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The Biology of Myocardial Infarction
- GUNNAR BIÖRCK
Circulation Volume 37, Issue 61 June 1968

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Myocardial infarction is a dreaded companion of the civilization of our time. The "heart attack," the coronary thrombosis, the myocardial infarction lurk behind the corner, striking strangers, patients, friends, and ourselves. The toll taken by this single "disease" in many hospitals equals or even exceeds that from almost all other diseases together. Must it be so? This is the question many physicians, and the lay public, are asking themselves today.Identification of some areas where our knowledge is particularly deficient is stressed. We must concentrate our efforts on reevaluating practices and procedures that have brought both the greatest success and the worst failures, at the same time that we ask ourselves what goals could be considered realistic.If myocardial infarction is the evil of our time, what does this mean in a greater biological context-in the evolution of human life and endeavor as viewed in perspective? Are we dealing with a "disease" in the restricted sense of the word, or are we dealing with a way of life and a consequent mode of death? If so, what can be done to achieve the goals of health as defined by the World Health Organization? In what terrain are the forces to be assembled and the battle to be fought-and by whom.
Relationship of Stroke to Other Cardiovascular Disease
- GARY D. FRIEDMAN,
- DONALD B. LOVELAND and
- S. PAUL EHRLICH
Circulation Volume 38, Issue 31 September 1968

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The frequencies of prior cardiovascular abnormalities were compared in 117 stroke patients and 234 control subjects. All were residents of a retirement community who had been examined initially and followed in the local medical clinic before the strokes occurred. Cases and controls were matched for age, sex, length of residence, and blood pressure.Prior coronary, rheumatic, and hypertensive heart disease were all more frequent in cases than in controls, as were cardiac enlargement, congestive heart failure, and digitalis therapy. There was a stronger association of stroke with atrial fibrillation than with other cardiac abnormalities, suggesting that atrial fibrillation in the elderly is an important precursor of stroke and should not be regarded lightly.Aortic calcification and intermittent claudication were also more frequent among the stroke cases than the controls. Since the blood pressures of cases and controls were matched, the association of both cardiac disease and noncerebral atherosclerosis with stroke is independent of blood pressure and is not attributable to the fact that hypertension predisposes to all of these conditions.
The Coronary Arteries in Early Life in Three Different Ethnic Groups
- ZEEV VLODAVER,
- HAROLD A. KAHN and
- HENRY N. NEUFELD
Circulation Volume 39, Issue 41 April 1969

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The histologic changes in the coronary arteries in full-term fetuses, infants, and children of 211 consecutive necropsy specimens from Ashkenazy, Yemenite, and Bedouin groups were studied, excluding cardiac deaths.The developmental structural pattern of the coronary arteries is similar in the three ethnic groups.Differences in the intensity and quantity of the structural findings between the sexes and among various ethnic groups are found in early life. The intimal tissue in the Ashkenazy male develops in an eccentric form, has more collagen tissue components, and is more highly developed than in the Ashkenazy female. Structural findings in the internal elastic membrane and the elastic fibers of the intima are less apparent in the Bedouin group, particularly in the female, than in the Ashkenazy and Yemenite groups.Statistical analysis of the quantitative data showed the intima and musculo-elastic layers to be more developed in the Ashkenazy male than in the Yemenite and Bedouin males. However, Ashkenazy males clearly have more intima and musculo-elastic tissue than do the Ashkenazy females. This was not true for Yemenites and was found in only one of three age groups among Bedouins.The relationship between the structural findings in coronary arteries of children under 10 years and the reported prevalence of coronary heart disease in the corresponding adult population in these three different ethnic groups has been pointed out.
Impaired Maximal Exercise Performance with Hypertensive Cardiovascular Disease
- HEE ONG WONG,
- IRWIN S. KASSER,
- ROBERT A. BRUCE,
- Gladys Pettet and
- Verona Hofer
Circulation Volume 39, Issue 51 May 1969

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Responses to a multistage treadmill test of maximal exercise were studied in 61 hypertensive patients: 13 had uncomplicated hypertension; 15 had associated retinopathy; 22 had left ventricular hypertrophy; and 11 also had coronary heart disease. Because of significant differences with aging normally, and differences in ages of these subgroups, responses were compared with those of normotensive persons matched for age and sex.With only elevated blood pressure there was no impairment of exercise performance and no increase in S-T segment depression. With ventricular hypertrophy and particularly with retinopathy, maximal exercise duration was shortened. Prevalence of postexertional myocardial ischemia, manifested by S-T segment depression, was increased threefold in those with hypertrophy of the left ventricle.Even greater impairment of exercise duration, maximal heart rate, and systolic pressure was observed in patients with coronary heart disease and hypertension. Prevalence of S-T segment depression was sevenfold greater.This ECG manifestation of myocardial ischemia may represent either an augmented contractile force or a significantly restricted coronary blood supply to limit myocardial perfusion. Differences in duration of exercise and circulatory responses, particularly the product of maximal heart rate and maximal systolic pressure/100, indicate these variations in pathophysiological mechanisms.
Predisposing Factors in Sudden Cardiac Death in Tecumseh, Michigan : A Prospective Study
- BENJAMIN N. CHIANG,
- LAWRENCE V. PERLMAN,
- MARY FULTON,
- LEON D. OSTRANDER and
- FREDERICK H. EPSTEIN
Circulation Volume 41, Issue 11 January 1970

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In an epidemiologic study of the total population of Tecumseh, Michigan, 98 deaths from coronary heart disease were observed between 1959 and 1965. Forty-five of the fatalities occurred within 1 hour of the onset of symptoms and were classified as sudden. The proportion of sudden deaths among men was nearly twice that among women, and the incidence increased progressively with age in both sexes.Hypertensive heart disease, coronary heart disease, or diabetes mellitus had been detected on prior examination in 62% of those who died suddenly. Physiologic abnormalities associated with a high risk of coronary heart disease were also found more frequently than in the total Tecumseh population.All but seven of the persons who died suddenly had abnormalities including arrhythmias and conduction defects which were detected in the standard 12-lead electrocardiogram.Although sudden deaths often seem to occur without warning, the victims are predisposed by conditions which are detectable long before the catastrophic event. The identification of conditions which are precursors of sudden death from coronary heart disease permits a rational consideration of possible preventive measures.
Intermittent Claudication : Incidence in the Framingham Study
- WILLIAM B. KANNEL,
- JOHN J. SKINNER,
- MELVIN J. SCHWARTZ and
- DEWEY SHURTLEFF
Circulation Volume 41, Issue 51 May 1970

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A general population sample of adult men and women was followed biennially over 14 years during which time 79 men and 46 women developed initial symptoms of intermittent claudication. A detailed examination of the incidence of this manifestation of atherothrombosis in comparison to that of coronary heart disease and atherothrombotic brain infarction was undertaken.As for coronary heart disease (CHD), the incidence of intermittent claudication increased with age. Women lagged behind men by 10 years in incidence. Atherothrombotic brain infarction in contrast exhibited no male predominance and after the early sixties the women actually surged ahead.Uncomplicated angina, surprisingly, resembled brain infarction more than intermittent claudication in the age-sex trend.A pronounced increase in risk of intermittent claudication was noted for persons with CHD in general and angina in particular, suggesting a common underlying basis for claudication and coronary disease. The principal hazard for subjects with claudication appeared to derive from an increased propensity to cardiovascular morbidity and mortality rather than from the consequences of impaired circulation to the limb. Risk of death was twofold for those with claudication as compared to those without.
Comparative Quantitative Analysis of the Electrocardiogram and the Vectorcardiogram : Correlations with the Coronary Arteriogram
Circulation Volume 42, Issue 21 August 1970

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Simultaneously recorded standard electrocardiograms (ECG) and Frank vectorcardiograms (VCG) were correlated with the coronary arteriograms and the left ventriculograms of 210 patients. Quantitative criteria were applied to ECG measurements made by manual technics and to VCG measurements obtained by computer technics.As the extent of significant arteriographic disease increased, the frequency of ECG and VCG evidence of "definite" myocardial infarction (MI) increased. The VCG was diagnostic of MI in a greater number of patients than the ECG (50 versus 39, P < 0.01) and excelled in the detection of multiple areas of infarction in a greater number of patients (13 versus six, P < 0.05). This increased sensitivity was gained in anterior, inferior, and true posterior infarcts. Excluding patients with myocardiopathy, all MIs diagnosed from the VCG and all but one from the ECG were associated with significant arteriographic disease in the distribution of the predicted nutrient artery.Quantitative VCG analysis appears superior to the usual ECG analysis in the accurate detection of MI. When MI is diagnosed by either technic, significant associated coronary artery disease can be anticipated in a predictable anatomic distribution.
Risk Factors and Prevalence of Coronary Heart Disease in Puerto Rico
- MARIO R. GARCÍA-PALMIERI,
- RAÚL COSTAS,
- MERCEDES CRUZ-VIDAL,
- MARCELINO CORTÉS-ALICEA,
- ANGEL A. COLÓN,
- MANUEL FELIBERTI,
- ANGEL M. AYALA,
- DOLORES PATTERNE,
- RAFAEL SOBRINO,
- RAQUEL TORRES and
- EMILIO NAZARIO
Circulation Volume 42, Issue 31 September 1970

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In spite of an apparently increasing mortality rate from coronary heart disease in Puerto Rico, the age-specific mortality rate from this illness is considerably lower in the island than in the U. S. mainland. Examination of 9,814 Puerto Rican urban and rural men in the 45 to 64-year age group revealed sizable and statistically significant differences in monthly income, cigarette smoking, ingestion of fats, blood pressure, heart rate, relative weight, serum cholesterol, serum glycerides, prevalence of diabetes, and prevalence of hypertension (lower in rural dwellers), and also in vital capacity, consumption of calories per unit body weight, and physical activity (higher in rural area). No urban-rural difference in coronary heart disease prevalence was found, but the prevalence of definite myocardial infarction, established on basis of electrocardiographic criteria alone, was significantly higher in the 45 to 54-year urban group. Follow-up of this population to study incidence of disease and the influence of the various factors upon the development of disease is being conducted.
The Oslo Diet-Heart Study : Eleven-Year Report
- PAUL LEREN
Circulation Volume 42, Issue 51 November 1970

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The study deals with 412 men, aged 30 to 64 years, randomized 1 to 2 years after a first myocardial infarction. For the experimental group a diet low in saturated fats and cholesterol, and high in polyunsaturated fats was recommended. After 5 years, as reported previously, the incidence of fatal and nonfatal myocardial reinfarction was found to be significantly reduced. "Sudden death" was uninfluenced. Major coronary heart disease (CHD) relapses, including fatal and nonfatal events (MI), were significantly reduced (P = 0.05).After 11 years, death from all causes had occurred in 101 of the original dieters and 108 controls. A significantly reduced myocardial infarction mortality in the original diet group was found (32 versus 57, P = 0.004). The total number of coronary deaths (fatal myocardial infarction and sudden death) was 79 in the diet group and 94 in the control group (P = 0.097).The CHD mortality was correlated with age, serum cholesterol level, blood pressure, body weight, smoking habits, and a combination of these risk factors.
Resting and Postexercise Phonocardiogram and Electrocardiogram in Patients with Angina Pectoris and in Normal Subjects
- WILBERT S. ARONOW,
- RONALD R. UYEYAMA,
- JOHN CASSIDY and
- JOSEPH NEBOLON
Circulation Volume 43, Issue 21 February 1971

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One hundred patients with angina and 100 normal subjects, mean age 51 years, had simultaneous phonocardiograms and electrocardiograms at rest and after a double Master's test. A fourth heart sound was present at rest in 43% of the patients and 14% of the normal subjects, and after exercise in 94% of the patients and 29% of the normal subjects. All patients and the normal subject who had a third heart sound at rest had a fourth heart sound at rest, and all who had a third heart sound after exercise had a fourth heart sound after exercise. Fifty-nine per cent of the patients and 4% of the normal subjects had an ST-segment shift ≥1.0 mm, and 67% of the patients and 6% of the normal subjects had an ST-segment shift ≥0.5 mm. After exercise, 97% of the patients and 30% of the normal subjects had a fourth heart sound or an ST-segment shift ≥0.5 mm.
Diphenylhydantoin in the Prevention of Recurring Ventricular Tachycardia
- NEIL STONE,
- MICHAEL D. KLEIN and
- BERNARD LOWN
Circulation Volume 43, Issue 31 March 1971

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The efficacy of diphenylhydantoin in preventing recurrent ventricular tachycardia was studied in ten patients, nine of whom had documented coronary heart disease. Prolonged continuous ECG monitoring of up to 72 hr was performed in each case. Oral and intravenous loading doses of 1000 to 1500 mg were given on the first day of therapy to insure rapid attainment of therapeutic blood levels. Diphenylhydantoin was uniformly ineffective in preventing recurrence of ventricular tachycardia despite the presence of what is regarded as adequate therapeutic plasma concentrations (greater than 19.0 µg/ml in five patients, 10.8-18.0 µg/ml in the remaining five) shortly after onset of ventricular tachycardia. Nystagmus was noted in eight patients, but plasma diphenylhydantoin levels varied widely (8.6-35.0 µg/ml) when this sign of neurotoxicity was first detected.
Onset of Angina Pectoris in Relation to Circulatory Adaptation during Arm and Leg Exercise
- JOHN WAHREN and
- STELLAN BYGDEMAN
Circulation Volume 44, Issue 31 September 1971

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The circulatory adaptation to arm and leg exercise was studied with stepwise increased work loads in 10 patients with signs of coronary artery disease. Both arm and leg exercise elicited angina pectoris in all patients. Anginal pain appeared at the same level of pressure-time per minute (PTM) in the two forms of exercise, but at a smaller work load and a lower pulmonary oxygen uptake during arm exercise than during leg exercise. Heart rate, PTM, and peak systolic, systolic mean, diastolic, and mean arterial pressures all increased more steeply in relation to work load during arm exercise than during leg exercise. The differences in circulatory adaptation during arm and leg exercise are attributed in part to a lower mechanical efficiency and a higher sympathetic outflow during arm exercise. These factors may in turn reflect the involvement of smaller muscle groups and a larger component of static work with trunk muscles during arm exercise. The pattern of response to exercise resembles that seen in healthy subjects and provides a pathophysiologic background for the earlier appearance of anginal symptoms during arm than leg exercise in patients with coronary artery disease.
Carboxyhemoglobin Caused by Smoking Nonnicotine Cigarettes : Effects in Angina Pectoris
- WILBERT S. ARONOW and
- STANLEY N. ROKAW
Circulation Volume 44, Issue 51 November 1971

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The effects of increased carboxyhemoglobin levels caused by smoking nonnicotine cigarettes upon exercise-induced angina were investigated in 10 patients. The mean carboxyhemoglobin level after smoking eight nonnicotine cigarettes, one every 30 minutes, rose from 1.58 to 7.79%. Smoking significantly decreased the mean exercise time from the onset of exercise until the onset of angina from 109.8 to 83.5 seconds. There was significantly less of an increase in systolic blood pressure, heart rate, and product of systolic blood pressure times heart rate after exercise-induced angina after smoking compared to the nonsmoking state. Smoking nonnicotine cigarettes increased the carboxyhemoglobin level, decreasing the rate of oxygen deliverability to the myocardium, with angina developing sooner, following less cardiac work.
Occurrence of Ventricular Arrhythmias with Exercise as Compared to Monitoring
- BERNARD D. KOSOWSKY,
- BERNARD LOWN,
- RICHARD WHITING and
- TIMOTHY GUINEY
Circulation Volume 44, Issue 51 November 1971

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Treadmill exercise testing and prolonged ambulatory electrocardiographic monitoring were compared for their ability to reveal ventricular ectopic activity in 81 patients. Both proved more effective than a 3-minute standard electrocardiogram (ECG) in displaying ventricular arrhythmias. Of 66 patients in whom the resting ECG was normal, prolonged monitoring was positive for arrhythmia in 18, or 27%, whereas exercise was positive in 26, or 39%. In 12 cases ventricular arrhythmia was recorded only with exercise. In addition to displaying an increased incidence of arrhythmia, exercise also revealed more serious rhythm abnormalities which would not have been suspected on monitoring alone. This was true in patients with and without coronary heart disease (CHD). Thus, exercise is an effective means of eliciting suspected arrhythmias. The prognostic significance of exercise-induced arrhythmias in patients with CHD remains to be determined.
Prevalence of Plasma Lipoprotein Abnormalities in a Free-Living Population of the Central Valley, California
- PETER D. S. WOOD,
- MICHAEL P. STERN,
- ABRAHAM SILVERS,
- GERALD M. REAVEN and
- JOBST VON DER GROEBEN
Circulation Volume 45, Issue 11 January 1972

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In an epidemiologic study of 1,118 free-living volunteers, aged 25 to 79 (552 male, 566 female) drawn from eight counties of the Central Valley, California, the following determinations were included: a medical history, blood pressure, resting electrocardiogram, plasma total cholesterol and glycerides (following a light, fat-free breakfast), and (when lipids were considered to be elevated) plasma lipoproteins determined by electrophoresis. A subgroup of the entire study population (494 male, 503 female) free of overt diabetes and electrocardiographic abnormalities, and with diastolic blood pressure not above 100 mm Hg, that was considered to be clinically "normal," forms the basis of this report.Significant sex differences for mean levels of total cholesterol were absent or of small magnitude at all age decades up to and including the seventh. In contrast, glyceride levels for men were significantly higher than for women aged 25-59, and differences were substantial. Beyond the seventh decade, females had higher mean levels of both plasma total cholesterol and glycerides.The type IV lipoprotein pattern was the most common abnormality (8.6%) within the entire normal population and was 2.7 times as common in men (13%) as in women (4.8%). Type II pattern was less common overall (3.7%) and was more frequent in women than in men. Types III (0.2 to 0.4%) and V (0.2%) were both very uncommon, and type I was not encountered. Results were similar when the entire population (normal and abnormal) was considered.These findings suggest that sex differences in plasma total-cholesterol level cannot account for the known male preponderance in coronary heart disease within the population studied. Prolonged elevation of plasma glycerides (usually expressed as the type IV pattern) in males during the years when atherogenesis is occurring might account for the sex difference.
Interrelationship of Serum Lipids with Relative Weight, Blood Glucose, and Physical Activity
- MARIO R. GARCÍA-PALMIERI,
- RAÚL COSTAS,
- JOYCE SCHIFFMAN,
- ANGEL A. COLÓN,
- RAQUEL TORRES and
- EMILIO NAZARIO
Circulation Volume 45, Issue 41 April 1972

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Serum cholesterol, serum glyceride, blood glucose, relative weight, physical activity, percent calories from fat, percent calories from carbohydrate, and polyunsaturated/saturated fatty acid (P/S) ratio were determined in 1780 rural and 4023 urban fasting men aged 45-64 years being followed prospectively to ascertain reasons for the low prevalence of coronary heart disease mortality in Puerto Rico as compared to other countries. Lipid and glucose levels and relative weight were higher and physical activity lower in urban men. Glyceride was positively correlated with cholesterol, glucose, and relative weight, and negatively correlated with physical activity. Cholesterol was positively correlated with glyceride, glucose, and relative weight, and not correlated with physical activity. Percent calories from fat and P/S ratio were significantly higher and percent carbohydrates from starch significantly lower in urban men. These variables taken together were not significant in predicting the differences between urban and rural serum cholesterol or glyceride values. Relative weight was the most significant variable in explaining urban-rural differences in serum glyceride and cholesterol levels. These findings confirm the importance of weight control in dietary management for reduction of serum lipids.
Long-Term Follow-up Study of Survival and Recurrence Rates following Myocardial Infarction in Exercising and Control Subjects
- PETER A. RECHNITZER,
- H. A. PICKARD,
- ALLAN U. PAIVIO,
- MICHAEL S. YUHASZ and
- DAVID CUNNINGHAM
Circulation Volume 45, Issue 41 April 1972

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Male subjects (N = 68), under age 51 years, with previous myocardial infarction, who participated in a program of graduated exercises over a 7-year period (1964-71), have been compared with a control group (N = 131) for incidence of nonfatal recurrence and cardiac death. The controls fulfilled the criteria to enter the exercise program, but did not. Of the 68 exercising subjects, 66 were traced in January 1971. Two (3.0%) had had a nonfatal recurrence. Of the 131 control subjects, only 117 gave valid information concerning possible recurrence. Thirteen (11.1%) had suffered a nonfatal recurrence (P < 0.10). The incidence of cardiac death (7.6%) was significantly lower (P < 0.05) in the exercising subjects than in the 127 control subjects (four of the 131 could not be traced).In 1969 a separate comparison of recurrence and survival over a 5-year period was made between 77 exercising subjects who had remained in the program for a minimum of 3 months and 127 control subjects in Toronto. One (1.3%) of the exercising subjects had had a nonfatal recurrence, and 31 (27.9%) of 111 Toronto control subjects (16 others were alive but information on recurrence was lacking) gave a history of nonfatal recurrence (P < 0.001). There were three (3.9%) deaths in the exercise group and 15 (11.8%) deaths in the Toronto control group (P < 0.10).Variables affecting prognosis, but not included in the study, were blood pressure, prior angina, and current angina. Although results of this investigation suggest that an exercise program in a selected group may favorably affect prognosis following recovery from myocardial infarction, they should be interpreted cautiously. One or more variables not related to the exercise program per se may have been operative in producing the apparent benefit.
Left Ventricular Papillary Muscles : Description of the Normal and a Survey of Conditions Causing them to be Abnormal
- WILLIAM C. ROBERTS and
- LAWRENCE S. COHEN
Circulation Volume 46, Issue 11 July 1972

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The left ventricular papillary muscles appear to be the last portions of the heart to be perfused by coronary arterial blood. As a consequence they are sensitive anatomic markers of myocardial ischemia. Foci of necrosis or fibrosis therefore are commonly seen in these structures, particularly the posteromedial papillary muscle, which has a poorer blood supply than does the anterolateral muscle. Coronary arterial luminal narrowing is the most common cause of necrosis or fibrosis of the left ventricular papillary muscles. Other conditions, all associated with inadequate cardiac output, which may produce these lesions include left ventricular outflow tract obstruction, especially that resulting from congenitally malformed aortic valves, acute valvular regurgitation (infective endocarditis), various cardiomyopathies, and primary endocardial fibroelastosis with or without anomalous origin of one or both coronary arteries from the pulmonary trunk. Various infiltrative diseases, including inflammation (Aschoff bodies, sarcoid, abscesses), amyloid, iron, and neoplasms, also may involve the papillary muscles. Their most common congenital malformation is the parachute or single papillary muscle. Fibrosis or necrosis of adjacent left ventricle free wall without involvement of the papillary muscles themselves may simulate clinically "papillary muscle dysfunction." The anterior papillary muscle of the right ventricle is frequently affected by conditions which also affect the left ventricular papillary muscles. Whether or not necrosis or fibrosis of the right ventricular papillary muscle causes tricuspid regurgitation, however, is unknown at present.
Effects of Coronary Bypass Graft Occlusion on Left Ventricular Performance
- RICHARD P. ANDERSON
Circulation Volume 46, Issue 31 September 1972

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High-fidelity recordings of left ventricular (LV) pressure and its corresponding first derivative (dP/dt), electrocardiogram, and systemic arterial pressure were obtained intraoperatively following insertion of aortocoronary saphenous vein bypass grafts in eight men. During sequential 3-min periods, the bypass grafts were, in turn, open, occluded by vascular clamps, and opened by releasing the clamps.Peak dP/dt averaged 1342 mm Hg/sec before graft occlusion, fell to 1223 mm Hg/sec during occlusion, and rose following release of occlusion to 1373 mm Hg/sec. LV end-diastolic pressure (LVEDP) averaged 14.5 mm Hg before, 17.6 mm Hg during, and 16.1 mm Hg after graft occlusion. Arterial systolic and diastolic pressure and heart rate showed little change (P > 0.05) throughout the experiments. Left ventricular performance as gauged by peak dP/dt/LVEDP decreased an average of 25% (P < 0.001) during graft occlusion and returned to control levels following release of occlusion. Total vein graft blood flow, measured immediately before the occlusion experiments, averaged 164 ml/min. Good correlation was lacking between vein graft blood flow and performance changes during graft occlusion in individual patients.Aortocoronary vein bypass grafts are capable of participating directly in the mechanical events of the cardiac cycle. Acute graft occlusion can impair, while restoration of graft flow can improve, left ventricular performance.
Angina Pectoris in Men : Prognostic Significance of Selected Medical Factors
- CHARLES W. FRANK,
- EVE WEINBLATT and
- SAM SHAPIRO
Circulation Volume 47, Issue 31 March 1973

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Prognosis of men whose first manifestation of coronary heart disease was angina without antecedent infarction was found to resemble closely that of men followed after an initial MI. Overall mortality over a period of 4.5 years following a baseline examination was the same in the two cohorts: 17.5%.In both groups of men electrocardiographic abnormalities and blood pressure elevation identified subsets of coronary patients with a relatively poor prognosis, but the course of disease was apparently not influenced by the serum cholesterol level. Among the men with angina no relationship emerged between symptomatic status at time of baseline and risk of mortality in the ensuing observation period.The findings are from the HIP (Health Insurance Plan of Greater New York) study of the incidence and prognosis of coronary heart disease, a prospective study of a general population of 110,000 men and women aged 25-64 years.

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