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Ter. Arkh., 1987 (15): 112-115 EFFECT OF "PASSIVE" SI+lO1CIaTG ON THE PHYSICAL LOAD TOLERANCE OF CORONARY HEART DISEASE PATIENTS E.Sh. Khalfen and V.A. Klochkov Saratov Branch of the Leningrad Scientific Research Institute for Cardiology of the Ministry of Health of the RSFSR (Director: Prof. E.Sh. Khalfen) Summary "Passive" smokin¢ has been shown to produce a marked negative e(Iet: on, CHD: patients. Short-term airinQ of a toum does not pre.ent a neQative effect of 'passive' unokinQ. Translated from Russian N O TE:''TF_ r5 ?S 1"T O'!" A

EFFECT OF "PASSIVE" SMOKING ON THE'PH'YSICAL LOAD TOLERANCE OF CORONARY HEART DISEASE PATIENTS By E. Sh. Khalfen and V'.A. Klochkov There is no doubt at the present time that smoking can promote the development of coronary heart disease (CH!D) [1,2,4,5]. The risk of CHD i~s doubled or tripled in people who smoke more than one pack of cigarettes per day [i3,10]. The incidence of a myocardial infarction an& sudden death has been linked directly to smoking [5,7]. Furthermore, the risk of a second myocardial infarction and sudden~death is reduced 20~to 50% (11,12] if the smoker stops smoking. A negative correlation between cigarette smoking and tolerance to physical loa& has been found in bicycle ergometry tests [1]. A spasm confirmed by coronary angiography in~the coronary arteries and intensification of thrombocyte aggre„ation have beem linked with smoking [9]. However, the overwhelming maj;ority of investigations have been carried out on smokers. Nevertheless, it has been shown [8',11] that even "passive" smoking, i.e., just being present i'n a smoky environment and breathing tobacco, has a strong negative effect on the state of the cardiovascular system. D. Makkenzi [S1 believes that about a thousand English people die every year from the effects of "passive" smoking. "Passive" smoking has not yet been investigated adequately. We have therefore performed'a study aimed at evalubti~ng the effect of "passive"' smoking on the indices obtained' in the bicycle ergometer test on CHD patients. , ~-*~u"-;a`~;

-2- We made observations on 81 people, 10 of whocm were practically healthy and range& from 25 to 48 years of age (average age 38) and 71 patients with angina of effort ramging from 31 to 63 years (average age 49'). All the subjects were men. The angina patients included 33'smokers (who smoked an average oF one pack of cigarettes per day) and 38'nonsmokere. The healthy group included 5 smokErs and 5 nonsmokers. Thirty-nine CHD patients hod functional class I and II angina of effort and 32 had class III and IV angina of effort. Fifteen had undergone a transmural myocartial infarct±on in the past and 10 suffered from stage II hypertensive disease. All the smokers abstained from smoking for two hours before taking the bi~cycle ergometer test. All the patients refrained from using antianginal agemts several days before the t-.sts, except for nitroglycerine tablets. The bicycle ergometer test was carried outt with the subjects in cA sitting positi~on on a Simens-E1ema bicycle ergometer, registering the EKG with three Nebo leads on a:fiingography-82 current polygraph. A continuous load was employed lasting 3 minutes, increasing by consecutive steps of 25 W. The bicycle z!rgometer test was stopped when a submaximum pulse rate was cnached, when the ST segment shifted horizontally or slanting down ward 1 mm or more below the isolines, when a typical angina attack occurred, which was arrested by administration of ni'troglycerine, or when the T wave was inver ted in two or more of the traces. In evaluating the bilcqcle ergometer test, we considered the I

-3- following indices: tolerance to load (in Watts), the double product of DP (in arbitrary units) and the ratio of the DP to the power load (DP/W). The bicycle ergometer was installed and the test conducted in a 24-m2 room, 3.2 m high. The test was performed on the subjects at first under the usual conditions in eccordance with the procedure described above. Than eight cigarettes were smoked in the room over a two-hour period (one cigarette every 15 minu~tes):. The subjects were in the room for this entire period, si~tting in a chair, reading magazines, talking, or playing checkers. A second bicycle ergometer test was performed after this two-hour period im the smoky room. The test was modified for 15 of the subjects by ventilating the smoky room for 10 minutes through a 0.5.-m~2 transome twice .. during their two-hour stay (at the end of each hour). In order to determine whether or not the first bicycle ergometer test affected the indices of the second test two hours later, tolerance to load tests were made on class II and IV angima of effort patients (average age 48')~twice„ two hours epart, after they had been in the room described above but without any smoke. The original tolerance to load averaged, 62.5 + 1.4 W and tolerance in: the second test after two hours was 70 + 2.0 W(threP angi~na of effort patients showed tolerances in the second; test that were one step higher, by 25 W). The tests confirmed the validity of using paired bicycle ergometer lioads. The validity of such a test has been demonstrated by extensive experience in our country and abroad inn grading patients who take antiangimal preparations.

-4- The tests have shown that the t;olerance to load in a group of practicall'y healthy people before a stay in a smoky room averaged 192 + 5.5 W, DP averaQed 246 + 7.2 arbitrary units, and the DP'/W' index was 1.3' + 0.04. Af ter "passive" smoking, the tolerance to load in this group was 197 + 5.7 W, DP was 238 + 7.1 arbitrary units, and DP'/W' was 1.2 + 0.03. Thus, there were no statisticaLly significant differences in the bicycle ergometer indices in healthy people and after "passive" smoking. We made a separate analysis of the results of the "passive" smoking test in the CHD1 patients without room ventilation (Group 1) and in those with a short period of ventilation (Group 2). The average tolerance to load in the Group 1 angina o.f effort patients was 8'7'± 2.6 W' before the "passive" smoking test in the unventilated room and 63 + 1.8 W after the test (p < 0.01). The n,ain reasons for stopping the bicyclie ergometer teat both bo ~ore and, after smoking were an attack of angina of effort in 21 people, ashift in the ST segmient 1 mm or more below the isoline in 18, inversion of the T waves in four, and achieving a submaximal heart contraction rate in three. "Passive" smoking in anigina of effort patients results i~n a losrer tolerance to load„ a lower DP and a higher DP/W ratio (Table 1). These changes were much more pronounced in class III and IV angine of effort patients than i'n class I and II angina puticnts. Thlus, smokers who were class I and LI nngina of effort ~ patieats shoued a 17% decrease in tolerarce to load, whereas class III, and' IV angina patienits showed a d'ecrease of 47%.

Functional cl~ass of angina of effQlrt -S- T.1BLE 1. Bilcyle ergcmeter test indices in patients with angina of ef'fort: A), before the 2-hour scay in the unventilated smoke-filled room; B) after the 2-hour stay (M+m). , Nonsmokers Smo kers Ind,_x I A I B . A B i o ~era»r:r to load, V I09f3,9 90t 2.8 <0.01 125 f 3.8 116t Z;s <a0s DP, arlii% .*ur its191t5,7 182_-t S.5 >0.03 18a=5+/ l77t5.3 >0.05 1.8t0.06 2.0d.-0.06 >0.05 1i.5t040S I.St 0.05 >0.03 Ialiit'alic:! to load, W 57t 1.6 30tt 1.0 <0.01 50:t: 1.5 28t0.8 <0,01 D"', art it. u 1tS1<8t1.3 12G:L0+6 <0.01 129:tJ,5 115*1.5 <0,01 Di jiT 2,6:t 0;07 4,2tt1:I <0.01 2.6_0.07 1.0*0.07 <O.W *srb-.trary units

The tol!erance to physical load and the DP after staying in the smoky room dropped distinctLy whether or not the patient was a smoker. However, the drop in bicycle ergometer indices induced by "psssive" smoking was somewhat Lower in smokers than in nonsmoktrs. It should be pointed out that such a difference was detecte& in, patients with more moderate an,gina of effort, whereas class III and IV angina of effort patients reacted almost identically to "'passive" smoking whether they were smokers or not. Patient E. A'ge 47. Diagnosis: CHD, functional, class III ' angina of effort. Pressing chest. pains radiating to the left shoulder appeared daily when walking or ascendi~ng a stairway. Pains Lasted 2 to 3' minutes af ter he stopped movinig or took nitroglycerine. The coronary angiographly indicated 90% stenosis of the right coronary artery and 507 stenosis of the c:ircumflex branch of the left coronary artery. A bicycle ergometer test was performed on June 27, 1985. No pathological changes in the EKG were detecte& at rest before the ergometer test. The bicycl!e ergometer test before "passive" smoking gave a tolerance to load of 75 W, o DP'of 220 arbitrary units, and a DP/W' ratio of 2.9. The test was stopped because of an angina attack and a shift of the ST segment 1 mm below the isolines om two traces (see Figure 1). A second ergometer test was performed after he had spent two hours in the smoke-filled room. This time tolerance to load was 50 W, DP 200 3rbitrary, units, and DP/W 4.0. The test was stoppe& because of an ansi;na attack and a shif t in the ST se-ment 1.5 mm below the isolines om the two~traces.

R B a b Figure 1. Dynamics of the EKG in patient E, age 47, during bicycle ergometer test: A) before 2-hour stay in unventillated, smoke-filled room; B) after the 2-two stay. a) EKG at rest; b) EKG during the bicycle ergometer test. Explanation in text.

-8- Thus, load tolerance droppe&, DP dezreased, and' DP/WW increased in a patient suffering from class III angina of effort after "passive" smoking. When the test was conducted by ventilating the room for a short time during the "passive" smoking period, the load tolerance of group 2 angina patients was 89 + 2.5 W before "passive" smoking and 63 + 1.7 W' thereafter (p < 0.01). The bicycle ergometer tests were stopped because of an attack of angina of effort in 7 patients, followed by nitroglycerine administration; because of a shift in the ST segment 1 mm below the isolines in 6; and because The rather large room used in this stu~dy was not very smoky, since only 8 cigarettes were smoked in two hours. In reality, we often encounter a much higher concentration of tobacco smoke in rooms. However, "passive" smoking in a rooL. with a relatively loww smoke concentration had a pronounced negative effect on all the subjects who were CHD patients, lowering tolerance to physical load, decreasing DP, and raising the DP/W ratio. A short ventilation period through a transom (which is usually typical of residential and service rooms) did not prevent "passive"'smoking of inversion of the T wave in 2. A marked decrease in load tolerance and DP' and an increase in DP/W were found'in the patients. Two 10-minute ventilation periods in two hours did not prevent the effect of "passive"' smoking (Table 2). from exnrting its effect. .

,. Functional class of angi~na of Ffllort -9- TABLE 2. Bicycle ergometer test indices in patients with angina of effort: A) before 2-hour stay in smoke-filled room ventilated for short time; B) after the 2-hour stay (M+m). Index Tolerance to load, W DP, arbit. uni j~P [W l~o~ierance to loaid, W DP arbit. uni DP)W Nonsmoicers A I B I 0 A Smokers B I' . 120t: 3,3 105t 3.1 i <0.01 113.t 3.5 110f3.3 >0,05 S 196f 5,7 183*5,5 >0.05 1'90!t 5.4 1d8*5.2 >0;05 1 ,6:t0,05 1.8:L-0.06 >0.05 ;'.7=0106 1:9 :L-0.06 >0,05 5u.-!: 1.4 25t 0,7 <0:01 50f L4 25t ae <0.01. s 143:L- 4,2 118:t 3.6 <0.01 137f3;4 . 110-29 <0A L 2a* 0,08 1.7t0.1 <0,01 Z8* 0.07 4.0Z- a09 <o,on