MANAGEMENT OF PATIENTS WITH CORONARY DISEASE

GENERAL MANAGEMENT OF PATIENTS WITH CORONARY DISEASE
The treatment of actual attacks of pain should be looked upon as a minor part of the management of coronary disease. Reduction in the number of attacks is of far greater importance, and a great deal can be done to achieve this end. Much more will be accomplished by regulation of the mode of life at work and at play, of habits regarding meals and the use of alcohol and tobacco, and by advice on other mundane matters than by the administration of drugs. Today, attempts are being made to modify the progress of the atherosclerotic process by measures to lower the blood cholesterol level and to prevent recurrent infarction with long-term anticoagulant therapy. It is a travesty of our therapeutic knowledge to make a diagnosis of effort angina and to send the patient away merely with a supply of nitroglycerin and instructions to chew a tablet when the pain is felt.
A large proportion of patients are of the overweight, thick-set type, and in these reduction in weight is probably the most potent therapeutic measure. The loss of one or two stones of superfluous weight greatly eases the burden imposed on the heart, and frequently results in a striking improvement in the exercise tolerance without the use of drugs. The sufferer from angina should be encouraged to attain a weight slightly under the average for height, age and sex. This can be achieved by simple dietetic restrictions, provided the co¬operation of the patient is secured. A further dietetic point hinges on the well-known tendency of attacks to occur when exercise is taken soon after a meal. Reavy meals are certainly to be avoided, and a rest or short sleep after. lunch or dinner may greatly reduce the frequency of attacks.
The family physician, from his knowledge of the patient's habits and mode of life, is best qualified to instruct him as to what to do and what to avoid in his daily routine. A large proportion of cases occurs in the active type of business man around fifty years of age, and in such careful consideration of habits and circumstances will reveal the steps to be taken to reduce the demands on the circulation. In all subjects of angina, and probably in all men over 50, sudden strenuous unaccustomed exertion is dangerous. The writer has repeatedly seen cases in which such activity (e.g. cranking a car, shovelling snow, hurrying with a suitcase for a train) has immediately preceded the onset of myocardial infarction. The avoidance of business worries, relegation of as much work as possible to juniors, the giving up of committee work involving strain, etc., all require con¬sideration. Physical effort can be reduced considerably by taking thought— securing office or bedroom on the ground floor where there is no lift; going late to the office and leaving early, and thereby avoiding the rush hours of com¬muting ; cutting down the week-end golf from two strenous days to a pleasant easygoing round, and so on. In men employed in heavy manual labour, or in vocations demanding physical effort (postmen, rent collectors, shopkeepers, etc.), it may be difficult to reduce exertion at work without jeopardizing their liveli¬hood. In certain cases it may be necessary to advise a change of occupation or to recommend retiral. Each patient demands individual assessment, and sound judgment in weighing the risk involved by continued work against the financial worry and hardship that follow invalidism. Certain occupations should never be permitted to the subjects of angina, because of the risk not only to themselves but to others—e.g. drivers of locomotives, buses, etc.; and the fitness of any patient to drive his car must be determined, and periodically reviewed.
Whatever other measures are taken to spare the heart, it is always possible to arrange that the patient can have at least eight hours' sleep each night; and he can spend Saturday afternoon and Sunday in bed if required. At the outset of treatment in severe cases considerable improvement follows an initial period of two to three weeks' rest in bed. The relief may persist after return to activity, and the increased cardiac reserve is shown by increased exercise tolerance. Periodic spells of rest in bed are of value to many patients who otherwise have difficulty in securing enough rest.
The use of nitroglycerin to relieve angina of effort has been dealt with above. This drug can also be effectively used in anticipation of exertion which would ordinarily cause pain : a few minutes before the extra effort is called for the patient may chew one or two tablets of the B.P. preparation. Attacks produced regularly by climbing a flight of stairs may thus be prevented, or the strain of an important business meeting undertaken without discomfort. Many tablets can be taken daily over long periods without untoward results. For example, in patients with angina decubitus attacked by pain on turning in bed, sitting up for a meal, or straining at stool, anything from ten to twenty tablets may be necessary to keep the patient free from pain throughout the day. This is important and is insufficiently appreciated, since it is common to find patients on a doctor's advice attempting to cut their daily consumption of nitroglycerin to a minimum. The ambulant patient, using vasodilators to prevent attacks, must be warned that they are intended to allow him to pursue his essential daily business at a slower pace and are not to be taken with the object of allowing him to return to a more .strenuous mode of life.
A combination of theophylline and ethylene diamine (aminophylline, B.P.) is efficient as a coronary vasodilator when injected intravenously, but has little place in the treatment of angina of effort. Oral medication is of limited value because adequate doses result in nausea and vomiting. The combination of 0-2 g. of aminophylline with 0-25 g. of aluminium hydroxide gel permits higher dosage with less gastric upset. In patients in whom spasm of coronary arteries is suspected as the cause of pain coming on at rest or at night, papaverine (0-2 g.) as a pill is sometimes effective.

Reduction of Blood Cholesterol.—During the last 20 years increasing attention has been paid to the correlation between the incidence of coronary artery disease and high blood cholesterol levels. There are a number of pointers with a bearing on this problem, e.g. the frequency of coronary disease among the well nourished western nations and its rarity among the underprivileged nations of the East and tropics. The average blood cholesterol levels in individuals of different races show a parallelism to the incidence of coronary disease, being at their highest in the western world and at their lowest among the Bantu of South Africa. Further, diseases known to be associated with a high blood cholesterol level such as diabetes mellitus and myxcedema, have a known high tendency to myocardial infarction. There is evidence also that the blood lipo-protein pattern has some bearing on susceptibility to coronary disease, and the sex differences in the alpha and beta lipo-protein proportions are to some extent paralleled by the relative susceptibility of the sexes to myocardial infarc¬tion and angina. It is thus understandable that efforts have been made to reduce the blood cholesterol in order to diminish the incidence of myocardial infarction. Whether such attempts are misguided or justified is a matter which the writer believes is not yet fully determined. It is well, however, to review the methods in use so that the physician is familiar with them.
Diet.—Reduction of the cholesterol intake in the diet, by avoiding foods rich in this substance, is of only transient value in depressing the blood cholesterol level. On a cholesterol-free diet the level falls initially over a period of weeks but soon starts to climb and reaches its pre-treatment height despite continued consumption of the strict diet; endogenous cholesterol synthesis is responsible. On the other hand, diets which are rich in unsaturated fatty acids produce ~-significant and sustained fall in blood cholesterol level and this despite the continued ingestion of substantial quantities of saturated fats. Such unsaturated fatty acids are generally of vegetable origin and occur in quantity in maize (corn) oil, safflower and sunflower seed oil and many other products; they occur also in sardine and pilchard oil as well as in the familiar olive oil. The more active unsaturated fatty acids contain two or more double bonds, for example linoleic acid, linolenic acid and arachidonic acid. By taking about 50 g. of such an oil daily the blood cholesterol level may be reduced. Commercial preparations are widely available, incorporating such oils in margarines, cheese preparations, and salad and cooking oils, so that the requisite quantity may readily be incorporated in the diet without drastic alteration in its palatability or nature.
Nicotinic Acid.—Nicotinic acid is a vasodilator producing flushing of the skin after ingestion of moderate doses. It has been shown that large doses (300 mg. thrice daily) may produce a sustained fall in the blood cholesterol level. Such doses initially cause side-effects of flushing and palpitation, but these tend to subside with continued administration. It is noteworthy that nicotinamide is devoid of this cholesterol-lowering action.
Hormones.—The sex difference in the lipo-protein pattern stimulated the inquiry as to whether the sex hormones could produce a change in males toward the feminine a//? ratio with the object of retarding the progress of coronary disease. Given to a man, the female sex hormones produce side-effects such as gynascomastia and impotence which are distressing and of such degree that few persist with this treatment. To date no preparation is available which will alter the lipo-protein pattern without at the same time producing such side-effects as render its continued administration impossible. Similarly thyroxine and other hormones, e.g. tri-iodo-thyroacetic acid, known to alter the ratio, have side-effects on the heart and circulation which militate against their use, and there is no analogue of thvroxine available which does not in time produce undesired cardiac effects. A more promising recent introduction is chlofibrate (ethyl-a-p-chlorophenoxy-isobutyrate), which has a cholesterol-lowering action without serious side-effects. It does, however, potentiate anticoagulant drugs.
Cholesterol Synthesis Inhibitors.—Since the blood cholesterol level is mainly determined by endogenous synthesis, substances have been used to block the metabolic process which builds cholesterol at some point in the chain. One such substance, for a time widely used, has been withdrawn in view of side-effects in long term use.
In summary, the author is of the opinion that the evidence is insufficient that the rate of progress of coronary disease can be stayed by drastic intervention in the dietetic habits of individuals or by the ingestion of drugs to lower the blood cholesterol level. Obesity and over-eating are on general grounds detrimental to the subjects of coronary disease, and such dietetic measures as are required to achieve weight-reduction are eminently justifiable. It is probably sound practice to attempt to reduce the cholesterol concentration in those patients having very high blood levels, and the author confines the tentative use of the methods described above to them.
Long-Term Anticoagulant Therapy.—Attempts have been made to reduce the incidence of recurrence of myocardial infarction among those who have survived an attack by prolonged administration of anticoagulant drugs. Several large and carefully controlled series have been reported including one in this country by the Medical Research Council. Such is the variability of the course of the disease in different individuals that evaluation of such treatment is as difficult as of the value of the drugs in acute infarction, but there is some evidence that among men of the younger age-group, under 65 years old, a fair reduction in relapse rate and mortality over the first year at least is achieved. In older men and in women the benefits are problematical. It has been the — author's practice for some years to offer such protection as long-term anticoagu-lant treatment affords to men with a history of infarction in the age-group under fifty and to some patients who have suffered a recurrence of infarction within a few months of the original attack.
Phenindione is a suitable drug, the daily dose varying from 50 to 150 mg.,
adjusted in the light of the blood prothrombin level as determined by the Quick or Thrombotest methods. It is enough to aim at prolongation of the prothrom¬bin time to twice the control figure. Once stabilization on the drug has been achieved blood tests may be necessary only at intervals of 14 to 28 days.