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NOTICE This matzrial' may be THE pr3tected by Copyright law ;>'.itle 17 U:S. Codel. NEW ZEALAND MEDICAL JOURNAL 12 July 1989 Vol'ume 102 lu o 871, Deaths from lung cancer and ischaernic heart disease due to passive smoking in New Zealand I Kawachi MB, ChB. MRC Training Fellow in Epidemiology; N E Pearce PhD, Lecturar in Epidemiology. Department of Community Hea/th. W.Ninqton School of Medicine. Wellington; R T Jackson MCCNZ. Research Fellow in Epidemiolopy. Department of Community H.atth, University of Auckland School of Medicine, Auckland Abstract Pausive smoking is increasingly recogni.ead'u a public haalth hazard. Among New Zealanders who have never smoked. the ptevaleacs of exposure to spousal smoking has been eatimated' to be 12.7% for men and 16.1 % for women- The prevalence of exposure to passive smoking in tbe workplYce has been estimated to be 33.6% and 23.4% for never smoking men and women respectively. Tba pooled risk estimatas from epidemiological studies of the health effects of passive smoking were used to estimate the numbers of deaths from lung cancer and isrtia.r+;r heart dieeax attsibutable to paaova smoking in New Zealand in 1985. The pooled relktive risk estimates for lung cancer mortality were 1.3 (95% confidetue interval (CII: 1.1-1.51 in both men and women expoeed' to passive smoldng at home, and 2.2 (CI 1.4-3.0)'ia both men and women exposed to passive smoking at work. Using these relative risk estimates, it was calculated that 30 lung cancer deaths (rangt: 11-41) were attributable to invohintLry'smoicn~ in New Zealand in 1985. From pooled relative risk eetimates of ixhaamic heart disease death of 1.3 (CI 1'.1-1.61 and' 1'.2(CI 1.1-1.4) for e:po.un to spousal smoking in men and women respectively, it was estimated that a further 91 isch.emic heart disease deatha (range:, 39-177) were due to passive smoking at home. Tba number of iscbaemic heart disease deaths due to passive smoking in the workplace was even higher, at 152 (rangr. 62-2241. aas' R+ing relative risks of 2.3 (Cl 1.4-3.41 and 1.9 (CI I.4-2.5) for men and' women respectively. The total number of deaths due to passive smoking from lung cancer and t.ri.YT'v beart disease was therefore estimated to be 273 pr year (rangti 112-442). !R 1La Ji ta! ta 2046 Introduction Racent reviews bave conduded that ezpostur to passive smaltiitg is harmful to health It~l. Tha effects of pasaave smcAing on health have been reparted'to include acute effecta& sucb u•*a^er++ariM of aathma and aagi.oa, as we11 as chronic eftects such as the incraased'risk of upper and lower airways infection in children and tba inczeaxd risk of fnns uncer in adults Nl: Tbe asaooatioc of lung c.ncer with pasive smoking appear to satiafy epidemiolopcal tritarie of causality le.s1 To dat. 13 studiee have be® completed in siz countries. 10 of which have reported a positive associatioo betwem lung cancr and pasaive smoking /sl Three studies have failed to show an aaaodation r7•sl, but in each study the precision of the effect eatimates was such that an increased risk could not be rubd wt Publication bis, is, bias which occurs when papers with ^o^iificant results are eitber not submitted or aozepted for publication. has been put forward' as an explanation for the association between passive smoking and lung canccr Iiol: However. this claim has been criticised and discredited iiil. More recenUy, evidence has begun to accumulate which implicates passive smoking in the development of ischaemic heart disease I1t•14G Passive smoking is therefore a potentially important public health problem in New Zealand. aad'it is desirable to assess the magnitude of the problem. Taking the relative risk estimates reported in epidemiologlcal studies and applying them ta estimates of the proportion of the New Zealand population exposed to passive smoking, we have made a preliminary eetimate of the impact of pasaive smoking on the health of nonsmokers.. We here report estimates of the numbers of deaths from lung cancer and ischaemic beart disease attributable to prolonged exposure to passive smokmg in New Zealand in 1985: The evidence of excess deaths from other causes-ieu cancers of sites other than the lLwgs. and chronic respiratory disease- due to passive smoking is more tenuous 12G Death from these causes has therefore not been considered hers. StatJsUt:al methods The proportioo of deaths lrom a particnilar di.easa attributablato a speaSa exposure is Jmown aa the pcqulatioa attnbutabie ruk IaLo rcferred to as tbe a.twlbpc frsctoni: If p is the proportion of tbe genai papuLtioo exposed to the raak factor lin this cara involuntary smolnno and RR u tbe relauve nsY tbea of dying of the disease in ezpowd'ventu cone>3xi..d iodividuals, t;be population attributable risk is given by list PAR - p(RR,- 1) pRR-1D+1' 'Ilus measure has bean used in many pr.vious studis.. including two studis wbicb estimated tbe propcrsno of deatds io New Zealand atznbutabie to active smoking jiaj7t u..il as in a Can.diaa awd'y wbuh setlmatsd the proportion of lung caarer deatha attributable to pa=ve smoicns n In tbe current sWdy, the relative riak ercimat.s from ov.rssaa studies wers appliod to New 7.alYnd' data on paacvs smolan~ ezpo.ura and the drivad populatim attributabis risks wa. tbae applied to Iuat cs^ew and iach.emic b.at diiresae deatfts ia 1965 among p.rseaa who had never smoked fisF The populauon attributable nska and deaths attributable to puave smokung ww+ m'ud .eparauty for men and:woeyn. and forarporun at home and'u worit EstJmation of exposura to passive smokirty Farimat/oa of ezpoeurs to passive smotfng at home:. Estimatea of the prevalence of exposure of never smokers to passive smoking at home were obtained from the Auckland heart study (work in progresal: The study found that 12.7% of' never smoking men and 16.1 % of never smoking women aged 35-64 yeirs in Aucklaad in 1987-88 were exposed to paasive smoking in tbeir homea. Thex figures an not limited to ezposttn to spousal smoking, but include exposure to all

338 NEW ZEALJ.ND SfED1CAL JOURNAL II lULY 190% other sourcas of passive smoking withia the household On the other Sand theee figuree are likelN to undetesumau the effects of iong term exposure to spousal smoking. stace we have not waen account of never, smoiters who have been previously exposed to passive smoking: but are currently widowed': separated. divorced. or tivtng wtch ezsmoker3, E.timatoos of exposure to paaaive smoking in the warkplJ.ac The prevalence of exposure to passive smokmg in the woricplac+ was also obtatned from the Auckland bears study. Itl this study. 33.6% and 23.4% of never smoking matt and .vomen. aged 35-64 years ia Auckland in 1987•88. wen exposed to passvve smoking at worr A recant random teiephone survey of the Wellington reglon reported that the proportion of nonsmokers exposed to pan.uve smoking in the .•oritplan may be even higher. reaching up co 80°b,i19t However a ssgaificant proportion af the respondents reported: that most of their exposure occurred dutang tea and lunch breaks. Therefore we adopted the more conservative prevalence esttmaus. Estimation of r.Iatllre risks associated'with e:posurs to passive smoking FAcimatioa ot the relative risk of lung cancer doe to p..ai.. .moking at bome: The relative risk of dyusg of lung canars in never smokers exposed to spousaPsmoking was obtaaned' from the pooled resulta of 10 case control studies and two prospective studies 1201. The relative risk of lung cancer mortality in women who harl never smoked and who were marrud'to ever smokersm weignted by the Mantd'Ha.ns,t.l pmocedura was 1.3 (95% confidence intarvaLl 1.1-1.51 Iml There have been few studies .:' lung cancer among men who have never smoked We have i+sumed. as others have done RIL that the relative rask of luag cancer ih never smoking men asrrled to ever smoking women is the same as for nsv.r smoking women marned to ever smoking men ITable 1). Tebie 1.-EarUmats of rn/atiw -x ofdrthe from 14ne canCM.snd i.c6semic heart df.aese due to a.sive .motina. I>a% confldenca intervaJl Dis.as. RelLtove rs from exposure a home R.lative risk from e==poswe at wot Sfee w'omm Mea Woman Luns cancer 1.3 1.3 2.2 2.2 I1.1•LS1 ;1.1•1.51 (1.4-3.01 I1I4-3.01 Iscbrmu heart di+ease 1.3 1.2 2.3 1.9 hl.l•1_Q1 L1•1i.el (1sW.4/ (1.4_TSI' Eatimatiun of tbe relative riai ol lo.as eascQ due to p.saive smokzng in the workplace: Tb& elevated lung cancer risk from passive smoking has beea well eeublish.d but few studiee have specifically examined ruks from woricpiica ezpoeur+s. Thus iasuad of uaing direct escimat.ea, the relative rutk for lung cancer death from ezpoetue to passive smoking in the workplace was estimat..d via an ezpoettre reaponse relationship derived by Repan and Lowrey If.21y They estimated that the degree of exposure to passive smokin.g at home_ at work. and at both sa ces correspooded'to respective daily inhalation of 0.45. 1.82 and 2.27 mg of the particulate pdu. of ambient tobacco smoke (e~ Aornrding to this model~ espcxure to palave smoidag at woric should rvult in a hiatier r>sic for lung cancer than erposure at homa Haaed an tke relacive risk rumate of 1.3 for bome espo.urs (Table 11, the relative risk of lung cancer in per.oos arpoeed to paasve smoking in the workpllsee was estimated to be 1+ 40:3 z 1.8?J0.48). yielding a r.tative risk ..amatr a[ 2.2 (raoge: L4-3.011Tabl. 1). Thia estimate is ennaist:mt with the relative risk of 3.3 196% a.+a8da-o iat..wa1• 1:0-10.51 ftr twer amnitaes exposed to passove amokcng at work reqertad by Kabas aad Wyndar issL in one of the few studl.e that has di-t;*: ;-b-^ e=pwur+ at worti 4om arpo.ar* at bu- Ho+.vair. ws have .doptrd tbe mc:e conacvacve aetimaru of 22 (Table 11. Eitima dra of the e.i.tfve ri.k d Lcka®ie bret di....e d.etf doe to prsed" safto(IC/sg as bcmc ?be snnmat.s for the tdattrf r¢sk ot iscb+.micheat dSa.w d.ath m nev.r smnitss ezz+a..d mp"ytvsalokFSg w•r. oix~a.d Sr~ W.da• pnoid anabais of 5ve cohort studies and'two casm control studies lut The poo/.d' rolauve rtsk for man exposed to spou»L amona. +etght.d by the 'Wantal-H'senszal proc.dure. was 1-3 /CI: 1.1•1.61: and the eoereapoading eetiT-•- fa women was l.2 ICI: 1.1,1.41 12st Fitisnatioe of the relicve rcuh of iaeh.amirbeart dls.a.edrth due to passive smokin= in the woraplaci: Then u at prwnt scaat data Otl the relauve rtsk Of irh-TK heut disaaae drath due to passive smoking in the workplaee. The study by 5vendsen et aI (13L based on daa from the MRFIT tnaL reported that the ralattve risk of coronary heart disease death in men exposed to coworkers smake compared with mea whose coworiters did not smoke. was 2.6 Iln However. the risk estimau wau lmpredae CI: 0:5•12.7: p-O:231. and m addition. the MRFIT trsal'iavolved mea who were at high rvk of coronary heart disease at entry. Neverthdaes, a higher vdue for the relettve riak of iae aemie beaet disease death from ezposure to passive smoking in tbe workplace aompared to the home ia c++nso-taat with tne greats prevalence and intensity of exposure obtaused ia tbe former setting Is4 Using th. same assumptions as in our caltuLauon of the r.lative rult of lung cancer frcm paasive smokoing tn thl workplace, we eetimated that the relative risk of ixhaettue 4r:eart disease death from paanve smoking in the workplan was 2.3 Irange: 1.4-3:41 for maa and 1.9 (rang.c 1.4-2.3) for woman. respectively (Table 11j Estimation of deaths du• to passive smoking Tbere aea a cottsid.rable number of uncertaintaes in the estimation of deaths due to pveive smoking in New Zealand. These redau to unrR•„*ties in the number of deaths in never smokers, the prevalence of ezposure to passive smoking, and the relative risks due to passive smoking. The main uncertainty stems from the relative rtsk esumates. Aceordingiy, to provide a range of plausible valuen for the population attzibutable rvics- the 95% confidenci interval for the relative risk estimatas (Table 1) have been usedL and the other e.stimates have beea rsgtirded u fized Rangp have alao been provided for the estimates of the numliar of deaths in never smokere ITablse 2•5) in order to give an indication of their prsdsioa but thetie rsngea have not bem ua.d~ia furtbt caicuiationa. Estimatiba of lung taatesr deaths attributable to passi.e smoldag at homc In 1985 there were 1197 lung cancer deaths in New Zealkad (lal-86fi in mm aa&331 in womm. It was estimated from the cancer regutry dtta that 8% Of these deaths oeeurred in never smolCess (z.l. Therefore 69 male lung cancer deaths. and 28 famale lling cancer deatha occurred in never smokeas (TabL 2). Tabi.2-Esdrnetad numbeeof deetls hoen h+np onear erttib%rtaW.. ta o..we.rywun to spoad vnoke in..M~ 2riand in tSMS..bV sa M.a Wom.a Total m of lung cancer deachs B66 331 % of'p.opl. who h.d tw~ smoitd 8% 8% No at lung canc.r d.aths in rltor wbo Ead never smobad 69 28 PrWvajdace of ae~w sawkwo arpo..d to syw..l +mdrms 127; 16.110 Ralaave nak of htnt c-aor fer a~o~~n rn spnoaal amos 1.3 1.3 . IC11 tl.l•1.s1 (1.1•1.51 PAR apouasf smdoa 3.7% e.Et (rsaae/ f 1.Sd:0 x I I t.67. S S I No ol Am= oaoer d.erJu a o.vw smok.n atatbutahie te R~W --k+at 3. 1 /nasw/ 11!dl 162f PA&-pepalaioa amsDasabi+ tzak Tb. poWlaac:i .m'sbutibie naka were calealated to be 3.7% (tiasc 1_3•l.0%1 for mea aad 4.6% (raaQc 1.B-7.5'y) for wam.n (Table 21. 'I3s numbrs ot ]ung ra M- deacha in 1983 atal.'batibie to paea.e amoitms at home were therefore ..amaud tn ha~n been 3(rangc 1~) for men and 1 IrusgC 0-M Eor wosns. Qv=S at cc ~ of 4 Itanget 1.4 1.

JULt' 1989 %E>t' ZEALA.NQ vtEDif.41 JOt'RNtL Estimation of lus= tascer deaths attributabie to paseive smoking in the workplace: Assuming a relatave rtsk of2:2: the population attributable risk for lung cancer deaths due to passive smoking in the workplace is 28.7% lrange: 11.&40.M (or men. and 21.9% (rattgec 8.6•31.9°61 for women,lTable 31. The number of lung cancer deaths in never smokers attributable to pasatve smokutg in thi workplace is therefort: estimated to have been 20 Irange: 8-28) for men. and 6(range: 2•71 for women. giving a total of 26 (range: 10-351 (Table 31. The tocal annual number of lung cancer deaths attributable to pusive smoking is thus estisaated to have been 30 (range: 11•41). of which 87Qb is attributable to exposure in the workplace. Teb+e 3. - Estitnated nutnbet of deaths from lung cancer attributable to passive {mokinp inthe work plica in New Zealand. iM.bv sas Man Women No of lung cancer deatles in never smokers 69 26 Ptevalence of esposure to pasaive smokang to never smokan who work 33.6% 23.4'>i Relauve risk of lung cancer for ezposut+ to passive smoking at work 2.2 2.2 iCl) 11.4•7.01 11.4•3.01 PAR. work exposure 26.746 21.9% Iran=ef 111.8•40.2*.l e8:b34:9~1 No lung canoer deatha in never smoken attribucable to passive smoktns at work ' 20 6 traagel &261 12-71 PAR- population aCtrlbfitable rtak Deaths from ii-ebaemic beart disease attributable to pasaive smoking at bome: Data on the proportion of iachaemic bean disease deaths occurring in never smokers in New Zealand were not available. We estuaatad this proportion by applying the relative risks of ischaemic bean disease death - obtained from the cohort atudy by Doll and Peto Ips.2e1- for each category of smoking (never smoked. ezsmoker, smoking between 1•14. 15•24. and over 25 cigarettes per dayl to the proporuoss of New Zealanders aged over 25 years in each cateaory: based on the 1981 cearus data Irli!, The proportions of aever smokers among iacbaemic been deaths were then calculated as the percentage of all iscbaetnic bean disease deaths that would be ezpected to oavr. based on there relative risks. It was thua estimatod~ that 32.3% and 42.0% of ischaemic heart disease deaths otns in male and female never smoken, respactively. T6ese Ctgures are in close agreement ,with unpublished data from a coronary bean disease register in Auckland (Jackson R: work in progress). The population attributab{e risks for ischymv buartdissase deaths in persons ezposed to spousal smoke were estimated to be 3:7% (range: 1.3•7.1961in men. and 3.1% (1.6-6.1961 in women (Table Cl, The number of ischaemic bean: disease deaths attributable to passive smoking in the home in estimated to have been 51(rangs•. 18-971',i=1 maa aad,401ransa: 21•801 in women. a total of 91 deaths franie: 30-1771: Tabh 4. - Eatlmeted number of Matrta from iaehaeenlt haert dlaeree emibutabN to paaeve eapoaas to apouW arnokino In New 2"iand. 101011. by eea Man tvomae Total' no of daetlis from IHD 4234 3106 % of pera}'s who had oevNr Imoilad 32.3% 42:0% No of W41e who had asver smoked Ptevale]ra of ilpOfUrtr to spoYaal 13ia l306 smoke a1Son[ mafrled neMf amokar7 12.7% 14.1% Ralative riak of IHD for a:poeu» to spousaJamoka 1.31 1.2 ICII i1.1•1.61 11.T•1.41 PAR. spouaal amolta 3.7% 3.1% Iransel (1.b7aT.l Il.b 6:I7~1 No of I7dD slaaths in oever smokers attributable to spousal smokias Si 40 lrsaa-I 116-971 121•601 , PAR - populatwn attnbuuble risk: IHD'- iscbaamic lrart disasf+ 139 Deaths from iachsemic bean diseaae attributablk to passive smoking in be workplace: Since the risk of tschaern,c heart diseax from active smoking dimirwhes rapidly after cessation of smoking. it was assumed that the risk of lachaemu heart disease death from exposure to paasive smoking in the workplace would similarly decline after withdrawal from the workforce. Fiuthertaore, the estimates of workplace exposure used in this study (Tables 3 and SI were based on data for Aucklanders aged 35~'i4 years. Thus. conservative estiraates of ischaemic heart disease deaths due to exposure to pas„ve smoking in the workplace were denved, from the number, of ischaertuc heart disease deaths which occurred among those of workutg age, it. those aged under 65 years. In this age group there were 1276 deaths in men and 366 in women in 1985 11en (Table SI. Tabb 6-Esomatad nun+ber of derW from iect+wrnic -wrt 640ew attributable to paaaive amokinf intAe workplsca in N*w Zealand in t= `teo Women Total number of isclurmic lieart disease dr«aths in Ppp4 aged <6S years 1276 366 'b of people who had never smoksd 32.3% 42.0% Number of iscrsem.ic heart disease deaths in never smokers ated <65 years 412 164 Prevalbnu of ~ espoeure to,passive smoking in never smoksn who work 33.6% 23 4% Relateve rtsk ofuchaemsc Fieartdiseaae from exposure to,paaatve smoking in the workplace 2.3 1.9 ICI)01.4.3;41I 11 .4•2:5v PAR. worltplaca exposure 30.4% 1' 4% iranae) (11.8-44.6%1 16.6•26.0".I No of iachaeauc Mart disease deaths in never, smokets attributable to smoking in the workplace 125 27 lranseli 149-1841 r13-401 PAR - population attributsble risk The population attributable riaks for deaths from ischaemic heart disease due to puaive smoking in the workpliace. assuming relative risks of 2.3 for maa and 1.9 for won>•n. were 30.4% (rangr: 11.8-44.6961 in men and 17.4% (range: 8.6-26.0'S1! in, women. These yielded estimates of, 125 (raage: 49-1841 iscbaemic heart disease deaths in men. and 27 (range: 13-40) deaths in womea a total of 132 deatll.s (rangr 62-2241 fTabik 51: Discussion The esti:natad~total of 30 lung cancer deaths attributable to passive smoking represents 2.5% of all lung cancer deaths in 1985: and 31.6% of lung cancer deaths in those who had never smoked. These resulta are similkr to previous estimates for USA lei and' Canada Isl Repace and Lowrey estimated that paasive smoking was responsible for 5% of the totallannua]' lung cancer deatha, and 30% of the lung cantw deaths in never smokers in the USA la} Wigla and Collishaw estimated that in Canada passive smoking .ca,s r*eponsible for 2.3% of the total annual lung c,nca- daaths. and'•S1qs of lun,g caaae daatlis in never smokers Ia{.! It is eetimated that 243 deaths from isckW*Y hsart disaase ocivered in 1985 due to passive smolting.'ibis ewpeeeecta 3.3% of all -xbaemic heart diaeaae daatha. and 9.1% of iscba..m;c heart disease deaths in never smokes•s. The total number of deaths in New Zalaland in 1f183 bom h.tn; riacst, and iV'bag%•^ ^ heart di,ease due to passive smoking was estimated to have been 273 (range: 112-44,21: of which 66.2'1[, was attributable to exposure in the workplace (Tabli 6). As we have stressed throughout, thars are a number of uncer-int»s in theae calntlarions, and the totil of 273 deaths per year from lung catscez and iacbumic heart diss,ase due to passive smoking should be regarded as only a preliminary estimate. Nevertheltys it doee indicate the Likely magnitude of the mortality due to pasaive smoking in New ZeaJand. The findiaga of this study will nead to be revi.wd as more acrurats data particularly on the reletive risks of diseaaes due to workplace ezposure to passive smoking, become available.

340 NEW gA/^ND stEDICAL JOURNAL However then arr a number of reasons to suggest tLat the Ctgures presented herr are underestuaates. Firsdy, we have not considered'the numbers of'd'eaths attributable to passive smoking in two groups of nonsmohen:111 never smokers who arm not currently esposed to passive smoking at home land in t:he case of ischaetnuc heart disea.srcaaes. at worki. buMho have been exposed in the paut. and (21 etsmokers currently exposed to passive smoking. Sscondly..ve have not considered exposure to passive smoking in situations other than at bome or at work.,nor the impact of passive exposure to pipe or cisar smoking. Thirdly. we have not made adjustments to the relative risks for possible rrusclassification of szposures., In studies which have corrected for these biases waat the net effect of the adjustment was to raiss the relative risk estimates. Fourthly. we have not attempted to estimate the numbers of deaths from cancers of sites other than the lungs. Based on three cohort and two case control studies. Wells estimated that the relative risk of cancers other than the lunss in never smoking women exposed to passive smoking was 1.16 43% confidence limits: 1.06-1.27)fz34 Excess cancers were observed for cancers of the breast. cervix. brain. paranasal sinuses and endocrine gland>t 1231. Although thesa studies have been criticised for their failure to control for risk factors known to be associated with cancers of these sites /21i it is nevertheless Ukely that at leaat some deaths from ths.e caoair types are attributable to passive smoking. Finally. we.have notattempted to estimats the numbera of pneumonia deaths attributable to passive smoking in chiliihood nor the ioawassd numbers of perinatal deaths associated wnth smoking dunng pregnancy 14 Despitt the uncertainties in the estimates presented'lun.& they nevertheless suggest that passive smoking is a malor public health problem in New Zealand. Although a more precise estimate of the number of deaths due to pusive smoking must await further studies, there is a clear case for taking action on current evidence. The protection of the bealth of nonsmokers. particularly in the workplace and in enclosed public places. must be given priority as an iasw of environmental health protection. It is encouraging that the necessary regulatory actions are beginniag to occur. Achaowledsmeats: The author. wish to thank Professor Robirt. Beaglehok. DnHutA Bonita. DrDsvmd Hay and Dr Murrsy Laua.e.a for thev valuabte advlce and susyeswons on eolier drafts of this rnanuscrspt: DrKawachi is supported by a Medio! Res.arsh Couadl of hew Z.alaed truaung feiiowship. Dr JKksoo'ls supported by the Nu+onal Hiart Fauadawn of Nev 7a1acd and tM Med+cal nMe.rcl+ CouoaJ of New Lalaad. t Health, Car*ee'e~aM.«: Dr I Kswschi Departzoent of Commun+ 5ouch: t't''.4Jlastoo ScLool of MetLaee. PO Box 7313. 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J E..e../e/ Isu t,1, als017 S•.r•r K H. KtJir LM: f1. WOetr J K Etl.ev M. e..a.., osawS u Ye aW6yr ~ frv taYr...~ vYt' Aa J E'pMrtl IM7: 121 `rJr!' 1. Ma.ar KJ S.dlr Dr G..Yd 6 W: C1r C Hw 6tsv er..uty r .~ L•Yr au' - Aa J CrMd IM/ IZT slbZ7, su ' - AM 1~...e.d DC E-.-..-..r..r..dsoa ae.a oa.a orP :reo 16 K.yD0. SrtS AH. fWV DM M.n.Yq .unAtYOr Y r~aa~y u ~w L.La\Z M.~ Iey'. M /tr. 17. GnrAJ It.aasJA.L're~M Tlrew..feev.aY..a.yr~wZ.Nr! %Z 1it.1'J 12411 t01 570... il •.ue" MWeAS•,.M-Gwua. Mw%.Yty...eba.pyAa 4YIMd Mayarv •.y...l MWti SYWt.e C-1n. 11/' 1! D"Ytawt a/C~ty MWt[ rwsNi~ treitYt.eM tnrar.w.~{Ye !Y ..v rWcal iWOwt Ae/R w.W'y1e WI4~ StMwn d..MwLaa..lw70 oYr WJ r~Jr prw.r.tyle rWrt ns J %.W C.rm Ln SMf T9 M>r 27 R..r J L L..r.r A H Pwt4eLae tL MuK( u.en rrY M Y...uc f1.ew ...rw4 A. 0.. sw Dulrel. tstIiO.. 32 K.a.r GCC w r.w . EL Lry .as a a...aak.. C..w I M. 13 1 t1.-t 1 27 »d1. AJ A...L-t .t .nJt rn.Yq rti. lf..Yi1 SwY. Ira.'..rq +reW E.wsme 1.t~y1Ltl 1sY. I... LFYi. •srrN'Mwit 9r,u.arp. Cwoa C.r C.Y IIM bt.a w np.rrrr.ee e.M" IN1 Yd 1962 . M'W'uela VµiN Hwlq S-Lmm t-tn IfLS 23 Dall IL hv IL Ma%anty. t. nlar Y...bae: !D r+MS.Y.r..~r.. r Mai. ar,uJpan~ . or Yty J Il7l LSkiJl34.. X DW R G..r. R H.hw S. hu R M.WeT.o nVSa Y e.me.e 22 rrs ...,. m r.m.ra Bnus! ewwr. 8, Md.J lsso I s./ca r Dsvt~t ds~ V.. Zr1wC ~ .f yqiWS~ rae.wllap IMl eW/wra..~.ntY .nea.4 M.uYr... D........e.a Sst.wio Isu7J r.W .J %.re." K tTa0p.r ffiM~.. CrrsJl MS'. D- b..rhrr nir p.ri. Y.eo aot. ~ v.e orew's. Mr J lfM. ifJ121'a1 Congenital long QT syndrome in adults Ian G Crozibr MD.,FRACP. Cardlbloyist:,Annamarie Louqhnan SSc. Cardirc Technician: Lazil• J Dow 6Sc, Cardiac Technician: Cflv J 5 Low MS. Chil. Cardioiogt Reqi'atrar:, Hamid' Ikram MD. FRCP. Cardioioyiet. Dapartment of Cardioibqy. Princeea Margaret Moapital. Chrtistchurch Abstract A family with the Romaao-Ward syndrome is present.d 7]us family showed typical' features of this syndrome wtth QT prolongation. torsades de pointes ventricular tachyeardta sudden death and an autosomal dominant inheritance pattarn The index case presented with an ez>,cerbation of torsadar de pointes ventrieuJar tachycardia from diuretic induced hypokalaetnit and respond.d to diurstir withdrawal and b.u blocker therapy. !R MY,.f J ts! I! arl Introduction Abnormalities of ventricular repolarisation predispose the heart to ventricular arrhythmias. typically pol'ymorphsc ventricular tachycardia (torsades de pointes): Abnormd~ repolarisation~ is typically represented on the surface electrocardiogram by QT interval prolongation. However T or U wave abnormalities may also reflect abnormal! repolarisatioiL Abnormal repolarisation is usually acquired due to cardiac injury:,metai+r+lic derangem.nt or drugs. Rar.ly: abnormal repolarisation is congenital and may occur either sporadically or a,s an auto.omJ11 r.caaaive or doaunant coodicion: We present a family witII auto.omal doraiaaat QT prolongation and torsad.r da point.* ventJitvlar tachycardia The patient The lndes case was a se ysar old fnaalb witli a life long history of syncope whied .u usually pr.npiuted by exertion or emouonal streu Thr.e months pricr to sdmusioo she waa commeneed ae cyclopentlu=de0.S mg d'aily for byp.rtansioa Sino coazuaenom.et ot cycloprnthluide sh. reported that the syocopal episodes became morw frequent and prolotta.d' Durias oae episods abe wu observed' by her husband to be pale and pulseleaa. Sbe had no other stsnabust put h,scory, and was on eo otbr medicauons On admission le hosplul sbe wu ansious but othr+sse well. Blood pressure v+s 140,80 mmHi and a.oers! ••••^lo•tioo eormaL' Reetsag rhythm see>•