Thursday, January 26, 2006

Early detection of cardiovascular disease - the future of cardiology?

E-Journal - Volume 4 - vol4n19: "Early detection of cardiovascular disease - the future of cardiology?
Prof. D. Duprez . Minneapolis, United States of America. Past-Chairman of the ESC Working Group on Peripheral Circulation
Recomendado por Marcelo Gustavo Colominas []
Our goal is to improve the precision for early detection and treatment of cardiovascular disease by identifying markers for early disease and the response to therapy. The traditional approach to cardiovascular disease prevention involves identifying risk factors that are statistically but not necessarily biologically related to disease. Health care expenditures are overwhelming national and corporate budgets, predominantly because of the escalating costs of advanced disease. Therefore there is an urgent need for early detection and treatment of asymptomatic cardiovascular disease."/.../

Early Invasive versus Selectively Invasive Management

Recomendado por Nelson Robson & Carmem []
(Full document available on request)
n engl j med 353;11 september 15, 2005

Current guidelines recommend an early invasive strategy for patients who have acute coronary syndromes without ST-segment elevation and with an elevated cardiac troponin T level. However, randomized trials have not shown an overall reduction in mortality, and the reduction in the rate of myocardial infarction in previous trials has varied depending on the definition of myocardial infarction.
We randomly assigned 1200 patients with acute coronary syndrome without ST-segment elevation who had chest pain, an elevated cardiac troponin T level (≥0.03μg per liter), and either electrocardiographic evidence of ischemia at admission or a documented history of coronary disease to an early invasive strategy or to a more conservative (selectively invasive) strategy. Patients received aspirin daily, enoxaparin for 48 hours, and abciximab at the time of percutaneous coronary intervention. The use of clopidogrel and intensive lipid-lowering therapy was recommended. The primary end point was a composite of death, nonfatal myocardial infarction, or rehospitalization for anginal symptoms within one year after randomization.
The estimated cumulative rate of the primary end point was 22.7 percent in the group assigned to early invasive management and 21.2 percent in the group assigned to selectively invasive management (relative risk, 1.07; 95 percent confidence interval, 0.87 to 1.33; P=0.33). The mortality rate was the same in the two groups (2.5 percent).
Myocardial infarction was significantly more frequent in the group assigned to early invasive management (15.0 percent vs. 10.0 percent, P=0.005), but rehospitalization was less frequent in that group (7.4 percent vs. 10.9 percent, P=0.04).
We could not demonstrate that, given optimized medical therapy, an early invasive strategy was superior to a selectively invasive strategy in patients with acute coronary syndromes without ST-segment elevation and with an elevated cardiac troponin T level.

Wednesday, January 25, 2006

Erectile Dysfunction Predicts Coronary Heart Disease - CME Teaching Brief - MedPage Today

Erectile Dysfunction Predicts Coronary Heart Disease - CME Teaching Brief - MedPage Today:
Min JK et al. Prediction of Coronary Heart Disease by Erectile Dysfunction in Men Referred for Nuclear Stress Testing. Arch Intern Med. 2006;166:201-206.
"Consider questioning men about sexual function when treating them for suspected coronary heart disease, noting that this study implies erectile dysfunction is an independent predictor of severe disease, at least among men referred for stress testing.

Advise patients that erectile dysfunction has been demonstrated to share a common profile of risk factors with coronary artery disease that includes diabetes, hypertension, cigarette smoking, and hyperlipidemia.

Note that further studies are needed to establish whether patients with erectile dysfunction but no cardiac symptoms should be screened for overt coronary heart disease. /.../"

In Coronary Surgery, Spare the Aorta to Save the Brain - CME Teaching Brief - MedPage Today

In Coronary Surgery, Spare the Aorta to Save the Brain - CME Teaching Brief - MedPage Today: "
By Peggy Peck, Managing Editor, MedPage Today
Be aware that this study suggests that it is surgical technique, not the use of a cardiopulmonary bypass pump, that increases the risk of cognitive impairment following heart surgery.

Explain to patients who ask that these findings are limited by the significant age differences between the traditional surgery arm and the two comparator groups."

Tuesday, January 17, 2006

Cardiovascular Risks of Ethos and Pathos at the Movies - CME Teaching Brief - MedPage Today

Cardiovascular Risks of Ethos and Pathos at the Movies - CME Teaching Brief - MedPage Today:
"Understand that this small study suggests that laughter can have a beneficial effect on the cardiovascular system by inducing relaxation of arterial endothelium, thereby improving circulation.
Advise patients that a good laugh has never been known to be harmful. "/.../

Friday, January 13, 2006

Cardiovascular Disease and Associated Risk Factors

Recommended by Marcelo Gustavo Colominas []. Full tex available on request
Objectives. An adequate description of the trends in cardiovascular disease (CVD) is not available for most of the developing world. Cuba provides an important exception, and we sought to use available data to offer insights into the changing patterns of CVD there.
Methods. We reviewed Cuban public health statistics, surveys, and reports of health services.
Results. CVD has been the leading cause of death since 1970. A 45% reduction in heart disease deaths was observed from 1970 to 2002; the decline in stroke was more limited. There are moderate prevalences of all major risk factors.
Conclusions. The Cuban medical care system has responded vigorously to the challenge of CVD; levels of control of hypertension are the highest in the world. Nonindustrialized countries can decisively control CVD. (Am J Public Health. 2006;96:94–101. doi:10.2105/AJPH.2004.051417)

Thursday, January 12, 2006

International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis.

International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis.Authors: Bhatt DL, et al. Reviewed by: Joaquin Barnoya, MD, MPH (ProCOR)
Atherothrombosis is the leading cause of cardiovascular morbidity and mortality around the globe. To date, no single international database has characterized the atherosclerosis risk factor profile or treatment intensity of individuals with atherothrombosis.
ObjectiveTo determine whether atherosclerosis risk factor prevalence and treatment would demonstrate comparable patterns in many countries around the world.
Design, Setting, and Participants
The Reduction of Atherothrombosis for Continued Health (REACH) Registry collected data on atherosclerosis risk factors and treatment. A total of 67 888 patients aged 45 years or older from 5473 physician practices in 44 countries had either established arterial disease (coronary artery disease [CAD], n = 40 258; cerebrovascular disease, n = 18843; peripheral arterial disease, n = 8273) or 3 or more risk factors for atherothrombosis (n = 12 389) between 2003 and 2004.
Main Outcome Measures
Baseline prevalence of atherosclerosis risk factors, medication use, and degree of risk factor control.
ResultsAtherothrombotic patients throughout the world had similar risk factor profiles: a high proportion with hypertension (81.8%), hypercholesterolemia (72.4%), and diabetes (44.3%). The prevalence of overweight (39.8%), obesity (26.6%), and morbid obesity (3.6%) were similar in most geographic locales, but was highest in North America (overweight: 37.1%, obese: 36.5%, and morbidly obese: 5.8%; P< .001 vs other regions). Patients were generally undertreated with statins (69.4% overall; range: 56.4% for cerebrovascular disease to 76.2% for CAD), antiplatelet agents (78.6% overall; range: 53.9% for 3 risk factors to 85.6% for CAD), and other evidence-based risk reduction therapies. Current tobacco use in patients with established vascular disease was substantial (14.4%). Undertreated hypertension (50.0% with elevated blood pressure at baseline), undiagnosed hyperglycemia (4.9%), and impaired fasting glucose (36.5% in those not known to be diabetic) were common. Among those with symptomatic atherothrombosis, 15.9% had symptomatic polyvascular disease. Conclusion
This large, international, contemporary database shows that classic cardiovascular risk factors are consistent and common but are largely undertreated and undercontrolled in many regions of the world.JAMA. 2006;295:180-189

Chronic Stable Angina and Asymptomatic CAD

Referred by: Marcelo Gustavo Colominas []
Full text available on request.
Primary Care Management of Chronic Stable Angina and Asymptomatic Suspected or Known Coronary Artery Disease: A Clinical Practice Guideline from the American College of Physicians
Vincenza Snow, MD; Patricia Barry, MD, MPH; Stephan D. Fihn, MD, MPH; Raymond J. Gibbons, MD; Douglas K. Owens, MD; Sankey V. Williams, MD; Christel Mottur-Pilson, PhD; and Kevin B. Weiss, MD, MPH; for the American College of Physicians/American College of Cardiology Chronic Stable Angina Panel*
In 1999, the American College of Physicians (ACP), then the American College of Physicians–American Society of Internal Medicine, and the American College of Cardiology/American Heart Association (ACC/AHA) developed joint guidelines on the management of patients with chronic stable angina. The ACC/AHA then published an updated guideline in 2002, which ACP recognized as a scientifically valid review of the evidence and background paper. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. This guideline is the second of 2 that provide guidance on the management of patients with chronic stable angina. This document covers treatment and follow-up of symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months. Sections addressing asymptomatic patients are also included. Asymptomatic refers to patients with known or suspected coronary disease based on a history or electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests. A previous guideline covered diagnosis and risk stratification for symptomatic patients who have not had an acute myocardial infarction or revascularization
procedure in the previous 6 months and asymptomatic patients with known or suspected coronary disease based on a history or electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests.
Ann Intern Med. 2004;141:562-567.

Saturday, January 07, 2006

XXVI Congresso Norte/Nordeste de Cardiologia

XXVI Congresso Norte/Nordeste de Cardiologia:

De: Pedro Albuquerque [] Enviada em: sábado, 7 de janeiro de 2006 01:24
Gostaria que fosse divulgado aos amigos da AMICOR que o XXVI Congresso Norte-Nordeste de Cardiologia e XXVIII Congresso de Ciruurgia Cardiovascular do Note-Nordeste será realizado em Maceió nos dia 8,9 e 10 de junho de 20006.
O site do congresso é, inscrições de TL online http:///
P.S - veja o anexo.
Muito Obrigado.
Pedro Albuquerque - presidente do congresso.

"Caros colegas cardiologistas,
Há meses as comissões Organizadoras do XXVI Congresso Norte/Nordeste de Cardiologia e do XXVIII Congresso de Cirurgia Cardiovascular Norte/Nordeste, encontram-se plenamente empenhadas no esforço de manter o alto padrão que sempre caracterizou esse megaevento, principal encontro da Cardiologia e da Cirurgia Cardiovascular dos norte/nordestinos.

Maceió prepara-se para, nos dias 8, 9 e 10 de junho de 2006, no Centro Cultural e de Exposições (Centro de Convenções), recebê-los de forma especial, mantendo-os fraternalmente acolhidos."

Friday, January 06, 2006

The John Snow Society

The John Snow Society: "The John Snow Society aims to promote the life and works of Dr John Snow, the pioneer of epidemiological method and celebrated anaesthetist.
As outlined in the Constitution, the Society has a serious intent, publishing news, collecting facts and dates related to the life and works of John Snow and organising the Annual Pumphandle Lecture Series, but it also aims to provide a communication network for epidemiologists and those trained in the Snow tradition throughout the world.
The Society currently has over 1,000 members worldwide, many of them eminent specialists in their fields. "/.../

Heart Disease and Dementia

Recommended by: Marcelo Gustavo Colominas [] Heart Disease and Dementia
American Journal of Epidemiology 2006 163(2):135-141
Heart Disease and Dementia: A Population-based Study
Francesca Bursi1, Walter A. Rocca2,3, Jill M. Killian2, Susan A. Weston2, David S. Knopman3, Steven J. Jacobsen2 and Véronique L. Roger1,2
1 Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN2 Department of Health Sciences Research, Mayo Clinic and Foundation, Rochester, MN3 Department of Neurology, Mayo Clinic and Foundation, Rochester, MN
Correspondence to Dr. Véronique L. Roger, Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905 (e-mail:
There are conflicting reports on the possible positive association between coronary disease and dementia. The objectives of this study were to examine the association between coronary disease, as measured by myocardial infarction and cardiac death, and dementia in a population-based study. By use of the record-linkage system of the Rochester Epidemiology Project, 916 cases of dementia and 916 age (±1 year)- and sex-matched controls were identified in Rochester, Minnesota, between 1985 and 1994. From the same population, the authors identified all subjects who experienced a myocardial infarction (defined using standardized criteria) during the period 1979–1998. For myocardial infarction occurring prior to the index year of dementia, the authors used conditional logistic regression (case-control analysis), while for myocardial infarction and death occurring after the index year, they used competing risk survival analysis to account for informative censoring (cohort analysis). Before the index year, the odds ratio for myocardial infarction among cases with dementia compared with controls was 1.00 (95% confidence interval (CI): 0.62, 1.62; p = 1.00). After the index year, patients with dementia had a 46% decreased risk of subsequent myocardial infarction (hazard ratio = 0.54, 95% CI: 0.36, 0.82; p = 0.004) and an 18% decreased risk of cardiac death (hazard ratio = 0.82, 95% CI: 0.70, 0.95; p = 0.010). There was no evidence of a positive association between dementia and preceding myocardial infarction, while there was a decreased risk of myocardial infarction and cardiac death following dementia.
case-control studies; cohort studies; death; dementia; myocardial infarction; odds ratio; survival analysis

ACC/AHA Clinical Performance Measures

Medicine is experiencing an unprecedented focus on quantifying and improving health care quality. The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed a multi-faceted strategy to facilitate the process of improving clinical care. The initial phase of this effort was to create clinical practice guidelines that carefully review and synthesize available evidence to better guide patient care. Such guidelines are written in a spirit of suggesting diagnostic or therapeutic interventions for patients in most circumstances. Accordingly, significant judgment by clinicians is required to adapt these guidelines to the care of individual patients, and these guidelines can be generated with varying degrees of confidence based upon available evidence.
Occasionally, the evidence supporting a particular structural aspect or process of care is so strong that failure to perform such actions reduces the likelihood that optimal patient outcomes will occur. Creating a mechanism for quantifying these opportunities to improve the outcomes of care is an important and pressing challenge/.../

New diureticHeart Failure

NovaCardia - Product Focus - Drugs in Development: "KW-3902: An Innovative Therapy for CHF
In-licensed from Kyowa Hakko in August 2003, KW-3902 (intravenous) is currently in Phase II development for Congestive Heart Failure (CHF) patients undergoing diuresis. This proprietary small molecule acts as an adenosine-A1 receptor antagonist. Current therapies for CHF introduce significant medical liabilities to patients, most notably the risk of worsening kidney function, a predictor of poor outcome. KW-3902, with its novel mechanism of action, has the potential to significantly improve the management of CHF, particularly in patients with renal dysfunction."

Thursday, January 05, 2006

Periodic Breathing in Heart Failure: Bridging the Gap Between the Sleep Laboratory and the Exercise Laboratory

Artigos na Íntegra - Merck Sharp & Dohme: Editorial do CIRCULATION de um AMICOR
"Periodic Breathing in Heart Failure: Bridging the Gap Between the Sleep Laboratory and the Exercise Laboratory [Editorial]
Ribeiro, Jorge P. MD, ScD
From the Cardiology Division, Hospital de Clínicas de Porto Alegre and Department of Medicine, Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
Correspondence to Jorge P. Ribeiro, MD, ScD, Cardiology Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350 90035 - 007, Porto Alegre, RS Brazil. E-mail
In the 19th century, Cheyne 1 and Stokes 2 described a pattern of periodic breathing in patients with heart failure, but over the past few decades, particular attention has been given to the occurrence of periodic breathing during sleep.3,4 Central sleep apnea, also referred to as Cheyne-Stokes respiration, is an abnormal periodic breathing pattern in which central apneas and hypopneas alternate with periods of hyperventilation that have a waxing-waning pattern of tidal volume that classically has been associated with severe decompensated heart failure.4 Up to 37% of patients with heart failure may present obstructive sleep apnea,5 in which there is complete or partial collapse of a narrowed pharynx; as many as 40% of heart failure patients may present central sleep apnea,6 in which there is reduction in central inspiratory drive. Despite the fact that obstructive sleep apnea and central sleep apnea have different mechanisms, both are associated with increased sympathetic activity at night and during daytime that results in vasoconstriction, an increased peripheral vascular resistance.3,4 Moreover, small cohort studies had previously demonstrated that the presence of central sleep apnea is associated with increased mortality in heart failure.7,8"/.../

Tuesday, January 03, 2006

Preconditioning: A New Concept About the Benefit of Exercise -- Domenech 113 (1): e1 -- Circulation

Preconditioning: A New Concept About the Benefit of Exercise -- Domenech 113 (1): e1 -- Circulation:
"Clinicians have learned about the beneficial effects of several factors that may prevent a myocardial infarction (MI), including avoidance of smoking; treatment of high blood pressure, diabetes, dyslipidemia, and obesity; and regular performance of exercise. This last factor is based on epidemiological observations such as a decrease in the incidence of MI in men who perform heavy work1,2; however, it is only in the last few years that the beneficial effect of exercise has obtained plausible explanations of its own, that is, apart from its effect on other risk factors. There are at least 3 distinct mechanisms for this benefit: (1) Improvement of endothelial function, thereby preventing atherosclerosis and coronary occlusion3; (2) prevention of remodeling after MI through the expression of oxidative metabolism-related genes4; and (3) delaying acute ischemic injury after a coronary occlusion by preconditioning. "

The Year in Cardiology, 2005 - CME Teaching Brief - MedPage Today

The Year in Cardiology, 2005 - CME Teaching Brief - MedPage Today: DALLAS, Dec. 30 - In 2005 heart disease killed more Americans than cancer, accidents or HIV infection, and it did so despite continued advances in heart disease diagnosis and treatment.
Those advances have made a dent in mortality, which declined from 322 per 100,000 in 1990 to 241 per 100,000 in 2002, but heart disease is unlikely to lose its No. 1 killer title any time soon.
The reason, authorities say, is that prevention is an elusive goal, not yet within the grasp of the cardiology's considerable reach.
For example, according to the CDC's National Center for Health Statistics, about half of America's aging baby boomers have hypertension and almost 40% are obese-a combination that is likely to spell cardiovascular mortality for many.
And yet another study found that nearly one in five Americans from the age of 12 through 49 -- an estimated 16 million -- can't pass a simple physical fitness treadmill test.
Nearing Medicare, Boomers Need Diets and Blood Pressure Control
Americans in Droves Flunk Fitness Test
While the diet-and-fitness message continues to be ignored by many Americans, researchers have been investigating mechanisms of heart disease progression as way to develop secondary prevention strategies.
Inflammation is considered a major contributor to plaque instability, which led many researchers to suggest that infection may be a trigger for cardiovascular events. And if infection could trigger an event, then antibiotics might prevent events.
That was the theory anyway, and 2005 was the year that it was debunked.
In a National Heart, Lung, and Blood Institute (NHLBI) trial, patients with stable coronary artery disease who underwent a year-long course of weekly azithromycin therapy were no less likely to have a heart attack or stroke than patients taking placebo.
Likewise, in a study sponsored by Bristol-Myers Squibb and Sankyo, acute coronary syndrome patients treated with Tequin (gatifloxacin) for a mean of two years had no reduction in cardiac events compared to patients randomized to placebo.
In announcing the negative results, NHLBI Director Elizabeth G. Nabel, M.D., said it was clear the antibiotics did not work, and it is time to focus prevention efforts on "the controllable risk factors for preventing coronary events."
No Role for Antibiotics in Cardiovascular Secondary Prevention
Another popular theory, that aggressive lipid lowering with high-dose Lipitor (atorvastatin) is better than standard therapy with Zocor (simvastatin) or other less potent statins, retained its adherents even though it was not confirmed in one major study.
That study, Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) trial, found that high dose Lipitor did not achieve a statistically significant benefit compared with usual-dose treatment with Zocor (simvastatin) in patients with a history of acute myocardial infarction.
Patients randomized to 80 mg of Lipitor had an 11% relative reduction in major coronary events versus patients randomized to 20 mg of Zocor (P=0.07).
Moreover the aggressive treatment failed to achieve a significant benefit even though high-dose Lipitor lowered LDL to 81 mg/dL versus 104 mg/dL in the Zocor group. There were no significant differences in either cardiovascular or all-cause mortality.
But those results did little to dampen the enthusiasm of many cardiologists who said they will stick to high=dose Lipitor regimens, and they have solid evidence to back up that clinical decision. In the Treating to New Targets (TNT) trial, which enrolled 10,001 patients with stable coronary disease, treatment with high-dose Lipitor to mean LDL levels of 77 mg/dL was associated with a 22% reduction in risk of major cardiovascular events compared with patients treated to a mean LDL of 101 mg/dL.
When he reported the TNT findings at the American College of Cardiology meeting in March, principal investigator John C. LaRosa, M.D., of the State University of New York Health Science Center in Brooklyn said, "We have entered a new era in the treatment of established coronary disease from starting at an LDL of 100."
AHA: High-Dose Lipitor Does Not Outdo Standard-Dose Zocor
ACC: LDL Cholesterol of Less than 80 mg/dL Reduces Risk of Heart Attack and Stroke
But a big-stick statin may not always be the safest treatment choice, according to an analysis of post-marketing safety reports from patients using Crestor (rosuvastatin), a super-potent statin, Lipitor (atorvastatin), Zocor (simvastatin), or Pravachol (pravastatin).
Patients taking Crestor were eight times more likely to develop rhabdomyolysis, nephropathy, renal failure or proteinuria than patients taking Pravachol, and 6.5 times more likely to develop those complications than patients taking Lipitor.
Richard H. Karas, M.D., Ph.D., director of preventive cardiology and the Woman's Heart Center at Tuft-New England Medical Center, noted that the absolute risk remains low: 28 events per million prescriptions for Crestor, versus 13 per million for Zocor, 3.5 per million for Pravachol, and 4.3 per million for Lipitor.
Safety and efficacy of devices was also a big issue this year, and most of the news for Guidant was bad. The device maker was forced to recall 170,000 pacemakers and implantable defibrillators, which was more than half of the company's devices. Moreover, Guidant's problems triggered a months' long series of events that included a demand by cardiologists for a reworking of device safety alerts and recalls and a two-day FDA conference on device safety.

Implantable Devices Take a Licking but Don't Always Keep on Ticking
Cardiologists Urge Changes in Safety Regs and Guidelines for ICD Use
Crestor Called Less Safe Than Other Statins
But while the year was a rocky one for the heart-device industry, it was another boom year for drug-eluting stents. These stents-Cypher, which delivers sirolimus to the endothelium and Taxus, which carries a payload of paclitaxol-now are the stents of choice for most interventionists. What remains, of course, is heavy competition between the two.
In this head-to-head race, Cypher came away as the winner in trials reported this year.
ACC: Cypher Stent Edges Ahead of Taxus in Head-to-Head Trials
ACC: Cypher Bests Taxus in All Comers Comparison Study
Just as Cypher was the odds-on-favorite in the world of stents, Plavix (clopidogrel) was this year's winner for the drug reporting the most positive trial results. It was difficult to find a cardiology journal, or a cardiology conference that didn't feature a positive Plavix study. The take home message was clear: give it early and often.
ACC: Adding Plavix to Clot-Busting Regimen Saves Lives
ESC: Pretreatment with Plavix Reduces MI, Stroke, and Death Before and After Stenting
Plavix-Aspirin Combo Reduces Acute Heart Attack Deaths
Finally, a pair of low-tech but significant observations: dyspnea is not a benign symptom, and for men heart rate reveals volumes.
First, a study of almost 18,000 patients referred for cardiac stress testing found that people with no known coronary artery disease who report a history of dyspnea are four times more likely to die from heart disease than asymptomatic patients.
Second, a study of 5,713 French men found that when a man's heart rate is too fast at rest, he had a 3.5-fold increase in risk of sudden cardiac death. Moreover, if a man had less than an optimum increase in heart rate during exercise, his risk of sudden death was 20% higher than men whose hearts speeded up appropriately during exercise.
Dyspnea Is Predictive of Cardiac and All-Cause Mortality
Sudden Death in Healthy Men Can Be Predicted by Heart Rate