Coronary heart disease in 48 autopsy patients 30 years old and younger

We studied 48 autopsy patients younger than 30 years who had severe coronary atherosclerosis. Twenty-one patients (44%) died suddenly, 26 (54%) had a history of chest pain, and one had chronic congestive heart failure. Twenty-one patients (44%) had single-vessel disease, 19 (40%) had two-vessel disease, and only nine (16%) had three or four major coronary arteries severely narrowed (greater than 75% cross-sectional area luminal narrowing) by atherosclerotic plaques. Thrombi in coronary arteries were noted in 27 patients (56%) and the left anterior descending coronary artery was the most frequently involved. The severity of coronary atherosclerosis was much less in patients younger than 30 years, and the atherosclerotic plaque consisted largely of foam cells, fibrous tissue, and pultaceous debris, with minimal calcific deposits. Thus, it is this population that is most likely to be susceptible to regression of the atherosclerotic plaque.     

Blood Levels of Inflammatory and Destructive Biomarkers in Coronary Atherosclerosis of Different Severity

In male patients with coronary atherosclerosis without acute coronary syndrome, the levels of inflammatory-destructive biomarkers of atherosclerotic plaque instability depended on the severity and dissemination of coronary atherosclerosis. The highest levels of C-reactive protein and matrix metalloproteinase 3 were found in men with atherosclerotic involvement of all three main coronary arteries, primarily their middle and distal segments, and in men with predominance of low-grade stenoses (<50%) of coronary arteries in areas of atherosclerotic plaques.     

Accelerated progression of atherosclerosis in coronary vessels with minimal lesions that are bypassed

Accelerated progression of atherosclerosis is known to occur in surgically bypassed coronary arteries in which the preoperative stenosis was greater than 50 per cent. To assess the effect of coronary bypass on vessels with lesser degrees of stenosis, we studied 85 men who had undergone coronary bypass surgery. In this group we identified bypass grafts placed in 37 arteries with minimal atherosclerosis, which was defined as less than 50 per cent stenosis of the vessel diameter. In the same 85 men there were 93 coronary vessels with minimal atherosclerosis for which a bypass graft had not been placed. Progression of atherosclerosis, defined as further loss of at least 25 per cent of the lumen, during an average follow-up period of 37 months was more than 10 times as frequent (38 per cent vs. 3 per cent) in bypassed arteries with minimal atherosclerosis as in comparable arteries that were not bypassed. These findings support the view that minimally diseased coronary arteries should not be bypassed.     

Down-Regulation of Endothelial Expression of Endothelial Cell Protein C Receptor and Thrombomodulin in Coronary Atherosclerosis

Coronary atherosclerosis with occlusive thrombosis is the major cause of acute myocardial infarction. Although plaque rupture is usually hypothesized to be the predisposing event in coronary thrombosis, the possibility cannot be excluded that local changes in the anticoagulant properties of the endothelium overlying the plaque contribute to this process. It is evident that thrombomodulin and the endothelial cell protein C receptor are critical players in the control of the thrombogenic process. This study examined whether thrombomodulin and the endothelial cell protein C receptor are down-regulated on endothelial cells overlying the atherosclerotic plaque in coronary arteries and thus could potentially favor local thrombus formation. Sections of archival left and right coronary arteries (n = 18 each) with severe atherosclerosis from the native heart of six patients who underwent heart transplantation were immunostained for CD31, CD34, endothelial cell protein C receptor, and thrombomodulin using a streptavidin-biotin-peroxidase method. Controls included left and right coronary arteries from autopsy cases with no atherosclerosis (n = 6), and also from cases with mild atherosclerosis (n = 5). The apparent density of all of these proteins was much higher in control than in atherosclerotic arteries. Our findings support the hypothesis that both endothelial cell protein C receptor and thrombomodulin are down-regulated in coronary arteries with atherosclerosis. These changes would be expected to result in reduced inhibition of thrombogenic and anti-inflammatory activity on the endothelium overlying atherosclerotic regions and thus could contribute to coronary thrombosis.     

Spontaneous plaque rupture and secondary thrombosis in apolipoprotein E-deficient and LDL receptor-deficient mice

Apolipoprotein E-deficient (apoE(-/-)) and LDL receptor-deficient (LDLR(-/-)) mice develop extensive atherosclerosis, but the occurrence of spontaneous plaque rupture and secondary thrombosis in these models has not been established. The goal of this study was to provide histological evidence of acute complications of atherosclerotic lesions in these mice and to assess their prevalence. Complications of atherosclerosis were initially studied in aortas of control mice which died during previous intervention studies. Coronary arteries and the aortic origin were then systematically assessed in serial sections through the heart of apoE(-/-) and LDLR(-/-) mice. Aortic plaque rupture and/or thrombi were seen in 3 of 82 untreated mice from past intervention studies. Screening of heart sections of 33 older apoE(-/-) mice (age 9-20 months) showed extensive atherosclerosis in one or more coronary arteries of 18 animals. In three coronary arteries, the presence of blood-filled channels within advanced atherosclerotic lesions suggested previous plaque disruption/thrombotic events followed by recanalization. In the aortic origin of the same mice, four deep plaque ruptures (or erosions reaching necrotic core areas) and a large thrombus originating from the core of a disrupted atherosclerotic lesion were observed. Although plaque ruptures/deep erosions were far less frequent than in human populations, these observations demonstrate that spontaneous plaque rupture and secondary thrombosis do occur in apoE(-/-) and LDLR(-/-) mice. These mice may therefore be suitable for studying factors contributing to thrombotic complications of atherosclerosis. However, the frequent absence of a clearly defined single fibrous cap in murine coronary lesions limits their usefulness as a model of fibrous cap rupture.     

ASSOCIATION OF CORONARY PLAQUE RUPTURE AND ATHEROSCLEROTIC INFLAMMATION

Coronary plaque inflammation may promote plaque rupture and thrombosis. To test this hypothesis, 351 coronary plaques from 83 patients were formalin-fixed and stained with haematoxylin and eosin. There were six groups: (1) ruptured plaques; (2) intact plaques from recently infarcted hearts; (3) plaques from hearts with severe coronary atherosclerosis without identifiable thrombosis; (4) native explanted hearts with severe coronary atherosclerosis; (5) cardiac transplant atherosclerosis; and (6) fatalities unrelated to coronary atherosclerosis. Selected arteries were immunostained for leukocyte markers and serially sectioned to identify plaque rupture. There were infiltrates of CD68-positive macrophages and CD3- and CD8-positive T cells adjacent to all plaque ruptures. Labelling with HLA-DR and CD30 indicated inflammatory cell activation. Plaque rupture was strongly statistically associated with the severity and frequency of superficial plaque inflammation but not that of deep plaque inflammation. Although atherosclerotic inflammation has been identified adjacent to rupture, this is its first comparison with control plaques. These results support the concept that inflammation in the fibrous cap is particularly associated with plaque rupture. © 1997 by John Wiley & Sons, Ltd.     

Risk factors for coronary atherosclerosis in a general Japanese population: The Hisayama study

To investigate risk factors for coronary atherosclerosis in men and women in the recent general Japanese population, we examined coronary arteries obtained from subjects autopsied in the Hisayama cohort study (autopsy rate: 78.7%). The subjects were over 40 years of age and consisted of 125 men and 108 women. They underwent an antemortem medical examination in 1988 and were subject to autopsy at death during an 8-year follow-up period. Atherosclerosis was globally assessed by examining 14 specimens taken from wide areas of epicardial coronary arteries and classified into 6 grades. The frequency of more severe grades of coronary atherosclerosis increased with age in both genders and was greater in men than in women of the same age. Multiple regression analysis revealed that age, systolic blood pressure, serum total cholesterol, and hemoglobin A_1C were significant risk factors for men. Age, systolic blood pressure, and waist to hip ratio were risk factors for women. Smoking was not significantly correlated with the grade of coronary atherosclerosis in either gender. Thus, aging, hypertension, hypercholesterolemia, obesity, and glucose intolerance are risk factors for coronary atherosclerosis in recent Japanese populations, and the significance of the metabolic risk factors is different between men and women.     

Atherosclerosis of the carotid arteries in young patients with familial hypercholesterolemia

Summary Patients with heterozygous and homozygous Familial Hypercholesterolemia exhibit a high incidence of premature coronary heart disease, presumably due to atheromatous plaque-formation in the coronary arteries. Clinical symptoms develop when the disease has progressed to more severe stages of atherosclerosis. Aim of our study was to visualize and document early atheromatous lesions in the carotid arteries of asymptomatic patients with familial hypercholesterolemia under 30 years of age by Duplex-scan.Of 44 patients, 70% had detectable carotid plaques, while only 12% of the controls were affected. All patients with severe carotid disease had serum cholesterol levels above 350 mg/dl. In the age group 2–20 years, 66% of the patients exhibited plaques. Only 6% of the FH patients 21–30 years had normal carotid arteries. We conclude, that the process of atheromatous plaque formation in patients with FH starts early in life, severity of atherosclerosis being a function of both extent and duration of hypercholesterolemia. Duplex-scan examination of the carotid arteries is an efficient and precise non-invasive method suitable to visualize this process and, by measuring regression, monitor the efficacy of therapeutic measures.Abbreviations FHC Familial Hypercholesterolemia - LDL Low Density Lipoprotein - CHD Coronary Heart Disease This work was supported by a grant from Deutsche Forschungsgemeinschaft     

A comparative pathology study of myocardial lesions and atherosclerosis in Japanese men living in Hiroshima, Japan and Honolulu, Hawaii.

Autopsies were conducted on Japanese men from 45 to 71 years of age in Hiroshima, Japan (191 patients) and in Honolulu, Hawaii (298 patients). They were performed according to a common protocol. In both locations the patients studied were representative of decedents from population-based cohorts with respect to age and cause of death. The degree of atherosclerosis in the coronary arteries and aorta, assessed according to the panel method, was found to be substantially more severe in men in Hawaii than in those in Japan. Areas of recent myocardial necrosis were 3.5 times more frequent in men in Honolulu than in those in Hiroshima. Large myocardial scars were 1.5 times more frequent in the men in Honolulu. It was characteristic of men in Honolulu that severe atherosclerosis and myocardial lesions appeared at younger ages than in those in Hiroshima. These data demonstrate that there is an increase in the frequency and severity of ischemic lesion in the myocardium of Japanese who have migrated to Hawaii and that this increase is the result of atherosclerosis of the extramural segments of the coronary arteries.     

Predictors of Coronary and Carotid Atherosclerosis in Patients with Severe Degenerative Aortic Stenosis

Background. Patients with degenerative aortic stenosis (AS) exhibit elevated prevalence of coronary artery disease (CAD) and internal carotid artery stenosis (ICAS). Our aim was to investigate prevalence of significant CAD and ICAS in relation to demographic and cardiovascular risk profile among patients with severe degenerative AS.Methods. We studied 145 consecutive patients (77 men and 68 women) aged 49-91 years (median, 76) with severe degenerative AS who underwent coronary angiography and carotid ultrasonography in our tertiary care center. The patients were divided into two groups according to the presence of either significant CAD (n=86) or ICAS (n=22).Results. The prevalence of significant CAD or ICAS was higher with increasing number of traditional risk factors (hypertension, hypercholesterolemia, diabetes, smoking habit) and decreasing renal function. We found interactions between age and gender in terms of CAD (p=0.01) and ICAS (p=0.06), which was confirmed by multivariate approach. With the reference to men with a below-median age, the prevalence of CAD or ICAS increased in men aged >76 years (89% vs. 55% and 28% vs. 14%, respectively), whereas the respective percentages were lower in older vs. younger women (48% vs. 54% and 7% vs. 17%).Conclusions. In severe degenerative AS gender modulates the association of age with coronary and carotid atherosclerosis with its lower prevalence in women aged >76 years compared to their younger counterparts. This may result from a hypothetical “survival bias”, i.e., an excessive risk of death in very elderly women with severe AS and coexisting relevant coronary or carotid atherosclerosis.     

C-reactive protein in vulnerable coronary plaques

BACKGROUND: An increased level of serum C-reactive protein (CRP) is a known prognostic factor for acute coronary events and sudden cardiac death, and it is associated with coronary calcification. CRP is expressed in coronary arteries, but its role in the development of coronary plaques is unclear. AIM: To investigate CRP immunoreactivity in relation to the severity of coronary artery disease and plaque morphology in human left anterior descending coronary arteries (LAD). METHODS: A prospective, consecutive autopsy series of 66 patients (mean age 63.4 years) in Tampere University Hospital, Tampere, Finland. RESULTS: CRP immunoreactivity was seen in 59% of the cases. In logistic regression analysis with age, sex and body mass index as confounders, CRP immunoreactivity in LAD was associated with >50% stenosis and plaque calcification. All three cases with acute coronary thrombosis due to rupture or erosion of the plaque showed a clear immunopositive reaction. CRP-positive cells were never detected in normal arteries, but were often found in early fibrous plaques (75%) and almost invariably present in the shoulder area of plaques with necrotic core (96%). CRP immunoreactivity adjacent to calcified areas in more stable plaques (71%) was less consistent with one-third of these plaques showing no immunoreactivity. CONCLUSIONS: CRP immunoreactivity is associated with the progression of atherosclerosis, and especially with unstable coronary plaques. The immunoreactivity could cease at the stable calcified stages of atherosclerosis.     

Anti-cytomegalovirus (CMV) IgG antibody titer in patients with risk factors to atherosclerosis

Studies have demonstrated cytomegalovirus (CMV) DNA particles in restenotic lesions in atherosclerotic coronary arteries. We have shown that high (>1:800) anti-CMV IgG antibody titers in the serum are associated with active coronary disease and with post coronary angioplasty restenosis. In this study we assessed the anti-CMV antibody titer in patients with risk factors for atherosclerosis (but without documented clinical manifestations). One hundred and eighly-seven patients (men and women aged 40-80 years) that were admitted to the Department of Internal Medicine were recruited to this prospective study. All had at least one risk factor for atherosclerosis, and none had documented coronary artery disease. Fasting blood samples were drawn on admission. Risk factors included hypertension, diabetes mellitus, active smoking, hyperlipidemia, and a positive family history. Ninety-three age- and sex-matched individuals without atherosclerosis risk factors served as the control group. One Hundred and twentysix patients had high anti-CMV antibody titers (>/=1:800) compared with none in the control group. Although 80 patients (90%) in the control group were seropositive, none had anti-CMV IgG antibody titers higher than 1:400. The statistical difference between the patients and the control group was highly significant ( p<0.0001). An immunological response against CMV (expressed as an anti-CMV IgG antibody titer) could be a marker of a long-standing immunological reaction causing an inflammatory response that eventually would cause advanced clinical atherosclerosis. We suggest that anti-CMV antibody titer should be used as an early predictor of atherosclerosis. Our findings support the infectious theory and an association between CMV infection and atherosclerosis at an early stage, maybe even years before clinical events occur.     

B-Lymphocytes in plaque and adventitia of coronary arteries in two patients with rheumatoid arthritis and coronary atherosclerosis: preliminary observations.

OBJECTIVES: To describe the subtypes of lymphocytes in coronary arteries of two patients with rheumatoid arthritis (RA) and coronary artery disease (CAD). MATERIALS AND METHODS: The Mayo Clinic database was searched for patients with RA and CAD who underwent an autopsy in 2001. Medical records were reviewed, and coronary arteries were examined microscopically. The percentage of B- and T-lymphocytes was determined using histomorphometry on representative sections stained with CD20 and CD3 antibodies, respectively. RESULTS: Two men were diagnosed with RA at ages 52 and 70 years and died at ages 60 and 82 years. One sustained an acute myocardial infarction 2 years prior to the diagnosis of RA and had stable CAD until an arrhythmic death. The other developed congestive heart failure secondary to ischemic heart disease 5 years after RA was diagnosed. Both patients had severe three-vessel CAD with both stable fibrocalcific plaques and acute lesions. B- and T-lymphocytes were identified in the plaque and adventitia of all coronary arteries. The mean percentage of B-lymphocytes was 37% to 52% in the plaque and 78% to 85% in the adventitia, while that of T-lymphocytes was 38% to 51% and 28%, for plaque and adventitia, respectively. CONCLUSIONS: In typical CAD, lymphocytic infiltrates are almost exclusively T-cells. In contrast, the two patients with RA and CAD showed prominent infiltrates of B-lymphocytes within plaques and adventitia. Thus, the leukocytic response in atherosclerotic plaques may be altered in patients with autoimmune disorders. This warrants further study.     

Gender paradox in cardiac calcium deposits in middle-aged and elderly patients: mitral annular and coronary calcifications interrelationship

OBJECTIVES: mitral annular calcification (MAC) occurs mainly in middle-aged and elderly patients and can lead to serious clinical consequences. Male predominance in the prevalence of coronary disease is well-established. Paradoxically, the prevalence of MAC, which is theoretically based on the same etiological mechanisms as coronary atherosclerosis, seems to be predominant in postmenopausal women. The goal of this work was to investigate gender influences on interrelationship between MAC and coronary calcifications (CC) in the same population of middle-aged and elderly patients with increased cardiovascular risk. METHODS: the study comprised 522 patients (284 men and 238 postmenopausal women, aged 52-80 years, mean 65+/-6), who were recruited to the International Nifedipine GITS Study of Intervention as a Goal in Hypertension Treatment (INSIGHT) study in our region. They underwent both fast spiral computed tomography of the heart and echo-Doppler. MAC was defined as advanced when its thickness was > or =5mm; otherwise it was defined as trivial. RESULTS: there were 37 (16%) women and 25 (9%) men with advanced MAC (AMAC), 97 (41%) women and 118 (42%) men with trivial MAC and 104 (44%) women and 141 (50%) men without MAC. The prevalence of any type of CC was significantly higher among men (P=0. 001). In sharp contrast to the distinct male predominance in coronary disease, AMAC was more prevalent among women. In patients without CC prevalence was 9 and 4%, increasing to 16 and 8% in those with nonsevere CC and to 38 and 14% in patients with severe CC, respectively (P=0.001). Multivariate analysis showed that AMAC can predict the presence of severe CC in women and men, with OR of 4.1 and 2.6 (CI 1.2-14.8 and 1.0-10.6) and coronary disease with OR of 2. 5 and 2.5 (CI 0.6-10.6 and 1.0-6.4), respectively. CONCLUSIONS: AMAC signifies a high probability of coronary atherosclerosis in patients of both genders. The inverted gender predominance in the prevalence of annular calcification and CC could be explained by additional etiological (likely osteoporotic) mechanisms of MAC development among postmenopausal women.     

Chronic lymphocytic leukemia involving the coronary arteries with accompanying acute myocardial infarction

An 83-year-old man with chronic lymphocytic leukemia (CLL) for 10 years presented with dyspnea and hypotension. Blood investigations and electrocardiogram were consistent with acute myocardial infarction. The patient deteriorated quickly and died shortly thereafter. At autopsy, there was severe atherosclerosis of the coronary arteries and an inferolateral left ventricular wall myocardial infarct. Microscopy showed that CLL involved the nodes, liver, spleen, bowel, and kidneys. The coronary artery walls were infiltrated with leukemia cells invading the tunica media and the atheromatous plaque. Infiltration of the coronary arteries by CLL is not common and the possible role in coronary syndromes is discussed.     

Atherosclerosis in Macaca mulatta: Histopathological,morphometric, and histochemical studies in aorta and coronary arteries of spontaneous and induced atherosclerosis

A comparative study of morphology, size, and histochemistry of the intimal lesions in aorta and coronary arteries of spontaneously occurring and cholesterol-induced atherosclerosis in rhesus monkeys has been carried out. A group of 30 normal monkeys was also investigated. Spontaneous atherosclerosis was noted in 10 of 55 adult monkeys autopsied serially; fatty streaks or atheroma in the aorta was noted in seven, fibrous plaque was noted in two, and diffuse intimal thickening was observed on one animal only. The coronary arteries showed fibrous intimal thickening without lipid in 8 of these 10 monkeys. There was fair to heavy deposition of acid mucopolysaccharides in the thickened intima along with proliferation of myointimal cells and collagen fibers. In the seven monkeys which were fed an atherogenic diet for 6 months, the aorta showed fatty streaking and atheroma in all animals. The coronary arteries also showed a variable degree of atherosclerosis but the lipid in the thickened intima was not marked. The atherosclerotic plaque height was not significantly greater than that in the spontaneous disease. These differences between spontaneously occurring and cholesterol-induced atherosclerosis in monkeys tend to indicate that the basic mechanism of lesion formation in the two states may be different.     

Anti-cytomegalovirus (CMV) IgG antibody titer in patients with risk factors to atherosclerosis

Abstract. Studies have demonstrated cytomegalovirus (CMV) DNA particles in restenotic lesions in atherosclerotic coronary arteries. We have shown that high (>1:800) anti-CMV IgG antibody titers in the serum are associated with active coronary disease and with post coronary angioplasty restenosis. In this study we assessed the anti-CMV antibody titer in patients with risk factors for atherosclerosis (but without documented clinical manifestations). One hundred and eighly-seven patients (men and women aged 40–80 years) that were admitted to the Department of Internal Medicine were recruited to this prospective study. All had at least one risk factor for atherosclerosis, and none had documented coronary artery disease. Fasting blood samples were drawn on admission. Risk factors included hypertension, diabetes mellitus, active smoking, hyperlipidemia, and a positive family history. Ninety-three age- and sex-matched individuals without atherosclerosis risk factors served as the control group. One Hundred and twentysix patients had high anti-CMV antibody titers (1:800) compared with none in the control group. Although 80 patients (90%) in the control group were seropositive, none had anti-CMV IgG antibody titers higher than 1:400. The statistical difference between the patients and the control group was highly significant (p<0.0001). An immunological response against CMV (expressed as an anti-CMV IgG antibody titer) could be a marker of a long-standing immunological reaction causing an inflammatory response that eventually would cause advanced clinical atherosclerosis. We suggest that anti-CMV antibody titer should be used as an early predictor of atherosclerosis. Our findings support the infectious theory and an association between CMV infection and atherosclerosis at an early stage, maybe even years before clinical events occur.     

Sex steroids concentrations in relation to bone mineral density in men with coronary atherosclerosis

BACKGROUND: Although suspected, relationships between sex steroids and bone mineral density (BMD) are not fully defined in male population. According to recent data there may also exist an association between low BMD and atherosclerosis. OBJECTIVE: Our aim was to investigate relationships between serum sex steroids and BMD, and between BMD and atherosclerosis in men with coronary artery disease (CAD). SUBJECTS AND METHODS: We recruited for the study 55 men aged 40-60 years with angiographically confirmed CAD and 30 healthy, age-matched controls. In each of the examined subjects serum levels of total testosterone (T), estradiol (E(2)), estrone and DHEA-S, as well as femoral neck, lumbar spine and total skeleton BMD were measured. RESULTS: We found that the prevalence of osteopenia/osteoporosis recognized on spine and/or femoral BMD (T-score below -1.0) did not differ between men with CAD and healthy controls (respectively 47% versus 47%; p=0.8 in chi(2) Yates test). The mean BMD value at different regions did not differ between both groups either. Hormonal status of men with CAD and normal BMD was similar to men with CAD and osteopenia/osteoporosis except for the level of testosterone. After adjustment for age and BMI, men with lower BMD had lower testosterone and lower T/E(2) ratio than men with normal BMD (geometric means for testosterone were respectively: 16.1+/-8.3 versus 16.2+/-4.2; p<0.05 in ANCOVA with BMI and age as covariates; for T/E(2) ratio it was: 202.1+/-94.7 versus 222.8+/-83.9; p=0.05). However, we did not find any correlation between sex hormones concentrations and bone mineral density. There was a relationship between the advance of atherosclerosis (ranged by number of stenotic arteries) and BMD: men with the most advanced form of the disease (three-vessels) had the lowest femoral neck BMD. The groups did not differ in lumbar spine BMD. CONCLUSIONS: Our data suggest that in middle-aged men with CAD: (1) lower serum testosterone and lower T/E(2) ratio are associated with lower BMD; (2) advance of coronary atherosclerosis is inversely related to femoral neck BMD, however this relationship is weak and requires further investigation.     

Comparative studies of the evolution of aortic and coronary atherosclerosis in Moscow, Ryazan, and Yakutsk males over 40 years

Repeated epidemiological morphological investigations of atherosclerosis of the aorta and coronary arteries were performed in apparently healthy men aged 20-59 years in Moscow, Ryazan and Yakutsk at a 40-year interval. More severe atherosclerosis and different rates of its progression were revealed in males of these towns over 40 years.     

Clinical presentation and coronary angiographic results in unstable angina pectoris

The syndrome "unstable angina" (UA) covers a broad spectrum of patients. In this study we tried to determine the relationship between the severity of UA and angiographic findings. We evaluated 1000 consecutive patients undergoing coronary angiography. Those with the clinical diagnosis "UA" were included in the study. In a retrospective analysis of their records we categorized them, using the Braunwald-classification for determination of the severity of the disease. 352 patients were include, 209 men and 143 women, the mean age was 65 years. 47% met Braunwald-Class I, 26% Class II and 27% Class III. Coronary single-vessel disease was present in 29%, two-vessel disease in 20%, three-vessel disease in 25%, normal coronaries in 13% and coronary atherosclerosis without critical narrowing in 13%. Left ventricular function was preserved in 72%, mild systolic dysfunction was found in 10%, moderate in 13% and severe in 5%. There was no overall correlation between clinical presentation (Braunwald-Classes) and angiographic findings. Women showed a similar distribution of Braunwald-Classes, but significantly more coronary arteries without critical obstruction. In patients with reduced systolic function the percentage of multi-vessel disease was significantly higher, the percentage without relevant coronary artery narrowing was significantly lower. 1) The lack of overall correlation between clinical presentation and angiographic findings supports the importance of coronary angiography in the evaluation of patients with UA. 2) The assessment of women with chest pain is more difficult than of men with regard to coronary heart disease. 3) UA in patients with impaired left ventricular function is a predictor of severe coronary artery disease.