BMJ No 7080 This week in BMJ

BMJ No 7080 Volume 314

This week in BMJ Saturday 22 February 1997

Social class affects coronary event rates and chance of treatment for heart attack: Event registers can give a more complete picture of myocardial infarction and deaths from coronary heart disease than studies that look only at those reaching hospital or entering a coronary care unit. In Glasgow Morrison et al examined 5542 consecutive coronary events occurring between 1985 and 1991 (p 541). They found that 68% of the people who died did so before reaching hospital and that only 66% of patients reached hospital alive, the overall case fatality being 50%. Event rates and case fatality increased with age. Social class affected event rates, chance of admission, and overall case fatality but not case fatality in hospital, which was around 20%. Social class differences in mortality would be better tackled by primary prevention to reduce event rates and secondary prevention to prevent recurrence, rather than expensive hospital treatments.

Socioeconomic position over lifetime affects mortality: The Department of Health's report Variations in Health recognises that differential lifetime exposure to health damaging or health promoting physical and social environments is the main determinant of socioeconomic inequalities in health. As yet, however, few data exist to support this contention. On p 547 Davey Smith et al report on a large morbidity and mortality study which shows that a cumulative lifetime socioeconomic indicator is strongly associated with health outcomes. The contribution of factors acting at various stages of life seem to have different importance, depending on the disease outcome of interest. Thus early life circumstances are particularly relevant to mortality from cardiovascular disease. Studies with data on socioeconomic position at only one stage of life are inadequate for fully elucidating the contribution of socioeconomic factors to health.

High job demands and stress worsen atherosclerosis in men: Susceptibility to disease varies widely and is influenced by biological factors, personality, behaviour, and the environment. On p 553 Everson et al report that employed middle aged men who showed exaggerated blood pressure responses to stress and who also reported high job demands experienced significantly greater increases in atherosclerosis of their carotid arteries over four years than men who were less reactive or who had fewer job demands. Known risk factors such as smoking and high cholesterol concentration did not account for these findings.

Low job control increases risk of heart disease: On p 558 Bosma et al also report the association between adverse psychosocial work characteristics and coronary heart disease in the Whitehall II study, a longitudinal study of British civil servants. They found that low job control among both men and women was related to increased risks of future coronary heart disease. Hence, giving employees more variety in tasks and a stronger say in work related decisions probably decreases the risk of coronary heart disease.

Gastric ulcers are less likely to recur after eradication of H pylori: Helicobacter pylori is responsible for the development of most duodenal ulcers and its eradication prevents recurrence. The association of gastric ulcer and H pylori is, however, less well established. On p 565 Axon et al report a multicentre study from Britain and Ireland that unequivocally confirms that eradication of H pylori changes the natural history of gastric ulcer and reduces ulcer recurrence. The authors do, however, caution that vigilance should be maintained to detect potentially curable cancers in patients with gastric ulcer.

Costs of community thrombolysis are modest compared with other interventions: The Grampian early anistreplase trial showed that early thrombolytic therapy given by general practitioners in the community reduced mortality compared with hospital thrombolysis by 11% at one year and 15% at 2.5 years. On p 570 Vale et al used data from this trial to perform an economic evaluation to establish the extra cost per life saved of community thrombolysis. In Grampian, where general practitioners already attend suspected cases of myocardial infarction, the extra cost per life saved was £425. The authors consider this modest compared with the cost effectiveness of other life saving treatments, such as switching from using streptokinase in hospital to alteplase.

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