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NEW ZEALAND MS'"L!,-JD1CAL JOURN'AL.~ passive smoking in New Zealand I hdwecj6r ead. 4nN. ar...~. sranisep t*UVw In ty."m;uiollY. :: : ot t.ommunity Health. WeNinyton School of Medieine. WNiiaston. R T./ar'laon MCCNZ. Rose..rctt Fatlow In Epidemioloyy. Oepartment of Community Health. Univenity of Auckland School of Medicine. Auckland Deaths from lung cancer and isr~haemic heart disease due to Abstract Passive smoking is increasingly recognised as a public health hazard. Among \ew Zealanders who have never smoked, the prevalen_e of exposure to spousal smoking has been estimated to be 12.7°'o for men and 16.1 •5 for women. The prevalence of exposure to passive smoking in the workplace has been estimated to be 33.61-o and 23.i"o for never smoking men and women respectively. The pooled risk estimates from epiderniological studies of the health effects of passive srnoking were used to estimate the numbers of deaths from lung cancer and ischaemic heart disease attributable to passive smoking in New Zealand in 1985. The pooled relative risk estimates for lung cancer mortality were 1.3495% confidence interval (C11: l.1•1.5) in both men and women exposed to passive smoking at home. and 2.2 (CI 1.3-3.01 in both men and women exposed to passive smoking at work. Using these relative risk estimates, it was calculated that 301ung cancer deaths (range: 11-t 11 were attributable to involuntary smoking in New Zea:and in 1985. From pooled relative risk estimates of ischaemic heart disease death of 1.3 (Cl 1.1•i.61 and 1.2 tCI 1.1-1.4) for exposure to spousal smoking in men and women respectively. it was esti.-nated that a further 91 ischaemic heart disease deaths Irange: 39-1771 were due to passive smoking at home. The number of ischaemic heart disease deaths due to passive smoking in the workplace was even higher. at 152 (range: 62-2=4t, assuming relative risks of 3.31C1 1.4-3.41 and 1.9 tCi 1.4-2.5) for men and women respectively. The total number of deaths due to passive smoking from lung cancer and ischaemic heart disease was therefore estimated to be 273 per year irange: 112 44'21. Y2 M.4 J t79 1'*_ LTJO Introduction Recent reviews have concluded that exposure to passive smoking is harmful to health 1: al. The effects of passive smoking on hralth have been reported to include acute effects. such as exacerba:.on of asthma and an3ina. as wrll as chronic effects such as the increased risk of upper and :ow•er airways infection in children and the increased risk of lung cancer in adults (al. The association of lung cancer w•ith passive smoking appear to satisfy epidemiological criteria of causality is FI. To date 13 studies !:ave been completcd in six countries. 10 of which have reported a positive association between lung cancer and passive smoking Isi. Three studies have failed to show an association 17-yI. but in each study the precision of the effect estimates was such thaL, ..n increased risk could not be ruled out. Publication bias. ie, bias which occurs when papers with nonsignificant results are eitner not submitted or accepted for publi_ation. has been put forward as an explanation for the association between passive smoking and lung cancer fto{. However, this claim has been criticised and discredited ittl. More recently. evidence has begun to accumu/ate which implicates passive smoking in the development of ischaemic heart disease 112•141. Passive smoking is therefore a potentially important public healtl. problem in New Zealand. and it is desirable to assess the magnitude of the problem. Taking the relative risk estim:,tes reported in epidemi-logical studies and applying them to estimates of the proportion of the New Zealand population exposed to passive smoking. we have made a preliminary estimate of the impact of passive smoking on the health of nonsmokers. We here report estimates of the numbers of deaths from lung cancer and ischaentic heart disease attributable to prolonged exposure to passive smoking in New Zealand in 1985. The evidence of excess deaths from other causes-ie. cancers of sites other than the lungs, and chronic respiratory disease- due to passive smoking is more tenuous I_,, Death from thesr- causes has therefore not bern considered here. Statistical methods The proportion of deaths from a particular dises.e attributable to a specific exposure is know•n as the popuiacon attributable risk ialso referred to as the aetioloRic fractioni. !f p is the prcportion of the general populatSon exposed to the risk factor in this case involuntary smokir.gi and RR is the relative risk of dr•.g of the disease in exposed sersus r.oneuposrd _ dividuals. then the popu:atiorn attributable risk is given by ta-~ PAR - Rp R-11 ppRR•11+1 This measure has been used in many previous studies. including two stud:es vah: -h estimated the proportion of deaths in New Zealand attributab:e to active smoking 1:i. ::{, as well as in a Canadian study which estimated the proportion of lung cancer deaths attributable to par..sive sawking Isl. In the current studv. the relative risk estimates from oversea3 studie+ were applied to New Zealand data on passive smoking exposure. and the deriv ed population attributabs risks were then appiied to lung cancer and ischaemic heart disease deaths in 1993 among persons who had never smoked li.t• Tbe population attributabie risns and deaths attribt.cabie to passive smc:.iag were estimated separately for men and women. and for exposure at lwme and at work. Estimation of exposure to passive smoking Fastimaaoo of exposure to passive smoking at boate: Estimates of the prevalence of exposure of never smokers to passive smoking at home were obtained from the Auckland heart study ;work in progress). The study found that 127-c of never smoking men and 16.1 % of never smoking women aged 35-64 years in Auckland in 1987-88 were exposed to passive smoking in their homes. These figures are not limited to exposure to spousal smoking. but include exposure to a'

bthatr aourar of p.dw .aookins w&btst tb.lbotts.6old. Oa tIN otltr band tbeaa Qgntls ar.likoly to rmd.ee.tiaaW tbe eNalb of ltstg tafin ea'pOM>Qa to aponsal smokieg. siaee we have aot tahsn acooaot of aerar smdters who have beee wia~ow,~ ~divor~aa. ~ crost a~tok Fs ~m:tioa of sttp.wcsre te p+~+si.c setotiqa In tb- ..erltplatm • Thw prwvaknc, of spMntn+ tn pa'".is•r ea eftirb fn the t,c:: ~;,tnta waa afa•)obtau:eti from thr.tiuclc:o^.d heart study. In this aWdy. 3s-69i and 23.4% of never smoking rtreo and .,omtts, agwi 3564 years in Audtland In 19S7.Sts, ww, ezpoaed tc ; a_ :.i. t.-~~ al wuti.. el rucsot rrwiant tdeplwoir wrvey w t:.o R'i euiryituu regian reported that the proportion of nuostuu1sarg eapuseti to passive smoking in tM watltplace may be even higAer, reaching up to 80% pfaL However a sign{Scant proportion of the respondents reported that most of their exposure occurred during tea and lunch breaks. Therefore we adopted the more conservative prevalence estimates. Estimation of relative risks associwted with••rw+sur.p t- r asa:ve antokinp Estimation of the relative risk of lung cancer due to passive smoking at home: The relative risk of dying of lung cancera in never smol.ars exposed to spousal smoking was obtained from the pooled results of 10 case control studies and two proepective studies 1=oi. The relative risk of lung cancer mortality In women who had never smoked and who were married to ever smokers, weighted by the Mantd-Haenszel procedure, was 1.3 (95% confidence interval: 1.1-1.5) (zo(- There have been few studies of lung cancer among men who have never smoked. We have assumed, as others have done Iel, that the relative risk of lung cancer in never smoking men married to ever smoking women is the same as for never smoking women married to ever smoking men ITable 1). -a Table t.-Estimates of relative risk of deaths from lung cancer and ischaemic heart disease due to passive smoking (969i confidence interval) ~.t=. F-- - Disease Relative risk from Relative risk from exposure at home exposure at work Men Women Men Women Lung cancer 1.3 1.3 11.1-1.51 11.1-1.51 ischaetnic heart disease 1.3 1.2 /1.1-1.61 11.1-1.41 2.3 1.9 (1.4-3.41 /1.4-2.51 Estimation of the relative risk of lung cancer due to passive smoking in the workplace: The elevated lung cancer risk from passive smoking has been well establishrd. but few studies have specifically examined risks from workplace expo:•ures. Thus instead of using direct estimates, the relative risk for lung cancer death from exposure to passive smoking in the workplace was estimated via an exposure response relationship derived by Repace and Lowrey Ie.21). They estimated that the degree of exposure to passive smoking at home- at work. and at both sites, corresponded to respective daily inhalation of 0.45. 1.82 and 2.27 mg of the particulate phase of ambient tobacco smoke 161. According to this model, exposure to passive smoking at work should result in a higher risk for lung cancer than exposure at home. Based on the relative risk estimate of 1.3 for home exposure iTable 1). the re3ative risk of lung cancer in persons exposed to passive smoiting in the workplace was. estimated to be 1+ 40.3 x 1.8210.45). yielding a relative risk estimate of 2.2 (rar-ge: 1.4-3.01(Table 1). This estimate is consistent with the relative risk of 3.3 (95°o confidence interval: 1.0-10.5) for never smokers exposed to passive smoking at work reported by Kabat and 1% } rider Iz2L in one of the few studies that has distinguished exposure at work from exposure at home. However. re have adopted the more conservative estimate of 2.2 (Table 11. Fstimatioa of tbe relative risk of ischaemic heart disease death due to passive s+ooking at home: The estimates for the relative risk of isclsaemic heart dise, • death in never smokers exposed to spousal smoking were obtained from Wells' pooled analysis e[ fi.A anbret atamas asd tws elf. eeal..t pOttbd rdati., ii.k for aalO"M.d t0 ap:..t°W'eM' weisdtd by tba btat~ai-HassssMl pvosdarw was 1 i' 1.1-1.61 and the eorre.poodtns..timat. fet wotas wa. ~, :" ICr:-la 1 4: ~ . - i r.ttmatJaS of tLa reiati.e ri.lt e[ Ythaamte ieret df...ae d.a1 dt!e to geed . e snsoideg ia the aorkplso.: Thert is at present e+atnt deta ett tbe re!!*wa tL•!t zf ipel:cxss lx.srt d~m: e drati d{A- kW p3:ysive srscskir.g in ths wos' i.ltae. 'i`h.s atuc:y -tiy Sversdaen et al (t~^ basett e+e data (e~em tM NRPPP trfe} reported that the retasive rfstt of eomioeery heaR df_"ax :.eaf io man e:puaed to coworkers' ntsok* compared with ssrc wbose Coworkas did not staoke, was 2:6 pal. Howeves. tM risk eatimate was ttapredaa (Cl: 0.S-1S-7t p-0.g3/, afld il: addition, the MRFIT trial involved men who wetn at high risk o: coron.ry heart dIsease at entry. Neverthdess. a higher value for the reiative risk of Lschac>:ric heart disease death from expoaure to passive smoking in alte workplace compared to the hotne is consistent with the gesatet prrvr!eriw and 'wtens?ty of exposure obtain.d in the Gxrner setting IeI. Using the same assumptions as in our calculatiot: of the relative risk of lung cancer from passive smoking in the wnrkplace. we estimated that the relative risk of Ischaemk heart disease death from passive smoking in the workplace was 2.9 (range: 1.4-3.41 for men and 1.9 (range: 1.4-2.5) tor women, rsspectively (Table 1). Estimi4tion of deaths due to passive smoking There are a considerable number of uncertainties in the estr-zation of deaths due to passive smoking in New Zealand. These relau to uncertainties in the number of deaths in never smoken. the prevalence of exposure to passive stnoking, and the relative risks due to passive smoking. The main uncertainty stems from the relative risk estimates. Accordingly. to provide a range of plausible values for the population attributable risks, the 95% confidence interval tor the relative risk estimates (Table 11 have been used, and the other estimates have been regarded as fnted Ranges have also been provided for the estimates of the number of deaths in never smokers /Tables 2-SI in order to give an indication of their precision, but these ranges have not been used in further calculations. Estimation of lung cancer deaths attributable to passive smoking at home: In 1983 there were 11971ung car-eer deaths in New Zealand ps1-866 in men and 331 in women. It was estimated from the cancer registry data that 8% of these deaths occurred in never smokers 1241. Therefore 69 male lung cancer deaths, and 26 female lung cancer deaths occurred in never smcker s (Table 21. Table 2--Estimated number of duths from lung cancer attn-butaMe to passive exposure to spousal smoke in Nsw Zealand in 1986. by sex Men Women Total no of lur.g cancer dea•-!:s 868 331 % of people who had ne%er smoked 8% 8% No of lung cancer deaths in those who had never smoked 69 26 Prevalence of never smokers exposed to spousal smok3r.g 12.7% 16.1% Relative risk of lung cancer for exposure to spousid smoke 1.3 1.3 ICI/ i1.1-1.3i l1.1-1.51 PARl spousal srroka 3.7% 4.6% lran:e) 11.3-6.0%1 /1.6-7.5!i! No of lung cancer deaths in never smokers attributable to spousal smoking 3 1 (rangc, 11-41 10-21 PAR-population attributable nsk: The population attributable risks weire calculated to be 3.7"fo (range: 1.3-6.0%) for men, and 4.6% (range: 1.6-7.5%) for women (Table 2l. Tbe numbers of lung cancer deaths in 1985 attributable to passive smoking at home were therefore estimated to have been 3/range: 1-4i for men and 1(range: 0-2) for women, giving a total of 4(range: 1-6). 50824 6530

i8d6..ti.. .f las eawcar d.atis atts$.table tro p.tad.. ..aokts b tro w1t6/1.e.c Aa.omtng a ralatfve riak o[ S.Z& tbt oopalatioo' attributabie rfsh for btng cancar deaths due to p.ssiv. .mokietg in tbe workplaca is 28-? 41,1raagg 11.lF•40.2x) for mao, and 21.9% frange: 8.d-31.99i) for woettat f'Pabl. 3). lti. +~ r i a:LZ ci,x,er dPat!•s in nu...rr aneo'.r.rs s.. _~a : ~.r. y? s _: . _ ,' • ~ t tI a ~ . :{ ~ ': ~tl ^v =T't the QIfOT~ri1l: C< ~a t11a:?i":Qr:c 2-7) /r7e wM.u~.~• R7v~ns w Inewi r.1 ?R f.ww...- !/0St ~'nAls R1, 7hr_ tM+t "e„ei nrenMr of ktrz ~ee•er des•~s ~ttrF!~ztsble to yassive smoking is thus estimated to have been 30 trattgw 11-111, of wbtth 87% ta attributable to e:po.ur. In tM .arttptaee- TabN i-Eadma-sd numb.r of deaths frorn lung cancw attributabte to pasalw smok;np in the work place In New Zealand. 1986. by sut Men Women No o! lung cancer deatbs in never s.•...knr. Fv y.. Prevalence of exposure to passive smoking in never smokers who work 33.6% 23.4% Relative risk mf lung cancer for wsposs.re to passtve smoking at work 2.2 2.2 IClI (1.4•3.01 11.4•3.01 PAR. work exposure 287% .Z1.99i kangel (11.8-40.29k) (8.6•31.9'b) No htng cancer deaths in never smokers attributable to passive smokitcd at work 20 6 Irangel 18•28) 42-7) PAR - population attr.butable risk Deaths from iachaemic heart disease attributable to passive smokit:g at hom-: Data o: the proportion of ischaemic heart disease deaths occurring in never smokers in \ew Zealand were not available. We estimated this proportion by applying the relative risks of ischaemic heart disease death -obtained from the cohort study by DoU acd Peto iss.st-for each category of smoking Inever smoked. essmu;cer. smoking between 1-14. 15-24. and over 25 cigarettes per dayi to the proportions of New Zealanders aged over 25 years in each categery, based on the 1981 census data 1:7). The proportions of never smokers among ischaemic heart deaths were then calculated as the percentage of all ischaernic heart disease deaths that would be expected to occur, based on these relative risks. It was thus estimated that 32.3% and 42.0% of ixhseatic heart disease deaths occur in male and female never smokers. respectively. These Clgtlres are in close agreement with unpublished data from a coronary heart d:sease register in Auckland IJackson R: work in prcgressl. The popu?ation attributable risks for ischse:r.:c heart disei:e deaths in persons exposed to spousal smcke were estimated to be 3.7% (range: 1.3-7.1°0l in men. and 3.1% t1.6-6.1°b) in women iTable 4). The number of iscaaemic heart disease deaths attributable to passive smcking in the home is estirr.at.ed to have been 51 (ra:.ge: 18-97) in men and 401range: 21-801 in women. a total of 91 deat.'t.s (range: 39-177). Table 4.-Estimatad number of daatha from ischaemic heart disease attr butable to passive expcsura to spousal smokiny in New Zealand. 1s86. by sas Men Women Total ao of deaths frcm IHD 4234 3106 % of peaple who had never smcked 32.3=. 42.0% No of people who had never smoked 1368 1305 Prevalerre of exposure to spousal smoke an:ong married never smokers 12.7 0 16.1% Relative ri%k of I)11) for e:yuaure to rr+ousa) smoke 1.3 1.2 tCJI 11.1-1.61 11.1•1.41 PAR. spousal smoke 3.7"e 3.1% UanBN (1.3•7.1°.e) ti.66.I9fr) No of IHD deaths in never smokera attributable to spousal %....ic:ng 51 40 (+'ange) /18-971 (21-801 PAR - population attributable risk- IHD ~ ischaemic heart disease ZNNBUi jlpt 1/eja.ttal" how& diaMtaf s>l/111buiibV ~ -- - ..~ io tC.e warbplae.e 8iaoM t5w r1sk ot ise6.amie beagt, diaMr aom aodw mtaldtg dimioltlr. *apidlt aR.r e6saJoq: ot.aokiryb it ws aatawn.d that eM risk ot i.eltaemie Mart di...ae d.atb fra.a sapoatnm to passive aesoldpa {s the wcr" .vould aimilarly ds,ciitu aftes witb'c.ra.rai Iram the R'c rSc.i .~ r;at.'.r rmore, the e.tL~aates of •,uasfc~sos esy~a.ltre uw.2 i.. t'siw a:.:+iy 1"i'a:,iw S.oa16) were b.ad on d.ta fot A.•rtrl_rr•ler-y eo•r136-44 yes=••. Tlsca. ton_.esvaKfve!sttmatem- of f-eha+»-ie h*,~t r}i•~~Rr drat+~i ~~ So e:por~re ta pasrive satoking in the worfcplace wera derived irom tba attmbts of laeba.mic beart disease deatbs wWeb oKttrr.d amoaR thn.e ot waldtsg age. f., tbose aged under 65 years. In tbfs ago grarp there were 1276 deaths in men and 366 in women in 1985 1181 t rabl. 5). TalN S.-Esdmeted number of de.tha front iaehaeenie hosrt Asosao aetrihutabte to passive smoking In th. workplace In New ZaaJand In 1986 Total number of ischaeraic heart disease deaths in people aged <63 yev+ '.i of people who bad never smoked Number of ischaemic heart disease deaths in never smokers aged <6S years Prevalence of esposure to passive sttwking in never stnokers who wnrk Reiative risk of ischaemic heart diaea.:e from esposure to passive smoking in the workplace IC11 PAR workplace exposure (range) No of iscbaemic heart disease deaths in never smokers attributable to smoking in the workplace /rangel PAR - population attributable risk 2.:... :Vv....+. 1276 366 32.3% 4209k 412 154 33.6% 23.4% 2.3 1.9 11.4•3.41 /1.4-4.5/ 30.4% 17.4'i 411.8-44.6!i/ /8.6-26.0ri1 125 27 (49-1841 /13-40/ The population attributable risks for deaths from iseltaemic bean disease due to passive smoking in the workplace. assuming relative risks of 2.3 for men and 1.9 ftx women. were 30.44's /range: 11.8-44.6°rc) in men. and 17.4°o Irange: 8.6-28.0°'0l in women. These yielded estimates of 125 (range: 49-18i1 ischaernic heart disease deaths in men. and 27 (range: 13-401 deaths in women. a total of 152 deaths lrange: 62-224)1Table S). Discussion The estimated 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 results are similar to previous estimates for USA lsi and Canada )sl. Repace and Lowrey estimated that passive smoking was responsible for 5% of the total annual lung cancer deaths, and 30%, of the lung cancer deaths in never smokers in the USA (el. W igle and Collishaw estima:ed that in Canada passive smoking was responsible for 2.31"e of the total annual iur.g cancer deaths, and 51 % of lung cancer deaths in never smokers isl. It is estimated that 243 deaths from ischaemic heart disease occurd ed in 1985 due to passive smoking. This represents 3.3% of all ischaemic heart disease deaths. and 9.1% of ischaeraie heart disease deaths in never smokers. The total number of deaths in `ew Zealand in 1985 from lung cancer and isebaemic heart disease due to passive smoking was estimated to have been 273 (range: 112-4421. of which 65.2% was attnbutable to exposure in the workplace ITable 6). As we have stressed throughout. there are a number of uncertainties in thPse c.alt•ulations, and the total of 273 deatbs per year from lung cancer and ischaemic heart disease due to passive smoking should be regarded as only a preliminary estimate. Nevertheless it does indicate the likely magnitude of the mortality due to passive smoking in 11Tew Zealand.l3e findings of this study will need to be revised as more accurate data. particularly on the relative risks of diseases due t• workplace exposure to passive smolting, become available

How...r tbere are a aiombar ot reaaooa to suggest t6at the aguwa pr.eanted d.re are Firstly. we hare not oonsidered tbe aumbers of deaths attribataLle S,o pwiw strtoliing irt two srottpa of nonasnoher>,: 11) aeverrimphert wbo Irr not eitrrently e=poaed to passive anNfking~hOSn! (and ia ;.i:e case of iachaemic hesrt ~wo cayea..«E ~ 1}), but who h.. ., !- n e=P` :~•! :rt t::e piwt, aud (2) usln ctrraaL'g Kiyuse.~ W y.Maivi aOit/aN>,& SuCMtltih/. tbi N! Wt C4NidW'a4~ c-;~e-~r !e ps•_sive ~~~+o fit ~!naticma oth tht~n et he„n! 94 nor the i2ttpact of pt.aive r>rposuri e or dgsr xk or at w . p . , ~i: *:+sc>~ .. 1 amokinl[. 'fbirdly. we have not made adjustments to the 1~•'T:'se"•".'+a 1 rriative riska for possible miseLasification of espoetma. In JF^"#`~. sttultes which bave eorrected for these biases tb M the aet IL:;J ' -- !Yw ?VQ[-.-_~ ~-. effect of the adjustment was to raise the relative risk estimates. Fourthly. we have not attempted to estimat,e 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 tdative risk of cancers other than the htng~ ... AP•.M .TAh t.....r...a.s .a.ww. ( tn Ifw..ivr •mttiting was 1 16 (95% confidence limits: 1.06-1.27) isal. E=cess cancers were observed for cancers of the breast, cerviu. brain. paranasal sinuses and endocrine glands 12a{. Although these studies have been criticiaed for their failure to control for risk factors known to be associated with cancers of these sites 121. it is nevertheless likely that at least some deaths from these cancer types are attributable to passive smoking. Finally, we have not attempted to estimat.a the numbers of pneumonia deaths attributable to passive smoking in childhood, nor the increased numbers of perinatal deaths associated with smoking during pre_aancy N4 Lrspite the uncertainties in the estimates presented here. they nevertheless suggest that passive smoking is a major public health problem in New Zealand. Although a more precise estimate of the number of deaths due to passive smoking must await further studies, there is a clear case for taking action on current evidence. The protection A the health of nonsmokers. particularly in the workplace and in enclosed public places. must be given priority as an issue of environmental health protection. It is encouraging that the necessary regulatory actions are beginning to occur. Ackne.iedgments: The authors wish to thank Professor Robert Beagi.hole. Dr Ruth floni: .. Dr David Hay and Dr Murray Laugesen for their valuable ad.•ice ind suggestions on earlier drafts of this manuscript. Dr Kawachi is supported by aMedical Research Council ellRewTrHad trai.ieg fYBswsNp urJaefast, ib Natle.al H..t load.tJo. d NewZedad sadtis CemeS eI New Zealaad C.n..po.dst.r Dr I 8awarbi, Departaesat d Cea.retty H..ka; : ~R.illnqeo. SCitaai of liMilriO~ PO Bea 9i{g. W.11rm:tat.900tli -; Refea-sa.:es '~ 3. \at:ua.t);..13azS:[wrr.21•s.a~eSCareawfAaasaE.:.a.eio.rWrfi'..s•ahi.i ~..rtl+ Csnb.Y.a zr.~~. . . . , ... . . ; .. sa t7s stwps Gt...L 7% k..kt, e..wq..aw d i...iataq.aits~ a q.rt.f W r_.S.~s c x-ut Td..-p'~d L~S ^RD1O. t`+s4e Y..a" Jn.Ett !'~t ' s. tbti.d a..rdt Gr..a. R..iea.wbt Wr moiw t.rtrha .qa..r.d M:•.c i<titai:.~J {s. 1rrc.: \:r.1 a3r.Y.17tiG a r.N.~ hriw h w tttireveAB Na 1W J tM! e' Ms#. . a wi~eD3:C.0YYwNtKMlrfi.J.IRrY.D.rb1.C~.Ma~iratrsit. .._.J.i &Rq.~n~..e. JL Iwnr ML A oaant t1ve a.tltare d as•ta.eY~JLa j ereit1.ii Mat• f. {lr c~OMmO. t~tJ. TW.~ C~.t isle2Laetiid tss's ttase Re.a tM27. a. J CG 1s71 391.182 eL • a- a.fate F. rkli. L H..o. 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Gra.AJ.awmYwJA.loupwsM.7beaaalt•i;wau.moktttSin Nee7.d••A.rt2 !Ld J Iflb. i81. 2?LLI. la % .uas.l H..ltA sutn.ues C.ntn. MwtaGtr twd d.arw.Oh,[ ew tM3. w.a,wpw. H.tieeal H..IM Suust.n C.eu.. 1MI'- lf. DePntmeat of Comezwt.tY He.ltA R.vaMan snd att..ud.0 t.0ssive taoLSns /th Yar te.6er student po).et. w.aNngtuw• M'.Wn4taw YeA..i at M.6itw. tlsa. 2a Blot wJ. r..us+.e; Jr. P..av..aa.ir,S ..a st,n, :onr... Jsiw C.na. t.a 1s11.: ns~ss. 2l. at7.e JL te.nY AH. P+.d.cs,aa the ktea eanc.r n.k eI dsawuc s..n,e.~eLt~tK As a.n asP Dis Isn-: 1Ja: 1308. 2t Kalat GC. wYttd.r EL l.w+a e.nnr n eae.nrik.s. Canasr 1984. 33. Ittttt. 3 w.Y. AJ. As..umatn or adult m.rtality ,w th. tatit.d sut.s rrun Oa..i.., seettt.S Ea.voameat latanauoe.l 1946. 14. 21965. 21. Naiun.l H.dtA St.ustas Cenc-. Caear Mu 19sS.dstaee.$ r.s.tntm..wd yalt. :Mi ..d 1!!2. wdlinr.ew: N.:.ue.l Health Statbt.es C.etn. 1263. 2s. Dntl R Peto R. Mmta{ity r niat,oe to ar,uYJng, 20 rws ol».n nuaa s m.te Driti.d, tloeter. Br M.r J 3la. 2.aS2b•2i. 2l tloa K. Gray R HNr B. P.to R. Dlu.tal,ty in niat:c' to stsWt.oK 22 yeus ola.. r/MmaM anta.A dortara B. lt.d J 1900: 1!67•71. 27. D.prun.et af Su.utxs \ee Latod an.us ef ptquLtim trd Q..e,nas :lli11r0.oa. .w ntar.st. anr4u.a K'.1liaaeon. Dp.rtwwnt ot 9tet.w.ea. Ils7 S!, wald U. Si.c4aAal K. TAampaen SGH. CuekY MS Dos besaN:vai aler yfwOleso tebacee.TOke caur lttng .anc.r• 9. M.d J 19114. 273 :217:. Congenitat long QT syndrome in adults str~- . Ian G Crozier MD. FRACP. Cardiologist; Annemarie Loughnan BSc. Cardiac Technician; Leziie J Dow BSc. Cardiac Technician: Clive J S Low MB. ChB. Cardiology Registrar: Hamid lkram MD. FRCP. Cardiotogist. Cepartment of Cardiology. Princess Margaret Hospital. Christchurch Abstract A family with the Roalar.oWard syndrome is presented. This famiiy showed typical features of this syndrome with QT prolongation. torsades de pointes ventricular tachycardia. sudden dca:a and an autoso nsal do:ninant inheritance pa'tern. The index case presented with an exacerbation of torsades de pointes ventricular tachycardia from diuretic induced hypokslaemia. and responded to diuretic withdraw•al and beta blocker therapy. Introduction Abnormalities of ventricular repolarisation predispose the heart to ventricular arrhythmias, typically polymorphic ventricular tachycart Itorsades de point.es). Abnormal repolarisation is typically representes on the surface electrocardiogram by QT :nterval prolongation. However T or U wave abnormalities may also reflect abnormal repolarisation. Abnormal repolarisation is usually acquired due to cardiac injury, metabolic derangement or drugs. Rarely. abnormal repolarisation is congenital and may occur either sporadically or as an autosomal recessive or dominant condition. We presPnt a family with autosomal dominant QT prolongation and torsades de pointes ventricular tachyeardia. The patient ThM index ca•ee wae a 44 year old female with a life long history of synmpe which was usuauy precipitated by exertion or emotiaaal stress. Three months prior to admission she •" coeemeneed oe cywoi.enthiaiide 0.5 mg daily for hypertension. Since comeoeoe.mest of cycktpenthiazide she reported that the syncopal epiaodes became more frequent and prolonged. During one episode she was obeerved by her husband to be pale and puiseless. She had no oth.r significant pllt history: and was olt no other medicatlons. On adQtis fipn to hospital she was anxious but otherwise well. Blood pressure was 140,60 mmHg and general examination normal. Resting rhythm stri-