Cardiac Infarction-Sharland JRNAL MEDICAL JOUJRNAL that there has been a significant change in policy since 1936, when Levine recommended a period of six to eight weeks in bed, with an appropriate convalescent period. Alternatively, it is possible that there is an increasing occurrence or recognition of milder cases.While most would acknowledge the considerable psychological benefits which are seen in a patient who is able to resume work, there are very few data concerning the physical effects of resumption of work, and it is impossible to answer the oftput questions, " Will I do myself any harm if I go back to work? " or " Should I have another month's rest from work? " The data presented in this series do not provide an answer to these questions except with respect to the mortality (the crudest index) which compares favourably with that recorded in doctors (Morris, Heady, and Barley, 1952 ;McMichael and Parry, 1960)-the mortality at one year is 4.2 %, compared with 4% of the doctors (who survived the first month after infarction), and at three years is 14%, compared with 10% in the doctors' series.Cook, Tuttle, and Kodlin (1962) report from a cardiac workevaluation centre an attempt to establish whether work had any effects on the progress of heart disease. They graded the work capacity of their patients into five categories ranging from normal capacity to confinement to bed. By comparing their assessment at the initial visit with the actual work being carried out when the patients were seen at six-monthly intervals they were able to classify the men into those who complied with the original advice, those who did more than recommended, and those who did less. The mortality of patients suffering from "atherosclerotic heart disease" showed a gradient from 9 % in those who did excessive work, to 5 % in those who complied with advice, and to 3 % in those who did less work than advised. Further studies are needed to confirm if hard work has any adverse effect on those who have suffered from cardiac infarction.The possible role of psychological stresses has not been considered as it was not possible to measure them. Summary and ConclusionsThe return to work of 212 men under 60 years of age who have survived one episode of cardiac infarction showed that 55 % were back at work within three months and 82 % within six months.The major changes in employment " status " had generally been achieved within six months of the initial cardiac infarction, and the various employment subgroups at this stage were therefore studied more closely. (a) Part-time work was usually a temporary phase which was ultimately followed by a return to full-time work. (b) A change of job was more common in those in social classes IV and V and those normally undertaking active or heavy work. (c) A review of the social class, physical activity of work, and severity of initial infarction of the few men who were not at work at six months (and who had not suffered any further episodes of cardiac infarction) did not show any obvious distinguishing featu...

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Two patients with intractable life-threatening ventricular tachycardias have been studied using intracardiac electrograms and programmed electrical stimulation of the heart. Both patients were shown to have an underlying re-entry mechanism in the ventricles as the basisfor the tachycardias. Both patients underwent epicardial mapping studies at cardiac surgery, and the site of re-entry was established. In one patient the re-entry front was found to start in the posterobasal region of the left ventricle and in the other patient the re-entryfront was found in the anterobasal region of the right ventricle. In both patients surgical interruption of the re-entryfront was carried out. Both patients are alive andfreefrom tachycardias at the time of writing.In recent years much discussion has centred around the underlying mechanisms of ventricular tachycardia. The two main mechanisms postulated *are that the tachycardia is due to a rapidly discharging focus or that some form of re-entry mechanism is responsible. Lown, Kleiger, and Williams (I965) showed that ventricular tachycardia could develop in the dog's heart exposed to large amounts of digitalis and suggested that this was because of the development of an increased frequency of discharge from the cardiac cells. Recently Wellens, Schuilenburg, and Durrer (I972) demonstrated in 5 patients with ventricular tachycardia that a reciprocal mechanism was the most probable underlying mechanism though the precise site of re-entry was uncertain. Spurrell, Sowton, and Deuchar (I973) using similar techniques showed that a reentry or reciprocal mechanism in the main intraventricular bundle-branches was the most probable basis for ventricular tachycardia in 4 patients. This paper describes 2 patients with intractable ventricular tachycardia in whom investigations by programmed cardiac electrical stimulation in conjunction with intracardiac recordings indicated a reentry mechanism. Both patients underwent surgery and the re-entry process was then further studied using epicardial mapping. From the results obtained from the intraoperative mapping studies a surgical approach specific to each patient was de- vised to interrupt the re-entry circuit and prevent further attacks of tachycardia. Patients and methodsThe full details of the 2 patients are given under individual case histories. The basic clinical details are summarized in the Table. Case I suffered an inferior myocardial infarction on I3 December I972. He began to develop attacks of ventricular tachycardia for which DC cardioversion was required on 7 January I973. He had 9 subsequent admissions to the local hospital with ventricular tachycardia requiring DC cardioversion, and was then referred to the Brompton Hospital, London, on IO

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