Objectives-To assess the impact of myocardial infarction on quality of life in four year survivors compared to data from "community norms", and to determine factors associated with a poor quality of life. Design-Cohort study based on the Nottingham heart attack register. Setting-Two district general hospitals serving a defined urban/rural population. Subjects-All patients admitted with acute myocardial infarction during 1992 and alive at a median of four years. Main outcome measures-Short form 36 (SF 36) domain and overall scores.Results-Of 900 patients with an acute myocardial infarction in 1992, there were 476 patients alive and capable of responding to a questionnaire in 1997. The response rate was 424 (89.1%). Compared to age and sex adjusted normative data, patients aged under 65 years exhibited impairment in all eight domains, the largest diVerences being in physical functioning (mean diVerence 20 points), role physical (mean diVerence 23 points), and general health (mean diVerence 19 points). In patients over 65 years mean domain scores were similar to community norms. Multiple regression analysis revealed that impaired quality of life was closely associated with inability to return to work through ill health, a need for coronary revascularisation, the use of anxiolytics, hypnotics or inhalers, the need for two or more angina drugs, a frequency of chest pain one or more times per week, and a Rose dyspnoea score of > 2. Conclusions-The SF 36 provides valuable additional information for the practising clinician. Compared to community norms the greatest impact on quality of life is seen in patients of working age. Impaired quality of life was reported by patients unfit for work, those with angina and dyspnoea, patients with coexistent lung disease, and those with anxiety and sleep disturbances. Improving quality of life after myocardial infarction remains a challenge for physicians. (Heart 1999;81:352-358)

Patients not receiving secondary prevention were less likely to be invited to cardiac rehabilitation. Social deprivation was the only factor significantly associated with poor uptake of cardiac rehabilitation in both years. There was no diVerence in the use of secondary prevention between those who did and did not attend cardiac rehabilitation. Conclusion-Those invited to attend a cardiac rehabilitation programme are likely to be in a good prognosis group, comprising those who are young and have received thrombolysis. Those at greatest risk, particularly patients from socially deprived areas, seem to be missing out on the potential benefits of cardiac rehabilitation. High risk patients should be specifically targeted to ensure that they are invited to, and encouraged to, attend a programme of cardiac rehabilitation.

Objective: To examine the incidence of cardiovascular diseases and cancer from published clinical trials that studied other outcomes of postmenopausal hormone therapy as some surveys have suggested that it may decrease the incidence of cardiovascular diseases and increase the incidence of hormone dependent cancers. Design: Trials that compared hormone therapy with placebo, no therapy, or vitamins and minerals in comparable groups of postmenopausal women and reported cardiovascular or cancer outcomes were searched from the literature. Subjects: 22 trials with 4124 women were identified. In each group, the numbers of women with cardiovascular and cancer events were summed and divided by the numbers of women originally allocated to the groups. Results: Data on cardiovascular events and cancer were usually given incidentally, either as a reason for dropping out of a study or in a list of adverse effects. The calculated odds ratios for women taking hormones versus those not taking hormones was 1.39 (95% confidence interval 0.48 to 3.95) for cardiovascular events without pulmonary embolus and deep vein thrombosis and 1.64 (0.65 to 4.18) with them. It is unlikely that such results would have occurred if the true odds ratio were 0.7 or less. For cancers, the numbers of reported events were too low for a useful conclusion. Conclusions:The results of these pooled data do not support the notion that postmenopausal hormone therapy prevents cardiovascular events.

F rom the patient's perspective, disease severity is gauged by its impact on health related quality of life (HRQL), whereas medical practitioners tend to focus on clinical parameters such as symptoms, signs, and investigations. HRQL assessment can complement clinical evaluation but has not been widely incorporated into routine clinical practice, perhaps because of an association with research, lack of familiarity, difficulties with data interpretation, or concern that outpatients is busy enough.The short form 36 questionnaire (SF-36) 1 is an established HRQL tool that has been evaluated in a range of medical conditions 2 and for which normative data are available. 3Survivors of myocardial infarction have notably impaired HRQL compared with a normal population, detected more readily by the SF-36 than the Nottingham health profile (NHP). 4 5 Despite being relatively user friendly, the SF-36 can be time consuming, especially when combined with essential demographic and other questionnaires, leading to reduced response rates, incompleteness, and unreliability.We investigated whether a shorter questionnaire, the short form 12 (SF-12), which derives summary scores from specific items from the eight domains of the SF-36, might provide equally reliable and sensitive information in a post-infarction population. METHODThe patient population has been described before. 4 Briefly, we mailed a detailed questionnaire comprising demographic questions, Rose angina and dyspnoea scales, SF-36, and NHP to all patients who had: (1) been admitted in a single year to Nottingham's two hospitals; (2) sustained an acute myocardial infarction, based on World Health Organization criteria; and (3) survived at least four years. HRQL scores for the SF-12 were calculated. RESULTSTwo hundred and five of 960 confirmed infarctions died in hospital; a further 210 died over the next four years. Those with recurrent infarctions or resident outside our health district were excluded, leaving 476 study patients.Response rates A total of 424 (89%) patients responded; 421 (99%) answered some or all of the SF-36, making it possible to calculate physical and mental summary scores for 304 (72%). Based on mandated questions within the SF-36, equivalent SF-12 summary scores were calculated for 286 (68%); 278 (66%) had physical and mental summary scale scores for both the SF-36 and the SF-12. Patient characteristicsThere were no significant differences in the demographic characteristics of responders and non-responders. The mean (SD) age of those for whom SF-36 and SF-12 summary scores were available was 64 (9.97) years. One hundred and ninety eight (71%) were male, 231 (83%) had a Q wave infarction, and 108 (39%) an anterior infarction; 192 (69%) were Killip class 0 on admission, and 29 (10%) had had a previous myocardial infarction. When the questionnaire was dispatched, 63 (23%) were working, 167 (60%) retired, and 29 (10%) unable to work. Patient symptomsTwo hundred and seventy two (98%) of 278 who completed all of the SF-36 completed the Rose angina ques...

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This study has shown that the results from Q fever micro-immunofluorescence vary according to the center in which they are carried out. This has implications for the interpretation of such tests, raises questions regarding the validity of using serological criteria alone as a means of diagnosing chronic Q fever, and affects the interpretation of epidemiological studies. We recommend that all results are interpreted according to the clinical picture and particular caution is applied in the interpretation of chronic serological profiles. In order to further our understanding of Q fever infection we propose that an international standard of Q fever serological investigation be developed.

At least in myocardial infarction survivors, the SF-36 appears a more sensitive tool and may have benefits for assessing health-related quality of life in this patient group.

Objective-To assess the medium to long term outcome of patients ineligible for thrombolysis compared to those enrolled in a clinical trial of thrombolysis and patients receiving non-trial thrombolysis. Design-Cohort study based on the Nottingham heart attack register. Setting-Two district general hospitals serving a defined urban/rural population. Subjects-All patients admitted with a confirmed acute myocardial infarction during 1992 categorised as either participants of a thrombolytic trial (group A, n = 140), receiving non-trial thrombolysis (group B, n = 329), or deemed ineligible for lytic treatment (group C, n = 431). Main outcome measures-Background characteristics, inhospital treatment, patterns of follow up, referrals to cardiologists, revascularisation rates, and short and long term survival. Results-Clinical trial recruits were younger by almost 10 years, were less likely to have a previous history of myocardial infarction, and more likely to be in Killip class 1 on admission than those ineligible for thrombolysis. Cardiology follow up was mandatory for all surviving trial participants but 22% of patients in group B and 31% of patients in group C received no follow up, and during four years less than 50% ever saw a cardiologist. Revascularisation was performed in 17.2% of patients in group A, 13.6% of patients in group B, and 7.5% of patients in group C. Cumulative mortality at a median of four years was 24.3% in group A, 36.8% in B, and 59.6% in group C. Adjusting for age, sex, previous myocardial infarction, type of infarction, and Killip class in a logistic regression model the odds ratios (OR) of death at four years for groups B and C were 1.60 (95% confidence intervals (CI) 0.97 to 2.63, p = 0.065) and 2.64 (95% CI 1.61 to 4.32, p < 0.001), respectively, when compared to group A (OR 1). Conclusions-Patientsenrolled into thrombolytic trials are at low risk. Patients deemed ineligible for thrombolysis are high risk, receive less surveillance, are less likely to be revascularised or receive trial proven treatments, have a poor long term outcome not entirely explained by increased age or severity of infarction, and deserve further evaluation. (Heart 1999;81:598-602)