Angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis

BACKGROUND: Angina pectoris has long been recognised as one of the principal symptoms of severe aortic valve stenosis (AS), even in patients without significant coronary artery disease (CAD). However, controversy exists concerning the prevalence of angina pectoris and associated CAD in such patients. OBJECTIVE: To determine the prevalence of CAD detectable by angiography and its relation to angina pectoris and coronary risk factors in patients with severe AS. PATIENTS AND METHODS: All patients with symptomatic AS who had undergone aortic valve replacement and preoperative cardiac catheterisation at the Austin and Repatriation Medical Centre between 1 January 1986 and 31 May 1996 were retrospectively analysed. Those patients with multiple valve disease, aortic regurgitation of grade 2 or more in severity, or who had had prior coronary artery or valve surgery were excluded from this analysis. RESULTS: A total of 328 consecutive patients with severe AS (242 men and 86 women; mean age 72 years, range 39-84 years) were studied. Significant CAD (reduction in luminal diameter > or = 50%) was found in 162 patients (49.4%). Typical angina was present in 74.7% of these 162 patients but it was also found in 44.6% of the 166 patients without obstructive CAD. Of the patients without angina (n = 133), 30.8% had significant CAD. By multivariate logistic regression, we have identified seven significant predictors for CAD among severe AS patients. Five factors increased risk. Expressed as odds ratio with 95% confidence interval, these included: (i) age in years (1.07; 1.04-1.11, P = 0.001); (ii) male gender (2.09; 1.14-3.80, P = 0.016); (iii) angina pectoris (3.19; 1.89-5.37, P < 0.001); (iv) history of myocardial infarction (2.87; 1.38-5.97, P = 0.005); and (v) peripheral vascular disease (2.28; 1.28-4.05, P = 0.005). Factors associated with decreased likelihood of CAD were serum high density lipoprotein (HDL) cholesterol (0.58; 0.34-0.71, P = 0.002) and peak systolic gradient across the aortic valve (0.97; 0.95-0.99, P = 0.0113). CONCLUSION: Coronary arteriography can probably be omitted for a patient with severe AS if that patient has no symptoms of angina and has no risk factors known to increase its incidence.     

Angina, aortic stenosis and coronary heart disease.

The pre-operative clinical and haemodynamic findings of 139 consecutive patients with aortic stenosis were analysed in an attempt to determine the incidence and influence of coronary heart disease on the mode of presentation of patients with aortic stenosis. The overall incidence of coronary heart disease was 32%. 105 patients (76%) presented with angina and of these, 41 patients (39%) had significant coronary heart disease as compared to 4 (13%) of the remaining 34 patients who did not present with angina. Clinical parameters including age, sex, severity of angina together with the presence of associated symptoms and precipitating factors were unhelpful in distinguishing those patients with coronary heart disease. Evidence of previous transmural myocardial infarction or the presence of ST-T abnormalities in the absence of digitalis and the changes of left ventricular hypertrophy were reliable electrocardiographic signs of coronary heart disease. Although peak systolic aortic valve gradient tended to decrease with increasing severity of coronary heart disease, the severity of aortic stenosis was not a reliable indicator of the presence of coronary disease. Patients with coronary heart disease in the absence of angina all had a combination of moderate aortic stenosis and single vessel disease. It is concluded that coronary heart disease cannot be predicted in patients with angina and, in the absence of angina occurs with an incidence sufficiently high to advocate the use of coronary angiography as part of the investigation of all patients with aortic stenosis being considered for valve replacement.     

血清脂蛋白（a）水平与冠状动脉狭窄及心绞痛类型的关系

目的 :探讨血清脂蛋白 （ a） [L p（ a） ]与冠状动脉狭窄程度及心绞痛类型的关系。方法 :将 91例冠脉造影患者按狭窄程度分组 ,比较各组血清 L p（ a） ,C反应蛋白及血脂指标等 ,并对其中 76例按心绞痛分 2组 ,也进行同样的比较 ,均进行统计学分析。结果 :血清 L p（ a）水平在冠脉明显狭窄以及多支血管病变患者显著升高 ,不稳定心绞痛患者的血清 L p（ a）水平也明显高于稳定型心绞痛患者 （ P<0 .0 1） ,L p（ a）异常率在冠脉造影阴性与冠脉造影阳性患者中有明显差异 ,不稳定型心绞痛患者的 L p（ a）异常率所占比例较稳定型患者高 （ 77% vs5 1% ,P<0 .0 1）。结论 :L p（ a）水平与冠脉狭窄程度和心绞痛类型明确相关     

颈动脉多普勒超声与心绞痛患者冠状动脉病变的关系

目的采用彩色多普勒超声仪分析心绞痛患者颈动脉病变,探讨其在冠状动脉病变中的临床诊断价值。方法选择因心绞痛行冠状动脉造影的住院患者328例,根据冠状动脉造影结果分为4组:对照组(80例)、单支病变组(102例)、2支病变组(62例)和多支病变组(84例)。用彩色多普勒超声仪测量颈总动脉内膜中层厚度(intimamediathickness,IMT)及颈动脉分叉处IMT,记录颈动脉斑块的位置、数量。结果与对照组比较,2支病变组分叉处IMT和斑块积分明显增高,多支病变组颈总动脉IMT、分叉处IMT和斑块积分明显增高,差异有统计学意义(P0.05,P0.01)。与对照组比较,多支病变组颈总动脉IMT增厚比例明显增高,差异有统计学意义(P0.05);与单支病变组比较,多支病变组颈总动脉IMT增厚比例明显增高,差异有统计学意义(P0.05)。糖尿病是冠状动脉病变的主要危险因素(OR=2.8,95% CI:1.18～6.63)。结论颈动脉粥样硬化与冠状动脉病变有相关性,采用彩色多普勒超声分析颈动脉病变情况,对冠心病患者具有较好的筛查及预测价值。     

Aortic valve replacement for patients with mild to moderate aortic stenosis undergoing coronary artery bypass surgery

Aortic valve replacement (AVR) is not normally recommended in asymptomatic patients, even if aortic stenosis is severe. However, as the population ages, an increasing number of patients with mild or moderate aortic stenosis will require coronary artery bypass grafting (CABG). In these cases, risk of "prophylactic" AVR needs to be weighed against risks of subsequent worsening of the mildly or moderately diseased aortic valve. If unoperated, aortic stenosis will worsen at an average of 6-8 mmHg per year (-0.1 cm2/year valve area), and one-quarter of such patients will require late AVR with a high operative mortality (14-24%). If AVR is performed at the time of CABG, operative risk is increased only slightly (from 1-3% to 2-6%), as are late mortality (1-2% per year) and morbidity (1-2% per year), mainly from hemorrhagic complications. Intrinsic gradients of most prosthetic valves are sufficiently low that even patients with low aortic valve gradients are likely to derive hemodynamic benefit from AVR. Thus, if there is a measurable (>20-25 mmHg) gradient across the aortic valve in a patient who requires CABG, the patient is at considerable risk for developing symptomatic aortic stenosis prior to reaching the end of expected benefit from CABG; in this case AVR should be considered. It may be reasonable in patients with very mild gradients (<25 mmHg) to defer aortic valve surgery; however, it should be noted that aortic stenosis progression is generally more rapid when the initial gradient is small.     

Relation between changes in severity of coronary artery stenosis and anginal patterns

Although myocardial ischemia causes angina pectoris, angina and the severity of coronary artery stenosis in individuals do not correlate. However, changes in anginal status over time correlated with changes in the severity of coronary artery stenosis as determined by repeated coronary arteriograms has not been previously studied. Coronary arteriograms, done both at entry into the Program on the Surgical Control of the Hyperlipidemias (POSCH) and 3 years later, were blindly graded for changes in overall severity of coronary artery stenosis according to protocol by the POSCH Arteriography Review Committee. Arteriographic and clinical data from 376 control subjects (347 men, 29 women) were analyzed. There was no statistically significant relation over a long-term (3 year) period between the absence, presence, development, or disappearance of angina pectoris and changes in coronary artery stenosis severity as determined by coronary arteriography. © 1994 Wiley-Liss,Inc     

Impact of coronary artery disease on outcomes after transcatheter aortic valve implantation

Background: Coronary artery disease (CAD) negatively impacts prognosis of patients undergoing surgical aortic valve replacement and revascularization is generally recommended at the time of surgery. Implications of CAD and preprocedural revascularization in the setting of transcatheter aortic valve implantation (TAVI) are not known. Method: Patients who underwent successful TAVI from January 2005 to December 2007 were retrospectively divided into five groups according to the extent of CAD assessed with the Duke Myocardial Jeopardy Score: no CAD, CAD with DMJS 0, 2, 4, and ≥6. Study endpoints included 30‐day and 1‐year survival, evolution of symptoms, left ventricular ejection fraction (LVEF), and mitral regurgitation (MR) and need of revascularization during follow‐up. Results: One hundred and thirty‐six patients were included, among which 104 (76.5%) had coexisting CAD. Thirty‐day mortality in the five study groups was respectively 6.3, 14.6, 7.1, 5.6, and 17.7% with no statistically significant difference between groups (P = 0.56). Overall survival rate at one year was 77.9% (95% CL: 70.9, 84.9) with no difference between groups (P = 0.63). Symptoms, LVEF, and MR all significantly improved in the first month after TAVI, but the extent of improvement did not differ between groups (P > 0.08). Revascularization after TAVI was uncommon. Conclusion: The presence of CAD or nonrevascularized myocardium was not associated with an increased risk of adverse events in this initial cohort. On the basis of these early results, complete revascularization may not constitute a prerequisite of TAVI. This conclusion will require re‐assessment as experience accrues in patients with extensive CAD. © 2010 Wiley‐Liss, Inc.     

Influence of coronary artery disease and percutaneous coronary intervention on mid‐term outcomes in patients with aortic valve stenosis treated with transcatheter aortic valve implantation

BackgroundA high frequency of coronary artery disease (CAD) is reported in patients with severe aortic valve stenosis (AS) who undergo transcatheter aortic valve implantation (TAVI). However, the optimal management of CAD in these patients remains unknown.HypothesisWe hypothesis that AS patients with TAVI complicated by CAD have poor prognosis. His study evaluates the prognoses of patients with CAD and severe AS after TAVI.MethodsWe divided 186 patients with severe AS undergoing TAVI into three groups: those with CAD involving the left main coronary (LM) or proximal left anterior descending artery (LAD) lesion (the CAD[LADp] group), those with CAD not involving the LM or a LAD proximal lesion (the CAD[non‐LADp] group), and those without CAD (Non‐CAD group). Clinical outcomes were compared among the three groups.ResultsThe CAD[LADp] group showed a higher incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) and all‐cause mortality than the other two groups (log‐rank p = .001 and p = .008, respectively). Even after adjustment for STS score and percutaneous coronary intervention (PCI) before TAVI, CAD[LADp] remained associated with MACCE and all‐cause mortality. However, PCI for an LM or LAD proximal lesion pre‐TAVI did not reduce the risk of these outcomes.ConclusionsCAD with an LM or LAD proximal lesion is a strong independent predictor of mid‐term MACCEs and all‐cause mortality in patients with severe AS treated with TAVI. PCI before TAVI did not influence the outcomes.     

The ear lobe crease sign and coronary artery disease in aortic stenosis

Ear lobe creases have been proposed as useful indirect markers of coronary artery disease. To test such a hypothesis, this physical sign was evaluated in 100 patients with symptomatic aortic stenosis undergoing cardiac catheterization to establish the hemodynamic severity of the obstruction and the degree of coronary artery involvement. This is a disorder where the coexistence of cardiac ischemia may play an important part in diagnosis and management. Criteria were established for the degree of ear lobe involvement with a grading of mild (Grade 1), moderate (Grade 2), and severe (Grade 3). Significant coronary artery disease was defined as narrowing greater than or equal to 50% and a coronary score was established. Sensitivity, specificity, positive and negative predictive values were calculated, using Bayesian analysis for three levels of assumed coronary artery disease prevalence. An ear lobe crease score was correlated with a coronary artery disease score, taking into account the variables of age, sex, and body mass index. No useful statistical correlations were found and it is concluded that this physical sign is of little practical value in this clinical setting.     

Comparison of coronary arteriographic and left ventriculographic findings in patients with single,double, and triple vessel disease and angina pectoris

The distribution and severity of coronary artery disease and degree of left ventricular dysfunction are described in 500 patients with single (103), double (119), and triple (278) vessel disease and angina pectoris. The coronary arterial patterns were divided into right (360), mixed (89), and left (51) systems, depending upon the blood supply to the inferior surface of the left ventricle. The following relationships were noted:

• (1) Coronary arterial patterns of right, mixed, and left systems do not influence the presence, distribution, or severity of coronary arterial lesions among patients with single, double, and triple vessel disease and angina pectoris.
• (2) Analysis of the distribution of lesions among patients with single and double vessel disease reveals that the circumflex/obtuse marginal arteries contribute least of the three major coronary arteries to angina pectoris.
• (3) Lesions of 70–90% reduction in coronary arterial luminal diameter are the most common, and 90–99% lesions are the least common. The latter are least stable among patients with both coronary artery disease and angina pectoris.
• (4) Quantitatively there is progression of both coronary artery disease and left ventricular dysfunction as one moves from single to double and then to triple vessel disease. However, the pattern of coronary arterial lesions (50–70%, 70–90%, 90–99%, and 100% reduction of luminal diameter) and the pattern of left ventricular dyssynergy (hypokinesis, akinesis, and dyskinesis) are similar among the patients with single, double, and triple vessel disease and angina pectoris.

     

Report: Association of coronary artery disease and valvular heart disease in chile

This study analyzes the prevalence of coronary artery disease (CAD) among patients with rheumatic valvular heart disease (VHD) in Chile. Coronary angiography was performed in all patients referred to cardiac catheterization with VHD who were over age 50 years and who had angina or ECG signs of ischemia. A total of 100 patients entered the study. Significant CAD (greater than 50% obstruction) was found in 14% of the cases: 7% in patients with mitral valve disease (MVD), 18% in aortic valve disease (AVD), and 21% in combined mitral and aortic valve disease (MAVD). Angina was present in 14% of the patients with MVD, 63% with AVD, and 53% with MAVD. Only 57% of patients with CAD had angina pectoris; 20% with angina had CAD. Hemodynamic parameters and left ventricular ejection fraction were not correlated with the presence or absence of CAD. We conclude that in patients with valvular heart disease, the incidence of CAD is lower in Chile than previously reported in the English literature. We confirmed the fact that angina is often not associated with CAD, and that CAD is often present in the absence of angina.     

Isolated, anomalous origin of the left anterior descending coronary artery from the right coronary artery with angina pectoris

The case of a 51-year-old woman with exertional angina pectoris and isolated anomalous origin of the left anterior descending coronary artery from the right coronary artery is reported. This anomalous artery was not narrowed, coursed in front of the pulmonary artery and did not present either anatomical derangement at the take off or intramyocardial course. The mechanism of ischaemia could not be identified.     

退行性钙化性主动脉瓣膜病的病理组织学分析

目的分析退行性钙化性主动脉瓣膜病(DCAVD)不同病变阶段的病理组织学特征.方法选择尸检和经外科手术的成人主动脉瓣膜标本共55例,利用组织学和免疫组织化学染色方法,对瓣膜内各种物质和细胞的表达情况进行分析.回顾各例心血管危险因素有关的临床记录.结果不同程度主动脉瓣膜病变均以瓣膜基底部增厚明显,增厚区病灶及附近的纤维层内蛋白质,脂肪和钙盐聚集.免疫组化染色示,不同程度病变中,CD68阳性的单核巨噬细胞浸润,偶尔可见T细胞;还可见由CD31阳性的内皮细胞围绕而成的新生毛细血管结构,以及骨母细胞标记物OPN表达,上述标记物随病变程度加重而表达数量增加.心血管疾病危险因素,如吸烟史、高脂血症、高血压、冠心病,在重度病变中的发生率显著高于轻中度病变.结论 DCAVD的病理组织学特征与动脉粥样硬化具有相似之处,这些特征包括瓣膜内脂质、蛋白质和钙盐沉积,单核巨噬细胞浸润,新生毛细血管增生以及骨母细胞形成.     

Topography of atherosclerotic coronary artery disease

This article reviews several issues relevant to current interest in coronary angioplasty, acute reperfusion, and the use of new interventional devices (stents, probes, atherectomy devices, etc.): diffuse versus focal nature of plaque, the number of vessels severely diseased, quantitation of luminal stenosis and length of stenosis, and the distribution of plaque in the four major coronary arteries in various clinical ischemic subsets.     

Long-term results of coronary artery bypass surgery for unstable angina: incidence of mortality,myocardial infarction,and angina resumption

To determine if routine treadmill testing would be helpful in identifying patients at high risk for subsequent events, the first 81 patients to undergo coronary artery bypass0 surgery for unstable angina pectoris at Stanford University Medical Center were reevaluated at four intervals after surgery. Evaluations, including assessment of angina pectoris and a treadmill test, were done at mean times of 18,40, and 72 months after surgery. At a mean time of 90 months postoperatively, angina status was determined in survivors. The prevalence of angina rose from 19% during the first year to 53% during the fourth and fifth postoperative years. Cardiac deaths and myocardial infarctions were frequent during the first postoperative year, and were more frequent in patients with three-vessel disease and those with one or more severely narrowed coronary arteries which were not bypassed. Cardiac events were rare between 12 and 36 months after operation; clinical and treadmill variables did not predict these events. During the fourth and subsequent postoperative years, the incidence of cardiac events increased. While the presence of stable angina pectoris was the clinical variable most useful prognostically, treadmill testing added additional independent prognostic information (p<0.0001). During the intervals between visits 1 and 2, and visits 2 and 3, cardiac events were ten times more frequent in persons with a maximal heart rate of 130 beats/min or less on the treadmill at 18 and 40 months. We conclude that the prevalence of angina increased steadily during the first 5 postoperative years. Myocardial infarction and cardiac death rates were high during the first postoperative year, low during the second and third postoperative years, and then began to rise thereafter. The early events were more frequent in persons with three-vessel disease and one or more severely narrowed coronary arteries which were unbypassed. The late events were more frequent in persons with a maximal heart rate of 130 beats/min or less on treadmill exercise testing. No other clinical or treadmill variables added additional independent prognostic information.     

Coronary artery disease confined to secondary branches of the left coronary system

Among 3,000 patients studied by coronary arteriography during a 4-year period, 31 patients (1%) had coronary artery disease limited to a diagonal branch of the left anterior descending (15 patients), marginal branch of the left circumflex (10 patients), or to both branches (6 patients). Ten patients had 50-69% and twenty-one had ?70% diameter narrowing. The suitability for grafting was noted in 20 patients as judged by the caliber and distribution of the diseased branches. Collaterals were noted in seven patients. Disease was present in 28 men and 3 women (age range 38-70 years). At least one major coronary risk factor was present in 27 patients. Angina was noted in 27 patients; prior myocardial infarction was noted in 5 patients by history and in 4 by ECG. The left ventriculogram was normal in 22 patients and showed mild segmental asynergy in 9; ejection fraction was normal in all. Exercise ECGs were positive in 12 of 25 patients; exercise201 thallium scans were positive in 13. All patients responded to medical therapy.     

Subclavian stenosis presenting as progressive exertional angina pectoris

Left subclavian stenosis is an uncommon cause of exertional left arm pain. In a patient who presented with exertional chest and left arm pain in an increasing pattern, clinical evaluation disclosed a discrepancy between right and left arm blood pressure. Exercise stress testing with thallium revealed normal myocardial perfusion. Aortic arch and selective angiography revealed a high-grade proximal left subclavian stenosis. Subclavian angioplasty was performed with complete resolution of symptoms. This case demonstrates that ischemic left arm pain due to subclavian stenosis can present as accelerated angina, and highlights the importance of determining blood pressure in both arms in routine evaluation of patients at risk for atherosclerosis.