Download Community of 30,000

The Spectrum of Coronary Heart Disease in
Community of 30,000
a
A Clinicopathologic Study
By RALPH E. SPIEKERMAN, M.D., JOHN T. BRANDENBURG, M.D.,
RICHARD W. P. ACHOR, M.D., AND JESsE E. EDWARDS, M.D.
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N ACCURATE ESTIMATION of the
Li incidence of death from coronary heart
disease in the United States has not been accomplished in a completely satisfactory manner.1, 2 White3 and Mainland4 showed that it
is not possible to determine accurately the
incidence of coronary heart disease from consecutive hospital necropsy series, since this
incidence is a reflection of the hospital population, which in turn is a biased sample. Incidences based on death-certificate statisties
not confirmed by necropsy are also inadequate
for this purpose and are subject to obvious
limitations.
A unique opportunity to avoid these objections exists in Rochester, Minnesota, a community of 30,000 people that has its medical
care furnished largely by the Mayo Clinic.
Because of this relationship, necropsies are
performed in more than two thirds of all
deaths at all ages that occur in the community
regardless of when or where death took place.
Thus, deaths at home, sudden deaths in the
city, and deaths in nursing homes, as well as
hospital deaths and deaths that will invite the
interest of the coroner all have a better thani
65 per cent chance of being investigated at
series in determining the incidence and mode
of death from coronary heart disease.
Methods
A total of 1,326 deaths occurred among those
persons whose permanent address was listed within
the city of Rochester, Minnesota, and whose death
occurred between 1947 and 1952, inclusive. Table
1 categorizes the total deaths according to the age
at death, sex, place of death, and respective percentage of necropsies. It should be noted that the
total number of deaths in adult males and females
was nearly the samne, that the total number of
hospital and nonhospital deaths among adults in
the study were 563 and 463, respectively, and that
the total number of adult deaths was 1,026. The
over-all necropsy incidence was 73 per cent. The
incidence of necropsies in adults dying in the
hospital was 67 per cent, and that in nonhospitalized adults was nearly identical (68 per cent).
All permissions for necropsy were obtained on
an impartial basis by physicians who were assigned
to the Section of Pathologic Anatomv of the
Mayo Clinic and were previously unfamiliar with
the cases. All necropsies were performed by this
same section, which has preserved its records and
specimens. The majority of patients had been
observed clinically for variable periods prior to
death by staff physicians of the Mayo Clinic. Information concerning the others was obtained from
the family physician or the family at the time
of death. Information necessary for evaluation
of each case was obtained from the clinic or
hospital notes, necropsy protocols, and gross and
histologic re-examination of the hearts. At the time
of necropsy, the coronary arteries were examined
by the multiple cross-section technic at intervals
of approxinmately 3 nu., and the ventricles were
cut into five transverse slices. The myocardial
lesions were diagrammed on ventricular maps as
shown in figure 1, a technic similar to the method
described by Sheldon and Sayen.5
Definitions
Grade of Coronary-Artery Sclerosis
necropsy by one pathologic service. Such a
necropsy rate for all deaths in the entire community circumvents the inadequacies of deathcertificate statistics and the bias of selected
From the Mayo Clinic and the Mayo Foundation,
Rochester, Minnesota.
Supported in part by research grant no. H-4014,
National Heart Institute, U. S. Public Health Service.
Read in part at the meeting of the American Heart
Association in St. Louis, Missouri, October 23, 1960.
Abridgment of thesis submitted by Dr. Spiekerman
to the Faculty of the Graduate School of the University of Minnesota in partial fulfillment of the requirements for the degree of Master of Scienee in Medicine.
Circulation, Volume XXV, January 1962
Grade 1 sclerosis indicates the presence of
minimal atherosclerosis or normal arteries;
grade 2 sclerosis represents from 25 to 50 per
57
o-8
SPIEKERMAN ET AL.
Table 1
Rochester Deaths and Percentage of Necropsies: 1947-1952
Categories
Male
Stillbirths
34
Deaths through 19 years
13i
D)eaths 20 years or older
516
Total deaths
680
IHospital deaths 20 years or older 260
Noiihospital deaths
20 years or older
256
Total adult deaths
516
Deaths
Female
38
98
510
646
303
207
510
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cent uarrowing of the arterial lumen; grade
3 sclerosis represents fronm 51 to 99 per cenlt
narrowing; grade 4 sclerosis represents complete ocelusion of the arterial lumren by atherosclerosis.
Acute Myocardial Infarct
This is a zone of myocardial necrosis that
measures more than 2 cm. in at least one dimension and that by gross and histologic
appearance is less than 4 weeks of age.
Healed Myocardial Infarct
This is a confluent zone of fibrous tissue in
the myocardiumn that measures more than 2
cm. in at least one dinmensioni; the gross and
histologic appearance must be such as to indicate that the underlying acute myocardial
infaret occurred at least 4 weeks previouslv.
The criteria outlined by Mallory and associates6 were used in estimating the age of the
myocardial infarets.
Fibrosis and Small Scars
Hearts having grosslv visible scars not more
than 2 cm. in their greatest dimension were
classified as showing fibrosis.
Acute Coronary Failure (Sudden Death)
This group represenits those patients with
coronary-arterv disease who died suddenly in
the absence of myocardial rupture or pulmonary eiubolization, with death apparently resulting from ventricular fibrillation or asystole.
Results
Degree of Coronary Sclerosis
The degree of coronary-artery sclerosis and
the number of deaths caused therefrom are
Total
Male
72
228
1026
1326
563
33
119
463
1026
373
525
Necropsies
Female
Total
7C
94.4
90.4
67.3
72.8
35
68
87
318
206
691
965
377
66.9
314
691
67.8
67.3
186
440
191
187
373
318
127
sumnnmarized in table 2. This information is
based on the 691 necropsies on persons 20
years of age or older, or "adult cases. " Coronarv sclerosis grade 1 or less was present in
178 (26 per cent) of these 691 adults, anid
eoronary sclerosis grade 2 to 4 was present in
513 (74 per cent).
Cause of Death
As deternminled by the clinlical records anid
necropsv findings, 221 of these 691 adult patients died of coronarv- disease and 470 died
of noneoronarv causes. Ineluded in the latter
group were 292 who had coronary sclerosis
grade 2 to 4. At necropsy it was found that
40 per cent of the men and 22 per cent of the
women died of coronary heart disease, giving
an over-all incidence of 32 per cent; the incidence based on the 965 necropsies comprising all ages was 29 per cent for males and 16
per cent of females. The mnale :femnale ratio
for the incidence of fatal coronary heart disease was 2.2:1 for the adults and 1.8:1 based
oni the entire group.
Age at Death
The deaths from coronary heart disease in
each decade of life are shown in figure 2. Tbe
peak incidence of death in men occurred 1
decade (60 to 69 years) earlier than that in
women (70 to 79 years). When these data are
compared to the 292 noncoronary deaths in
adults with coronary sclerosis grade 2 to 4
(fig. 3), one sees that death from coronarYartery disease shortened the life of the meni
by 1 decade but had no such effect on the
women. The mortality curves for the two
groups of men are similar in contour, but the
Circulation, Vclunme XXV, January 1962
CORONARY HEART DISEASE
59
Table 2
Coronary Sclerosis in 691 Adults:' 1947-1952
Coronary
sclerosis,
grade
1
2-4
Sex
MAen
Women
Men
Women
Total
Patients
No.
%
Type of deaths
Coronary
Noneoronary
No.
No.
%
%
75
103
298
215
691
0
0
151
70
221
11
15
43
31
100
0
0
68
32
100
75
103
147
145
470
16
22
31
31
100
*All persoins 20 years of age or more studied at necro
Table 3
Mode of Death in 221 Patients Dying of Coronary Heart Disease
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Per cent of:
Adult
Mode of death
Patients
Coronary
deaths (221)
necropsies
(691)
Men (373)
or
women (318)
Acute coronary failure*
94
43
14
Men
73
19
Women
21
7
Acute myocardial infaretion
87
13
39
Men
55
15
Women
32
10
Congestive heart failure*
32)
14
4
Men
19
5
Women
13
4
Thromboembolism *
8
4
Men
4
1
4
Women
1
Total coronary deaths
221
32
100
*These three categories include only those patients who died of these mechanisms, which
were not complications of or associated with acute myocardial infaretion.
eurve of coronary deaths is shifted to the left
(younger age area) by 1 decade (fig. 4).
Death among persons less than 30 years of
age is not often attributable to coronary heart
disease; therefore the causes of death for patients who were 30 years of age or older were
analyzed. From the total sample of 513 patients who died and at necropsy showed coronary arteriosclerosis of grade 2 to grade 4,
170 patients were 30 to 64 years of a.ge at
death and 343 were 65 years or older. A
comparison of the two age groups shows that
92 (54 per cent) of those 30 to 64 years of
age and 129 (38 per cent) of those 65 or more
years of age died of coronary heart disease.
In the younger group, 80 of the 92 patients
who died of coronary heart disease were meni
(63 per cent of all men 30 to 64 years of age
who died). In the group of patients 65 or
more years of age having arteriosclerosis of
Circulation, Volume XXV, January 1962
grade 2 to 4, 41 per cent of the men and 34
per cent of the women died of coronary hearT
disease. Only 12 women less than 65 years oi1
age died of coronary heart disease: oile ka
diabetic) was 34 years of age, one was 4b
years of age, five were in the sixth decauc,
and five in the seventh decade.
Type of Death in Patients Dying from Coronary
Disease
The mechanism of death in the 221 patients
who died of coronary heart disease in this
study was divided into four main types (table
3). Acute coronary failure accounted for the
greatest incidence of deaths, being the mode
of death in 94 patients (43 per cent). The
second commonest type of death was acute
myocardial infaretion, which was present in
87 patients, or 39 per cent of the coronary
deaths. A total of 32 patients (14 per cent)
died of congestive heart failure, and eight
60
SPIEKERMAN ET AL.
Slice 4.
50
45
i 40
35
30
~~~Mate
Femole//
~15
X(
4 5
0
v
-20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99
Age at deoth
Figure 2
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Figure 1
Myocardial "map" used to locate zone of myocardial infarction. (Reproduced with the kind
permission of the publishers from Achor, R. 'W. P.,
Futch, TV. D., Burchell, H. B., aind Edwards, J. E.:
Arch. Int. Med. 98: 162, 1956.)
patients (4 per cent) died of thromboembolism.
Cause of Death in Patients with Acute Myocardial
Infarction
An analysis of the 87 patients who died
during acute myocardial infaretion is presented in table 4. The main cause of death was
congestive heart failure in 30 per cent of these
patients, myocardial rupture in 24 per cent,
acute coronary failure or sudden death in 23
per ceint and thromboembolismn in 14 per cent.
Eight patients had severe systemic illnesses
in addition to the acute myocardial infaretion, which made it difficult to decide whether
the patient would have died had the myocardial infaretion not been complicated by the
associated systemic disease. The 21 cases of
myocardial rupture included three in which
the rupture was of the ventricular septum:
rather than of the free myocardial wall.
Cause of Death in Patients with Healed Myocardial
Infarction
An analysis of the 152 patients with healed
myocardial infaretion found at necropsy is
presented in table 5. Of this group, 37 (24
per cent) died from noncoronary disease and
115 (76 per cent) died from coronary disease.
The three leading causes of death in the 37
Deaths from coronary heart disease for each
decade of life.
patients with healed infaretion who died of
other than coronary causes were cancer in 24
per cent, cerebrovascular disease in 19 per
cent, and pulmonary emboli in 16 per cent.
Among the 115 patients dying of coronary
heart disease, acute coronary failure accounted for 48 deaths (42 per cent), whereas 38
persons (33 per cent) had acute myocardial
infarction and then died, 18 per cent died
of congestive heart failure, and 7 per cent died
of thromboembolism.
Cause of Death in Patients with Myocardial
Fibrosis
There were 144 patients who died whose
hearts at necropsy revealed only small patchv
zones of myocardial fibrosis. In this group, 43
deaths (30 per cent) were attributed to coronary disease, with 32 patients dying of acute
coronary failure and 11 of congestive hearifailure.
Aspects of Acute Coronary Failure
Of the 114 persons who died suddenly
(acute coronary failure), 12 per cent had a
normal myocardium, 42 per cent had healed
infarets, 9 per cent had acute infarction alone,
9 per cent had both healed and acute infarets,
and 28 per cent had fibrosis of scars nmeasuring not more than 2 cm. Coronary-artery disease was sufficient to produLce either gross
myocardial scarring or sudden death from
acute coronary failure (without apparent
niyocardial necrosis) in 37 per cent of the
entire 965 niecropsies, or 52 per cent of the
Circulation, Volume XXV, January 1962
61
CORONARY HEART DISEASE
55
50-
~454043520-'9 30-73 4
05
3L
3OMole
25
of2Q
life
20
patzents with
Ferornary-czrt
sclerosisale
10
5
20'9 30-3) 43-49 50-59 60-1-3 70-7
U
LJ
-0 9q
Aqe at 1-,I
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Figure 3
Deaths from noncoronary diseases for each decade
of life in patients with coronary-artery sclerosis
grade 2 to 4.
691 adults. In other words, more than half
of all the adults studied at necropsy in Rochester, Minnesota, had some evidence of heart
disease produced by sclerosis of the coronary
arteries. Analysis of the place at which death
occurred in the 114 patients who died of acute
coronary failure shows that 77 (67 per cent)
died at home (65 after light to moderate aetivity and 12 during rest or sleep), 18 (16 per
cenit) died in the hospital, 10 (9 per cent)
died in a public place or street, and nine (8
per cent) died while at work.
Comparison of Patients Dying from Coronary and
Noncoronary Causes
Some clinicopathologic associations are summarized in table 6 between the 221 patients
who died of coronary heart disease and the
292 patients with coronary-artery sclerosis
who died of other diseases. Notable is the low
incidence of angina pectoris in both groups
and the relatively high incidence of intracardiac mural thrombi in the 221 patients dying
of coronary heart disease. Thirty-two per cent
of the patients dying of coronary heart disease had at least one new coronarv-artery
thrombus, 33 per cent had at least one old
coronary-artery thrombus, 18 per cent had at
least one complete coronary-artery occlusion
from sclerosis, 1 per cent had evidence of coronary embolization, and 5 per cent had at
least one coronary-artery occlusion caused by
hemorrhage into an atheromatous plaque.
Circulation, Volume XXV, January 1962
20-29 30-33 40-49 50-59 60-69 70-79 80-89 90-99
Age at cdeath
Figure 4
Incidence of death of men who died of coronary
heart disease compared to men who died of other
causes. All patients in both groups had coronaryartery sclerosis grade 2 to 4.
Discussion
The purpose of this study was to determine
the incidence of death from coronary heart
disease based on necropsy studies comprising
an adequate sample of all deaths in an entire
community. This would preclude bias founid
in the selected and consecutive necropsy series that reflect hospital populations. A hospital population differs greatly from a community population with respect to coronary
heart disease because of the large percentage
of patients with coronary heart disease who
die in locations other than hospitals. In this
study, 84 per cent of the 114 acute coronary
deaths and 48 per cent of all the coronarv
deaths occurred in locations other than the
hospital. The necropsies in this study represented 73 per cent of all deaths in the community of Rochester whether they occurred
in the hospital or elsewhere. Therefore, it is
considered to inelude a representative sample
of the population. Based on consecutive
necropsy series, estimates in the literature for
the frequency of healed and new myocardial
infarets have ranged from a low of 3.9 per
cent to a high of 13.3 per cent.7 '6 In this
study, 21 per cent of the 965 hearts demonstrated acute or healed infaretion, another 15
per cent had scars not more than 2 cm. in
diameter or patchy fibrosis, and 1.5 per cent
of the patients died of acute coronary failure
prior to the development of gross myocardial
lesions. The 221 deaths from coronarv heart
SPIEKERMAN ET ALI.
62
Table 4
Cause of Decath in 87 Patients Dying During Acute Myocardial Infarction
Men
Cause of death
(Congestive heart f-iluhi e
Rapid death
Slow death
Rupture of myocardium
Acute coronary failure
Thromboembolisni
With congestive failure
WVithout congestive failure
Sy-steaiiic complications
Pineumonia
Tinfectedi braini infarets
Pyelonephritis
No.
Women
%
07
15
No.
11
10
Total
C/o
34.5
ko~No.
26
30
34.5
6.0
229.0
21
20
12
24
23
14
3.0
8
9
9
10
9
10*
18
18
33
9
ill
1
4
4
13)
1+
i
1
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Duodenal-uleer hemorrhage
1
Carciniomla of lung
1
Ruptured aortic aneurysm
1
a
Totals
32
87
5:)
100
100
100
*IlLeludes onie case of interveatricular septal rupture rather than free perforation into the
pericardium.
tIncludes two cases of initervenitricular septal rupture.
ADuodenal-ulcer hemorrhage.
disease in this study represented 24 per cenit
of all the necropsies; perhaps more meaningful than this would be the 32 per cent incidence of such disease for all persons 20 years
of age or older examined at necropsy. Coronary heart disease was the cause of death in
151 (41 per cent) of the 373 adult males and
70 (22 per cent ) of the 318 adult females.
Both of these figures are considerably higher
than estimates previouisIv presented in the
literature.
The data concerning death from coronary
heart disease in previous clinical studies have
shown variable ratios up to nine males for
every female dying of this disease. The ratios
in this study agree with previously reported
low ratios. For the entire series, the male fenale ratio was 1.8 :1, and the ratio was 2.2 :1
for the adult series. With regard to the average age of death from coronary heart disease,
this study agrees with the majority of prev-ious reports, which indicate that this average
is in the seventh decade of life for men and
itl the eighth decade for women.
Master and associates'6 did not find aniy
correlation between physical activity and
death from coronary-artery disease. Although
a particular stress may precipitate a fatal
heart attack, it appears from our study that
stress is not significantly important
in causing death.
In the 691 necropsies on adults, 513 hearts
(74 per cent) showed lnarrowing of at least
one segment of a coronary-artery lumen bv
25 per cent or more of its diamneter, and 47
per cent of the hearts had more than half of
the coronary lumen compromised by sclerosis
in at least one area. Two thirds of these patienits with more than 50 per cent narrowing
of the coronarv artery died as a result of this
disease.
The leading mode of death from coronary
lheart disease in this study was acute coronary
failure, or sudden death. Slightly more than
half of all deaths from coronary disease in
this series occurred in this manner. Sudden
death from coronary heart disease was much
more common in men than in women. In this
study, approximately half of all men dying
from coronary-artery disease died of acute
coronary failure and another 25 per cent died
of congestive heart failure; the deaths in the
remaining quarter were evenly divided between thromboembolic disease and myocardial
rupture. The women who died of coronary
heart disease could be divided into three equal
groups with regard to the mode of death;
one third died of congestive heart failure and
phlysieal
Circulation, Volume XXV, January 196-2
63
CORONARY HEART DISEASE63
Table 5
Cause of Death in 152 Patients with Healed Myocardial Infarets More Than 2 Cm. in Diameter
Men
Cause of death
Group
Cancer
Cerebrovascular disease
Healed infarctsnoncoronary deaths- Pulmonary emboli
Pneumonia
37 cases
Miscellaneous
Ruptured aortic aneurysm
Thromboemboli*
Congestive failure*
Total
Acute coronary failure
(sudden death)
Acute myocardial infaretion
ealed infaretsdeaths
11 5 cases
Hi
co ronary
%
5
2
3
5
4
1
0
0
20
25
10
15
25
20
5
0
0
100
36
223
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And then heart failure
Acute coronary failure
10
Fatal throinboemilbolisni
Rupture of myocardium
Congestive heart failure
Thromboembolism
With heart failure
Total
2
2
%
No.
%
4
5
3
0
0
2
2
1
17
23
29
18
0
0
12
12
6
100
9
7
6
5
4
3
1
37
24
19
16
14
11
8
5
3
100
47
12
32
48
42
30
15
40
38
33
10
21
8
18
7
100
115
100
No.
4
18
5
7
4
100
38
3
777
2
7
2
3
3
9
I14
Total
Women
No.
18
3
*Unrelated to the coincidental myocardial infarction.
one third of acute coronary failure; the deaths
in the remaining third were equally divided
between acute myocardial rupture and thromboembolic disease. Patients in this study who
died in acute cardiovascular collapse or shock
were placed in the category of congestive
heart failure, because all of them showed
pulmonary edema and other evidences of congestive heart failure at necropsy. Rupture of
the interventricular septum occurred in three
patients, accounting for 1.4 per cent of the
221 deaths from coronary disease.
Angina pectoris
was
diagnosed during life
one third of the patients who died of coronary disease but in only 7 per cent of those
who died of noncoronary diseases. The sex of
in
the patient did not influence the frequency of
angina pectoris. Two important aspects relative to angina pectoris are apparent: (1) only
a minority of patients with severe coronaryartery disease may manifest the classic symptoms of this disease and (2) angina pectoris
means extensive coronary-artery disease with
at least one complete occlusion likely and
means death from coronary heart disease in
the majority of patients. White and Bland'7
found that 82 per cent of 213 patients with
angina pectoris died a cardiac death and that
Circulation, Volume
XXV,
January 1962
the average duration of life after the onset of
angina was 4.9 years. Block and co-workers,18
in a study of 6,882 cases of angina pectoris,
found an average survival of 4.6 years after
the onset of the angina. The 10-year survival
in their series was 37 per cent; 15 per cent
had died by the end of the first year, and half
of the patients lived 5 years. In the present
Rochester study, 77 per cent of the patients
with angina pectoris died of coronary heart
disease.
A thrombus was found in one of the four
cardiac chambers in 28 per cent of our patients dying of coronary heart disease; this
figure agrees with the range reported in the
literature of 22 to 47 per cent.19' 20 However,
our series differed from others because it included hearts without myocardial damage or
with only minimal lesions. Ventricular aneurysms were present in 7 per cent of the patients dying of coronary disease as compared
to a range of 3 to 20 per cent in other reports.
Again the incidence is less in our study because hearts with little or no myocardial damage were included. The commonest mode of
death in the 15 patients with a myocardia]
aneurysm was, as might be expected, congestive heart failure. Only a third of these pa-
64
SPIEKERMAN ET AL.
Table 6
Associated Clinicopathologic Conditions in 221 Coronary Deaths and 292 Noncoronary
Deaths
Coronary
deaths
(221)
Clinicopathologic findings
deaths
(292)
No.
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Angina pectoris
Hypertension
Diabetes
Ventricular aneurysm
Mural thrombi
Left ventricle
Right ventricle
Left atrial appendage
Right atrial appendage
Coronary occlusion
New thrombus
Old thrombus
Grade 4 sclerosis
Coronary emboli
Hemorrhage into plaque
Pulmonary emboli
Rheumatic valvular disease
Calcific aortic stenosis
tients had hypertension, and only
Noncoronary
71
110
20
No.
32
50
9
2
15
44
2
5
11
197
3
1
2
1
1
9
9
3
3
32
33
18
1
5
11
heart
coronary heart disease.
Summary
The high rate of necropsy in deaths among
permanent residents of Rochester, Minnesota,
5
2
5
11
1
23
2
40
2
one
17
20
89
tontained an aneurysm of the posterior wall.
Aneurysms of the ventricular wall almost
never rupture, as has been noted in all series
reported.2'
Pulmonary embolization was present in 11
(5 per cent) of the patients with fatal coronary heart disease. Other authors have indicated that pulmonary emboli complicate 3 to
20 per cent of myocardial infarets. Rheumatic
valvulitis is said to be seen uncommonly in
conjunction with coronary heart disease but
the cliniician must be aware of their occasional
association; it is difficult to make this diagnosis, especially in the elderly patient. Two
per cent of our patients dying of coronary
heart disease had rheumatic valvulitis; in
addition, 12 (5 per cent) of the 221 patients
dying of coronary disease had calcific aortic
stenosis. Gardner and White22 stated that 6
per cent of 513 patients with coronary disease
had rheumatic valvulitis and that 7 per cent
of 436 patients with rheumatic valvulitis had
137
30
5
71
73
11
4
12
7
3
28
62
%
20
28
3
I
15
5
2
0.3
6
1
3
49
11
9
1
17
4
3
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
infaretion 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 infaretion died of congestive
heart failure (30 per cent), myocardial rupture (24 per centt), acute coronary failure (23
per cent), andl thromboembolism (14 per
cent), with the remaining 9 per cent dying
Circulation, Volume XXV, January 1962
CORONARY HEART DISEASE
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of a combination of acute myocardial infaretion 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.
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The Spectrum of Coronary Heart Disease in a Community of 30,000: A
Clinicopathologic Study
RALPH E. SPIEKERMAN, JOHN T. BRANDENBURG, RICHARD W. P. ACHOR
and JESSE E. EDWARDS
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Circulation. 1962;25:57-65
doi: 10.1161/01.CIR.25.1.57
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