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EARLY CORONARY CARE

ACUTE MYOCARDIAL INFARCTION due to underlying coronary artery disease is the commonest cause of death in Australia and other Western countries. The risk of death after a heart attack is greatest immediately after the onset of symptoms, and then decreases rapidly with time.! Of every 100 patients having an attack of acute myocardial infarction, about 40 die during the attack, while 60 survive.P Of those who die, about twothirds are instances of "sudden" death occurring within one hour of the onset of symptoms." Most authorities consider that "sudden" death in these patients is due to development of arrhythmias, of which ventricular fibrillation is the most important one." Some of these lives might be saved if the patients received adequate treatment in time. Grounds for such optimism are based on the major therapeutic success achieved in recent years by special hospital coronary care units. In the development of these units, workers in Australia have played a notable part.5 , 6 The aim of these units has been to detect primary arrhythmias through electrocardiographic monitoring, and to treat them promptly when they occur. Treatment has been so effective that primary arrhythmias have virtually been eliminated as an in-hospital cause of mortality in patients under the age of 70 years. Since the establishment of coronary care units the in-hospital mortality has fallen to between 15% and 20% of cases of myocardial infarction, compared with the figure of 30% and 40% which existed before such units. The present residual hospital mortality is due to failure of cardiac pumping, resulting in either severe cardiac failure or cardiogenic shock. One period during which a further overall reduction in mortality might be achieved, in the absence of any satisfactory means of primary prevention of coronary