Heart attack issue

BMJ 1998; 316 doi: (Published 04 April 1998) Cite this as: BMJ 1998;316:0

“People going ‘aahh’ and dying.” That was the preconception of a heart attack of a patient who delayed before seeking help for one that was much less dramatic. In a qualitative study of what patients do when they have a heart attack (p 1060) another delayed by trying some treatment at home: “I've got this indigestion and of course my missus says; ‘Well take some of your Zantac.’ So I did like, you know, but it made no difference and they [mother in law and wife] said: ‘Try some lemonade.’ Then her mum gave me some mints. I tried everything.” The study identified the features associated with calling medical help rapidly or delaying, and the most crucial difference was recognising that the symptoms were cardiac in origin.

This is a heart attack issue of the BMJ, and the qualitative study fits with an epidemiological study showing that three quarters of those who die of an acute coronary event die before reaching hospital (p 1065). This has been the case for 25 years. Tom Evans concludes that to reduce deaths outside hospital we need better secondary prevention, increased public awareness of the symptoms of a heart attack, and improved activation and response times by the ambulance service (p 1031).

We also need better primary prevention, and an analysis from Poland may help (p 1047). Deaths from ischaemic heart disease climbed steadily from 1960 to 1991 but then fell dramatically—faster than has ever been recorded elsewhere in peacetime. Why might this be? Witold Zatonski and others are confident that the fall is not an artefact. Nor is it changes in smoking, drinking, stress, or medical care. Their best bet is dietary change, particularly increased supplies of fresh fruit and vegetables. The authors may of course be wrong.

Meanwhile, a Danish group has found that smoking is more likely in women than men to increase the risk of myocardial infarction, even after adjusting for all other risk factors (p 1043). The authors speculate that women's greater risk may result from “an interaction of some hormonal factors with components of the inhaled smoke.” Feminists may suspect another male plot, but I think they'll find the data convincing.

But it's not all heart attacks in this issue. Philip Robson joins the growing medical chorus calling for further investigation of the medical uses of cannabis (p 1034). A personal view in which a doctor described how she felt guilty after she was unable to breast feed exclusively produced a large response, and respondents say that with enough support women can almost always breast feed (p 1093). Finally, R G Choa, a urologist, took all day to type a 400 word letter in which he describes how colleagues responded to his increasingly obvious illness that was eventually diagnosed as Parkinson's disease when he was 38 (p 1089): “Not a single person came to ask me whether I had a problem.”

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