Metamorphosis: The natural history of coronary heart disease. Sudden death is common. Unexpected death is not

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Abstract

It is a common practice to perform percutaneous or open coronary artery revascularisation in CHD to prevent sudden or unexpected death. Such a practice assumes that sudden and unexpected death is common in stable patients with uncomplicated CHD. This is a retrospective analysis of 248 patients (199, 80% men, 49, 20% women) who had median age 65.1 when assessed after stabilisation of their CHD and were followed up to 25 years until their death. Myocardial revascularisation was only performed after the patients had stabilised if they developed either progressive clinical disability or acute coronary syndromes. At stabilisation, 181 (73%) were uncomplicated, 59 (24%) had heart failure (HF) and 8 (3%) had other comorbidities. At their last visit before death, 67 (27%) were uncomplicated, 121 (49%) had HF, 41 (17%) had cancer and 19 (8%) had other comorbidities. Their median age at death was 72.4 years. 77 (31%) died suddenly, 47 (19%) of HF, 39 (16%) of cancer, 35 (14%) of acute myocardial infarction (AMI) and 50 (20%) had miscellaneous modes of dying. Unexpected death occurred in 26 (10%) of cases: sudden 12, AMI 7, stroke 3, suicide 2, abdominal aneurysm 1, motor vehicle accident 1. We conclude that the clinical condition of most patients with CHD deteriorates between their initial stabilisation and their final visit before their death—metamorphosis. Only a small proportion of deaths occur in patients with stable CHD and no HF. Intervention in stable patients without CHF is unlikely to reduce sudden or unexpected death in patients with CHD.

Section snippets

Patients and methods

This was a retrospective study of all patients who were known to have died from the commencement of practice in April 1978 till 31st of December 2003. All the patients had been followed regularly from their presentation until their death. The details of the practice have been described previously [2], [3]. Many patients were referred by general practitioners; others had survived hospitalisation for acute cardiac events; few were referred by other physician/cardiologists. Patients were offered

Results

This is a study of 248 patients, 199 (80%) of them men and 49 (20%) of them women.

Discussion

The major finding of this retrospective study was that unexpected death, or unexpected cardiac death was uncommon. Most of the deaths occurred in patients who were in CHF at the outset or who clinically deteriorated whilst under clinical observation. Thus, the occurrence of death, if not the timing of the death, was not unexpected. Unless it can be shown that routine revascularisation of stable patients with CHD can prevent the clinical deterioration which we have called metamorphosis,

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