceptable limits in four out of a total of five observers. The time of day and room temperature both made significant differences to the blood pressure measurement. High room temperatures in particular apparently had a marked effect in reducing the level of blood pressure. There were consistent and large positive associations with increasing age and overweight. The survey revealed a poor degree of blood pressure control in the community at the time of screening--only 7% of the "hypertensive" population had their diastolic pressure controlled to below 100 mm Hg.

Digoxin prescribing in general practice 1967--77.

Data from a survey of general-practitioner prescribing from 1967 to 1977 were examined to see how news of the changed potency of "Lanoxin" tablets in 1972 and of unbranded digoxin in 1975 had affected prescribing patterns. A stong downward trend in average daily dose was found, equivalent to a halving in lanoxin, almost as much in digoxin, and a one-fifth fall in prepared digitalis. This trend, however, preceded the publicity on potency and bioavailability, and in the case of lanoxin was apparent during the time that bioavailability fell. It had two components--reduced frequency of tablets per day, and increased popularity of low-dose tablets. From 1972 the proprietary 250 microgram tablet of lanoxin was prescribed increasingly at the expense of unbranded digoxin, but at a lower daily frequency until 1975. The number of people treated with digoxin and lanoxin has risen overall and constitutes perhaps 6% of those over 65. The determinants of prescribing behaviour are complex.

Predictability of sudden death from resting electrocardiogram. Effect of previous manifestations of coronary heart disease.

The sudden death rate from coronary heart disease over a mean period of 4 years was related to the electrocardiographic findings in 3 groups of subjects, survivors of myocardial infarction, employed men, and employed men with no symptoms or history of coronary disease. Within each group the sudden death rate correlated with the number of electrocardiographic findings, particularly Q, ST, and T wave items. However, between groups there were large differences in sudden death rates in subjects with the same findings. These were greatest in the case of ventricular conduction disturbances and disturbances of rhythm and rate which appeared to be benign in those free of symptoms but ominous after infarction. Findings predictive of sudden death were also predictive of non-sudden coronary deaths. It is concluded that the electrocardiogram is only one of several aids to the diagnosis and assessment of severity of disease and not a substitute. Prognoses derived from clinical case series are inappropriate to symptomless individuals in whom isolated electrocardiographic findings denote little increase in risk.

Apparent recurrence of Q fever endocarditis following homograft replacement of aortic valve.

A 39-year-old man with aortic stenosis and regurgitation developed Q fever endocarditis. After 15 weeks of chemotherapy with tetracycline the damaged aortic valve was replaced with a homograft. Organisms were present in the excised valve. Some months later the valve began to leak and the endocarditis recurred fatally. Because of the nature of rickettsial infection neither a course of chemotherapy nor an operation can guarantee a cure of Q fever endocarditis. Chemotherapy should be continued indefinitely even after operation.