Ticlid (Ticlopidine)
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HEART ATTACK AND RISK FACTORS: EXTERNAL STRESSES
Many heart-attack victims have done extensive overtime in the months before their illness, have lost a job or had a major argument with their spouses. Some research has indicated that repeated emigration is followed by an increased chance of coronary disease. Yet most of this work is tantalizing but inconclusive; there are problems of interpretation and inconsistencies between research results. At present we can only suspend judgment. So often when we have a major illness we are tempted to ascribe it with hindsight to a recent stress; but when such stresses (‘life changes’) were studied by Dr Theorell for their ability to enable us to predict heart attack, the results were entirely negative. The conclusions from ‘prospective’ research are more meaningful than those from the retrospective kind.
We have become accustomed to believe that the western urbanized way of life is highly stressful. Some years ago Professor W. M. Arnott of Birmingham made a valid comment about this:
‘ . . . the life of a physician in Birmingham is surely much less stressful than that of a peasant in the Yangtze valley with the ever-present menace of flood, famine, pestilence and war.’ It is hardly likely that the executives of Japanese industries and businesses are any less competitive, less dominated by the clock than their American and European counterparts: yet the Japanese, as we have noted before, are relatively immune from coronary disease.
John Hunter was a great surgeon and biologist, born just 250 years ago. He worked and died at St George’s Hospital, London, researching on a variety of subjects and sometimes acting as his own guinea-pig. He was well aware how important it was for the practicing doctor to understand the workings of the heart and circulation. In his later years he developed angina and recognized its association with stress. One day, anticipating a board-room confrontation at the hospital, he remarked that his life was at the mercy of anyone who provoked him. An argument took place the same day; he developed pain in his chest, collapsed into the arms of a colleague and died within minutes. Though coronary heart disease was not recognized in 1793, the post-mortem was quite compatible with this diagnosis.
This sequence of events is not rare. It does not mean that stress causes disease of the coronary arteries. But in people with already narrowed atherosclerotic coronary vessels, severe stress could well lead to a seriously abnormal heart rhythm. Thus, personality and stress are not unimportant; but the implication is that such influences are relatively harmless to the heart in the absence of major risk factors (such as high blood-cholesterol levels).
If responsibility and socio-economic status are graded by education and income (as Dr Paul Leren has done in Norway) it becomes clear why heart attack is not a ‘managers’ disease’. Leren studied men aged forty to forty-nine living in Oslo. The least privileged (Class V) had the highest score of risk factors; they included far more cigarette smokers than Class I, and far fewer who had given up smoking. Blood cholesterol and triglyceride levels were higher in Class V too. The reason for these trends is not certain; possibly better-educated individuals are more health-conscious in general and more aware of the evidence linking cigarette smoking and diet with disease.
Where there is a wider gap between privileged and underprivileged, as in Madrid and Naples, the class trend is reversed: Dr Keys has shown that the poor there have less coronary disease.
When purchasing power is so low, access to cigarettes, dairy products and meat may be curtailed. In England and Wales, shortly after the Second World War, heart-attack mortality was highest in managerial and professional classes (47 per cent above the national average in men in Class 1). This pattern has now been reversed.
Short-term severe stress can increase the blood-cholesterol level, but it is less certain that long-continued stresses do so. During the examination season, students’ cholesterol levels have been found to rise slightly, and this is true also of accountants during the onerous weeks around the end of the financial year. But it has not been ruled out that changes in diet or lack of exercise contribute to this temporary increase in cholesterol.
Finally, it is worth remembering that if some risk factors like smoking and high cholesterol levels can be changed, others, like advancing age, male sex and existing heart disease are immutable. The Type A personality was described by Dr Jenkins as a ‘deeply ingrained, enduring trait’; hence it seems to fit into the second category. Telling people to avoid stress can be a pretty vapid piece of advice, but there are a few simple guidelines.
*51/202/5*
