PROGNOSIS IN CORONARY THROMBOSIS. BY
Carey F.
Physician,
Not
so
higher
Coombs, M.D., F.R.C.P.,
charge of the University Centre of Research, General Hospital, Bristol.
and in
many years ago, if a candidate in examinations had been questioned
one as
Cardiac
of the to
the
prognosis of coronary thrombosis, he might have answered with impunity that there is none. The past decade has, however,
people
many
series of
cases
light the fact that these catastrophes. Various reported which bear this out,
brought
do survive have been
to
and to these I add notes drawn from 144
by myself. Examples
patients
seen
of sudden death without benefit
of
medicine, discovered post-mortem to be due to coronary thrombosis, have been excluded from this
object of these remarks is to help the doctor who, standing by the bedside of someone struck down by cardiac infarction, has to furnish to himself and others some sort of estimate of the patient's series
;
for the
chances of recovery.
Now, two broad facts emerge from this study. The first is that 49 out of 144, or 1 out of 3, died in or
shortly 277
after the attack.
Secondly,
of the 83 survivors
Dr. Carey F. Coombs
278
year ago 51 are still living. In other words, about one-third of those who survive the attack die within the year. It is only fair whose attacks occurred
to
over
a
add that with
and
thrombosis series
increasing experience make a diagnosis ready in relatively mild cases.
included would
diagnosis debatable
command
cases
the
general agreement.
If
in
would
dilute
picture
of the
added, these
were
and furnish
the fatalities
more
of coronary The present which
those
except
none
is
one
to
more
better
a
prospects. These
data
general
of several
of the influence
all
clinical
features.
In
(except
the
the
last)
number
total
also
can
of
be
the
reviewed.
and
follow
that
tables
column
tests
as
factors
setiological
first
cases
used
refers
the
to
second
The
expresses in percentages the proportion The itself. those who survived the attack
column of
third
column
who,
after
refers
the
to
percentage of those the attack, had also
living through through the subsequent year. The ages whole series may conveniently be considered
survived of the in
three
those who ages
lie
groups ;
those or
following table expresses the prognosis :? Age. Under 60
..
..
60-69 70
or
who
seventy between, in the were
....
sixty, whose
over,
seventh
the
of age
on
Non-fatal Non-fatal attacks.
48
06-6%
30
The
decade.
influence
Total Number.
66 over
under
and those
were
75-7% -3%
43
and surviving year
or
more.
51-8% 71-1% 70 -0%
&
Prognosis
in
The influence of way
:
Coronary Thrombosis
279
may be tested in the
sex
same
?
Non-fatal Total Number.
Males Females
and
surviving
a
year or more.
106
68-8%
58-0%
38
57-9%
75-0?/
..
..
Non-fatal attacks.
of liability to what may be broadly called coronary disease is too vague a factor to estimate in figures, yet I believe it is an unfavourable feature. A
family history
I have
examples kind of history which seen
in
seem
to
me
people with this proportionally more
than in those who have
numerous
but I
of fatalities in
must admit that I
produce
can
such
no no
history;
reliable
figures
support of this impression.
The state of the heart before the attack may be supposed to influence the prognosis, but it is difficult, in
a
of cases, to get much precise information However, it is practically always possible
majority
about this.
to learn whether the to cardiac
pain
on
patient
has
has not been liable
present series may from
The
effort.
or
this point of view be divided into who gave a history of this not. In tabular form the
groups may be
compared
kind,
prognosis
thus
Total Number.
group of 64 and 80 who did a
of these two
:?
Non-fatal attacks.
Non-fatal and surviving
a
year or more.
Attack
preceded by pain on effort.. Not preceded by pain on effort.. All that
can
64
65-6%
57-1%
80
66-2%
64-5%
be drawn from this series
influence of background
on
as
prognosis, therefore,
to the
is the
280
Dr. Carey F. Coombs
patients of seventy and calamity less successfully than
somewhat obvious fact that stand up to this do patients who are not
over
so
old.
The
prognosis, perhaps, depends more on severity of the attack than on the background. how is that to be measured ?
There
are
the But
two kinds
evidence, those which arise immediately from the anatomical change in the heart, and those which of
express the same thing in terms of function?data derived from the state of the peripheral circulation.
Now, after
examining all the evidence directly proving a structural change in the wall of the heart which was at my disposal, I found that it was not possible to use any simple clinical criterion of gross cardiac damage save one?the presence or absence of a pericardial rub. Here again, therefore, I divided my cases into two groups, those in which friction was heard and those in which it was not. The prognosis in these two groups I express
again
in tabular form.
Heard in 42
.
.
Not heard in 102
The
cases
.
year or more.
70
-1% 75-4%
..
worse
a
57
.
in which
therefore, rather
Non-fatal and surviving
Non-fatal attacks.
Pericardial friction.
rub is heard
pericardial
a
off
so
0%
58-1% far
as
are,
the immediate
is concerned than those in which it is not
prospect
Again,'
hopeful
when the
thoracic,
as
the
little less is abdominal than when it is
the outlook
heard.
pain following
Total Number.
Pain abdominal Pain thoracic
..
..
28 116
is, perhaps,
table shows
a
:?
Non-fatal Non-fatal attacks. 57
1% 68-1%
and survivinga year or more.
64-2% -8%
60
Prognosis The influence
Coronary Thrombosis
in
the
on
so,
as
it
has
far
as
not
always
to
be
been
impossible
to
collect
to
possible
So often the
necessary data.
in terms of
state
do
experience has gone, because
own
my
of the electrocardio-
prognosis
graphic picture is not easy figures ; in fact, it would
281
the
is too ill for
patient Persistent
ventricular early electrocardiography. tachycardia is generally admitted to involve a bad prognosis. Probably it is true here, as in cardiac disease in general, that the most serious changes are those which prove the greatest damage to the ventricular walls. Equally it is true that the
of the
course
estimated
towards
case
if
accurately
more
can
recovery
electrocardiograms
be are
taken at intervals. The immediate the
heart
will
not
circulation.
It is
failure that
we
in cardiac infarction is that
danger
able
be
fill
to
accordingly
peripheral signs of that
the
to
should turn for
the
a
of the
measure
prospect of recovery. It is this that makes extreme pallor so ominous a symptom. The rate of the pulse is not a good guide. I have known the heart beat to
the
at
moment
rhythmic,
a
disappeared. the
a
at
rate
which
in
a
fatal
case
ceased to
breathing
up be
few minutes before the cardiac sounds On the other
blood-pressure
evidence of the
the
normal
nearly to
extent
hand,
measurement
always
gives
which the
peripheral significant feature
impaired. blood-pressure in the systolic
of the
thrombosis is the fall is not always possible
to
be
sure
reliable
efficiency The
circulation is
of of
most
in coronary tension. It
that
this
has
282
Dr. Carey F. Coombs in many instances the pressure attack was unknown ; but what is,
taken
place,
before
the
after
for
all, the
most direct
is
the
heart is
damaged pulse-pressure. My
series
long
actual
of
of the
measure
with which the
efficiency
the vessels
filling (based on a regard the pulse-
custom
data) is
to
pressure as normal if it is about 40 per cent, of In coronary thrombosis, the systolic pressure. other forms of severe ventricular and however,
failure, it may fall
following
table
below is
or
shows
bad
a
low
as
that
sign
a
The
10
per cent. fall to 25 per
as
cent,
:
=
Pulse pressure /Systolic pressure less ; or bearing per cent,
25
on
prognosis.
Whole series P.P. low
(144)..
..
(27)
Unfortunately, it is converse, that patients are
sure
to
recover;
Died in
Died in year
attack.
following attack.
34-0% 70-4%
38-5 0/ /o
not
with
100-0%
possible a
yet if I
wide were
to
claim
the
pulse-pressure compelled to
sign alone it would prognosis the be pulse-pressure that I should choose. Curiously enough, an alternating pulse is seldom
rely
found
for
on
one
except when the immediate attack has been
secondary ventricular failure has set I say "curiously" because narrowed pulsein. pressure and an alternating pulse are so often associated in the progressive ventricular defeat of There is no time to discuss in the hyperpietic. detail the course followed by signs and symptoms The in those who survive the initial onslaught. survived and
Prognosis evidence
more
muscle
and the
worse
there is
reduction
are
beat
and
to
ventricular
ventricular
output
the of
Returning vigour of
signs.
and
rise
in
the
pulse-pressure complications, glycosuria and
Of
favourable.
damage
283
Persistence of fever and
bad
leucocytosis
of of
prognosis.
sounds are
Coronary Thrombosis
in
embolic accidents make the outlook graver still. |~ The ultimate outcome in those cases surviving both
the
attack
and the
subsequent year cannot be summarized yet statistically, because the period during which they have been observed is not long in
is
It
enough.
of
many
fair
only these
a
complete
has
taken
patients
have
been
on
with their work
and to
survive
the
claim, however, that
to
recovery that is apparently place. That is to say, the
enabled
provided attack
to
lesson is to
light
at
by
least
a
experience
similar
the cicatricial remains of cardiac
carry
arduous, decade. of those
series. The up when post-mortem evidence
followed
taught
and
it is not too
This is in accordance with the who have
resume
same
brings
infarction,
which must have occurred many years before death. Finally, there is no doubt that with an increasing
early diagnosis the prognosis is improving. Early diagnosis leads to thorough treatment, based on an adequate period of rest, and in this way an J appreciable number of lives are saved. accuracy of
Summary. Of
a
coronary thrombosis or
clinically diagnosed cases approximately one-third died
series of 144
shortly
after the initial attack.
of in
284
Prognosis
in
Coronary Thrombosis
Of those who survived the attack about died
during
the
one-third
ensuing
year. of the attack appears to have more severity prognostic import than the state of the patient before The
the attack. The
good
degree
pressure falls is of the attack.
to which the
index of the
severity
pulse
a
Editor's Note. A sad interest attaches to this paper, the proofs of which returned by Dr. Carey Coombs on the day before his
were
death with
paragraph
a
letter
to the
saying that he was sending one already in my paper. I
"
an
alternative only
think it is
same boat to dwell a little more than the bright side." The paragraph in question has been added in brackets on page 283.
fair to others in the I have done
on
Carey F.
Physician,
Not
so
higher
Coombs, M.D., F.R.C.P.,
charge of the University Centre of Research, General Hospital, Bristol.
and in
many years ago, if a candidate in examinations had been questioned
one as
Cardiac
of the to
the
prognosis of coronary thrombosis, he might have answered with impunity that there is none. The past decade has, however,
people
many
series of
cases
light the fact that these catastrophes. Various reported which bear this out,
brought
do survive have been
to
and to these I add notes drawn from 144
by myself. Examples
patients
seen
of sudden death without benefit
of
medicine, discovered post-mortem to be due to coronary thrombosis, have been excluded from this
object of these remarks is to help the doctor who, standing by the bedside of someone struck down by cardiac infarction, has to furnish to himself and others some sort of estimate of the patient's series
;
for the
chances of recovery.
Now, two broad facts emerge from this study. The first is that 49 out of 144, or 1 out of 3, died in or
shortly 277
after the attack.
Secondly,
of the 83 survivors
Dr. Carey F. Coombs
278
year ago 51 are still living. In other words, about one-third of those who survive the attack die within the year. It is only fair whose attacks occurred
to
over
a
add that with
and
thrombosis series
increasing experience make a diagnosis ready in relatively mild cases.
included would
diagnosis debatable
command
cases
the
general agreement.
If
in
would
dilute
picture
of the
added, these
were
and furnish
the fatalities
more
of coronary The present which
those
except
none
is
one
to
more
better
a
prospects. These
data
general
of several
of the influence
all
clinical
features.
In
(except
the
the
last)
number
total
also
can
of
be
the
reviewed.
and
follow
that
tables
column
tests
as
factors
setiological
first
cases
used
refers
the
to
second
The
expresses in percentages the proportion The itself. those who survived the attack
column of
third
column
who,
after
refers
the
to
percentage of those the attack, had also
living through through the subsequent year. The ages whole series may conveniently be considered
survived of the in
three
those who ages
lie
groups ;
those or
following table expresses the prognosis :? Age. Under 60
..
..
60-69 70
or
who
seventy between, in the were
....
sixty, whose
over,
seventh
the
of age
on
Non-fatal Non-fatal attacks.
48
06-6%
30
The
decade.
influence
Total Number.
66 over
under
and those
were
75-7% -3%
43
and surviving year
or
more.
51-8% 71-1% 70 -0%
&
Prognosis
in
The influence of way
:
Coronary Thrombosis
279
may be tested in the
sex
same
?
Non-fatal Total Number.
Males Females
and
surviving
a
year or more.
106
68-8%
58-0%
38
57-9%
75-0?/
..
..
Non-fatal attacks.
of liability to what may be broadly called coronary disease is too vague a factor to estimate in figures, yet I believe it is an unfavourable feature. A
family history
I have
examples kind of history which seen
in
seem
to
me
people with this proportionally more
than in those who have
numerous
but I
of fatalities in
must admit that I
produce
can
such
no no
history;
reliable
figures
support of this impression.
The state of the heart before the attack may be supposed to influence the prognosis, but it is difficult, in
a
of cases, to get much precise information However, it is practically always possible
majority
about this.
to learn whether the to cardiac
pain
on
patient
has
has not been liable
present series may from
The
effort.
or
this point of view be divided into who gave a history of this not. In tabular form the
groups may be
compared
kind,
prognosis
thus
Total Number.
group of 64 and 80 who did a
of these two
:?
Non-fatal attacks.
Non-fatal and surviving
a
year or more.
Attack
preceded by pain on effort.. Not preceded by pain on effort.. All that
can
64
65-6%
57-1%
80
66-2%
64-5%
be drawn from this series
influence of background
on
as
prognosis, therefore,
to the
is the
280
Dr. Carey F. Coombs
patients of seventy and calamity less successfully than
somewhat obvious fact that stand up to this do patients who are not
over
so
old.
The
prognosis, perhaps, depends more on severity of the attack than on the background. how is that to be measured ?
There
are
the But
two kinds
evidence, those which arise immediately from the anatomical change in the heart, and those which of
express the same thing in terms of function?data derived from the state of the peripheral circulation.
Now, after
examining all the evidence directly proving a structural change in the wall of the heart which was at my disposal, I found that it was not possible to use any simple clinical criterion of gross cardiac damage save one?the presence or absence of a pericardial rub. Here again, therefore, I divided my cases into two groups, those in which friction was heard and those in which it was not. The prognosis in these two groups I express
again
in tabular form.
Heard in 42
.
.
Not heard in 102
The
cases
.
year or more.
70
-1% 75-4%
..
worse
a
57
.
in which
therefore, rather
Non-fatal and surviving
Non-fatal attacks.
Pericardial friction.
rub is heard
pericardial
a
off
so
0%
58-1% far
as
are,
the immediate
is concerned than those in which it is not
prospect
Again,'
hopeful
when the
thoracic,
as
the
little less is abdominal than when it is
the outlook
heard.
pain following
Total Number.
Pain abdominal Pain thoracic
..
..
28 116
is, perhaps,
table shows
a
:?
Non-fatal Non-fatal attacks. 57
1% 68-1%
and survivinga year or more.
64-2% -8%
60
Prognosis The influence
Coronary Thrombosis
in
the
on
so,
as
it
has
far
as
not
always
to
be
been
impossible
to
collect
to
possible
So often the
necessary data.
in terms of
state
do
experience has gone, because
own
my
of the electrocardio-
prognosis
graphic picture is not easy figures ; in fact, it would
281
the
is too ill for
patient Persistent
ventricular early electrocardiography. tachycardia is generally admitted to involve a bad prognosis. Probably it is true here, as in cardiac disease in general, that the most serious changes are those which prove the greatest damage to the ventricular walls. Equally it is true that the
of the
course
estimated
towards
case
if
accurately
more
can
recovery
electrocardiograms
be are
taken at intervals. The immediate the
heart
will
not
circulation.
It is
failure that
we
in cardiac infarction is that
danger
able
be
fill
to
accordingly
peripheral signs of that
the
to
should turn for
the
a
of the
measure
prospect of recovery. It is this that makes extreme pallor so ominous a symptom. The rate of the pulse is not a good guide. I have known the heart beat to
the
at
moment
rhythmic,
a
disappeared. the
a
at
rate
which
in
a
fatal
case
ceased to
breathing
up be
few minutes before the cardiac sounds On the other
blood-pressure
evidence of the
the
normal
nearly to
extent
hand,
measurement
always
gives
which the
peripheral significant feature
impaired. blood-pressure in the systolic
of the
thrombosis is the fall is not always possible
to
be
sure
reliable
efficiency The
circulation is
of of
most
in coronary tension. It
that
this
has
282
Dr. Carey F. Coombs in many instances the pressure attack was unknown ; but what is,
taken
place,
before
the
after
for
all, the
most direct
is
the
heart is
damaged pulse-pressure. My
series
long
actual
of
of the
measure
with which the
efficiency
the vessels
filling (based on a regard the pulse-
custom
data) is
to
pressure as normal if it is about 40 per cent, of In coronary thrombosis, the systolic pressure. other forms of severe ventricular and however,
failure, it may fall
following
table
below is
or
shows
bad
a
low
as
that
sign
a
The
10
per cent. fall to 25 per
as
cent,
:
=
Pulse pressure /Systolic pressure less ; or bearing per cent,
25
on
prognosis.
Whole series P.P. low
(144)..
..
(27)
Unfortunately, it is converse, that patients are
sure
to
recover;
Died in
Died in year
attack.
following attack.
34-0% 70-4%
38-5 0/ /o
not
with
100-0%
possible a
yet if I
wide were
to
claim
the
pulse-pressure compelled to
sign alone it would prognosis the be pulse-pressure that I should choose. Curiously enough, an alternating pulse is seldom
rely
found
for
on
one
except when the immediate attack has been
secondary ventricular failure has set I say "curiously" because narrowed pulsein. pressure and an alternating pulse are so often associated in the progressive ventricular defeat of There is no time to discuss in the hyperpietic. detail the course followed by signs and symptoms The in those who survive the initial onslaught. survived and
Prognosis evidence
more
muscle
and the
worse
there is
reduction
are
beat
and
to
ventricular
ventricular
output
the of
Returning vigour of
signs.
and
rise
in
the
pulse-pressure complications, glycosuria and
Of
favourable.
damage
283
Persistence of fever and
bad
leucocytosis
of of
prognosis.
sounds are
Coronary Thrombosis
in
embolic accidents make the outlook graver still. |~ The ultimate outcome in those cases surviving both
the
attack
and the
subsequent year cannot be summarized yet statistically, because the period during which they have been observed is not long in
is
It
enough.
of
many
fair
only these
a
complete
has
taken
patients
have
been
on
with their work
and to
survive
the
claim, however, that
to
recovery that is apparently place. That is to say, the
enabled
provided attack
to
lesson is to
light
at
by
least
a
experience
similar
the cicatricial remains of cardiac
carry
arduous, decade. of those
series. The up when post-mortem evidence
followed
taught
and
it is not too
This is in accordance with the who have
resume
same
brings
infarction,
which must have occurred many years before death. Finally, there is no doubt that with an increasing
early diagnosis the prognosis is improving. Early diagnosis leads to thorough treatment, based on an adequate period of rest, and in this way an J appreciable number of lives are saved. accuracy of
Summary. Of
a
coronary thrombosis or
clinically diagnosed cases approximately one-third died
series of 144
shortly
after the initial attack.
of in
284
Prognosis
in
Coronary Thrombosis
Of those who survived the attack about died
during
the
one-third
ensuing
year. of the attack appears to have more severity prognostic import than the state of the patient before The
the attack. The
good
degree
pressure falls is of the attack.
to which the
index of the
severity
pulse
a
Editor's Note. A sad interest attaches to this paper, the proofs of which returned by Dr. Carey Coombs on the day before his
were
death with
paragraph
a
letter
to the
saying that he was sending one already in my paper. I
"
an
alternative only
think it is
same boat to dwell a little more than the bright side." The paragraph in question has been added in brackets on page 283.
fair to others in the I have done
on
