Acute Myocardial Infarction-Norris et al. MEDICA JOURNAL dying, heart failure on admission, as determined clinically and radiologically, being nearly as likely to result in death from arrhythmia as in death from failure. Patients suffering late arrhythmic death were, however, much more ill than the survivors, having a greatly increased incidence of shock and heart failure, and a greater incidence of transmural infarction, particularly involving the anterior part of the heart. A detailed analysis of our 70 cases of late arrhythmic death showed that, excluding a few who had clearly diagnosable reinfarction, all but four had radiological evidence of interstitial or pulmonary oederna on admission, or heart failure, hypotension, or a major arrhythmia during the first few days after admission.It is doubtful whether long-term E.C.G. monitoring of all patients at risk of late arrhythmic death is economically feasible or psychologically desirable, and it is probable that the yield in lives saved will be considerably less than by the institution of early intensive care as practised by Pantridge and his colleagues. It is also true that ventricular fibrillation complicating heart failure or shock has a poor prognosis in spite of monitoring and resuscitation (Robinson, 1965). Nevertheless, it is thought that arrhythmic death in patients who are recovering from circulatory failure is in many cases preventable with antiarrhythmic drugs, and the logical use of E.C.G. telemetry (Cerkez et at., 1965) is in this group of patients.It is now our practice, in a four-bedded coronary care unit which has opened at Green Lane Hospital since this study was completed, to readmit patients who have had heart failure or major arrhythmia during their three to seven day3 of initial monitoring from the ward to the unit if their condition deteriorates. Warning signs of impending death from ventricular fibrillation are taken to be further chest pain not quickly relieved by trinitrin, a fall in blood pressure, or irregularity in the pulse which was not present before. Nurses are instructed to feel the pulse at the wrist of all coronary patients for a full minute and to report irregularities and ectopic beats. As late arrhythmic death occurs so seldom in uncomplicated cases, it can be argued that it is unnecessary to keep these patients in hospital for more than a week, and that mobilization and rehabilitation may be correspondingly accelerated.We are grateful to the visiting physicians of Auckland, Green Lane, and Middlemore Hospitals for allowing patients under their care to be studied, and to the medical registrars for accurate recording of information. Dr. P. W. T. Brandt, radiologist to the cardiological and cardiothoracic surgical units at Green Lane Hospital, kindly reviewed all the chest x-ray films. Facilities for the transfer of data to punch cards and analysis of the results were provided by the medical statistics unit of the Auckland Hospital Board.
