Distribution and severity of coronary artery disease in 500 patients with angina pectoris

The distribution and severity of coronary disease in 500 patients with angina pectoris and at least one area of 50% or greater reduction of luminal diameter in a major coronary artery were compared with respect to patients' age and coronary arterial pattern. The coronary arterial patterns were separated into right (360 patients), mixed (89 patients), and left (51 patients) systems, depending upon the blood supply to the inferior surface of the left ventricle. The following relationships were noted: 1) In patients with angina pectoris, the distribution and severity of coronary artery disease is similar from the third to eighth decade. 2) Coronary arterial stenoses of 50-70% of greater reduction of luminal diameter involve most frequently the proximal portion of the major vessels. Coronary artery disease is multivessel in nature in 80% of cases. In single vessel disease the left anterior descending artery is involved most frequently. 3) The left main coronary artery is moderately to severely obstructed less frequently in individuals with left (2%) as compared to right (8%) and mixed (10%) systems. Otherwise, the distribution of coronary artery disease is similar in right, mixed, and left systems. 4) Coronary artery disease is a diffuse rather than a focal process. As demonstrated by coronary arteriography, patients with coronary artery disease have smaller vessels throughout the arterial tree as compared with individuals free of evident coronary atherosclerosis.     

Left ventricular function and oesophageal function in patients with angina pectoris and normal coronary angiograms

Left ventricular function and oesophageal function (including oesophageal manometry and pH monitoring) were investigated and a psychiatric assessment carried out in 63 patients with angina pectoris and normal coronary angiograms. Twenty two (35%) patients had regional abnormalities of left ventricular wall motion (group A). Thirty six (57%) patients had an oesophageal abnormality (group B); 19 patients had gastro-oesophageal reflux and abnormal oesophageal motility, five had gastro-oesophageal reflux alone, and 12 had abnormal oesophageal motility alone. Only four had regional abnormalities of the left ventricular wall and abnormal oesophageal function. In nine (14%) patients left ventricular and oesophageal function were normal (group C). Psychiatric morbidity was significantly less common in group A than in groups B and C and was similar in group B and group C. A definite abnormality of left ventricular function, oesophageal function, or psychiatric morbidity is present in a high proportion of patients with angina pectoris and normal coronary angiograms and in some instances this may lead to specific treatment. If quantitative assessment of left ventricular function is normal, oesophageal investigations should be performed. Endoscopy of the upper gastrointestinal tract may demonstrate oesophageal disease, but, if findings are normal, oesophageal manometry and ambulatory oesophageal pH monitoring (including during treadmill exercise testing) should be carried out.     

Left ventricular function and oesophageal function in patients with angina pectoris and normal coronary angiograms.

Left ventricular function and oesophageal function (including oesophageal manometry and pH monitoring) were investigated and a psychiatric assessment carried out in 63 patients with angina pectoris and normal coronary angiograms. Twenty two (35%) patients had regional abnormalities of left ventricular wall motion (group A). Thirty six (57%) patients had an oesophageal abnormality (group B); 19 patients had gastro-oesophageal reflux and abnormal oesophageal motility, five had gastro-oesophageal reflux alone, and 12 had abnormal oesophageal motility alone. Only four had regional abnormalities of the left ventricular wall and abnormal oesophageal function. In nine (14%) patients left ventricular and oesophageal function were normal (group C). Psychiatric morbidity was significantly less common in group A than in groups B and C and was similar in group B and group C. A definite abnormality of left ventricular function, oesophageal function, or psychiatric morbidity is present in a high proportion of patients with angina pectoris and normal coronary angiograms and in some instances this may lead to specific treatment. If quantitative assessment of left ventricular function is normal, oesophageal investigations should be performed. Endoscopy of the upper gastrointestinal tract may demonstrate oesophageal disease, but, if findings are normal, oesophageal manometry and ambulatory oesophageal pH monitoring (including during treadmill exercise testing) should be carried out.     

Oesophageal function in patients with angina pectoris: a comparison of patients with normal coronary angiograms and patients with coronary artery disease

Oesophageal function was assessed in 52 patients with angina pectoris whose coronary angiograms were completely normal and in 21 patients with angina pectoris who had significant coronary artery disease. During a standard oesophageal manometric study, abnormalities were found in 23 (44%) patients with normal coronary angiograms but in only 2 (10%) patients with coronary artery disease (p less than 0.01). Twenty-four (46%) patients with normal coronary angiograms were found to have gastro-oesophageal reflux disease during 24-hour oesophageal pH monitoring. Of the 52 patients with normal coronary angiograms, 19 (37%) had gastro-oesophageal reflux disease and abnormal oesophageal motility, 5 (10%) had gastro-oesophageal reflux disease alone, and 7 (13%) had oesophageal motility disorder alone. The use of provocation procedures, including intravenous edrophonium during oesophageal manometry and treadmill exercise testing during pH monitoring, enabled the oesophageal abnormality to be demonstrated simultaneously with chest pain in 25 of these 31 patients. Typical angina pectoris, coincident with abnormal oesophageal motility, was precipitated in a subgroup of patients who had been shown to have oesophageal manometric abnormalities and gastro-oesophageal reflux disease by the infusion of hydrochloric acid into the oesophagus; both the chest pain and manometric abnormality resolved following the oral administration of antacid.     

Relation of C-reactive protein to coronary collaterals in patients with stable angina pectoris and coronary artery disease

The heterogeneity in the degree of collateralization among patients with coronary artery disease (CAD) is poorly understood. We sought to determine whether chronic subclinical inflammation is related to coronary collateral development in patients with chronic stable angina pectoris and obstructive CAD. High-sensitivity C-reactive protein (CRP) levels were measured in 177 patients with stable angina pectoris before coronary angiography. Multivariable logistic regression revealed an inverse graded association between CRP and the presence of coronary collaterals (Rentrop grade 1 to 3). Compared with patients in the first CRP tertile, the adjusted odds ratio for the presence of coronary collaterals was 0.70 (95% confidence interval, 0.33 to 1.52; p = 0.45) for patients in the second CRP tertile and 0.33 (95% confidence interval, 0.15 to 0.75; p = 0.008) for patients in the third CRP tertile (p for trend = 0.008). In conclusion, an inverse graded association exists between CRP and the presence of coronary collaterals in patients with stable angina pectoris.     

Left ventricular dysfunction in patients with angina pectoris and normal coronary angiograms

Left ventricular function was assessed in 201 patients who presented with angina pectoris and who were subsequently found to have completely normal coronary angiograms. Left ventricular angiograms from 187 patients were suitable for analysis of systolic regional wall motion; 121 were found to be normal and 66 had a total of 115 hypokinetic segments. Patients with hypokinesia had a significantly higher left ventricular end systolic volume and a significantly lower left ventricular ejection fraction and exercise capacity than those in whom regional wall motion was normal. Thirty one per cent of patients with normal wall motion and 30% of those with hypokinesia had a resting left ventricular end diastolic pressure greater than 15 mm Hg. There were significantly more smokers in the group with hypokinetic segments. Thus of patients with angina and normal coronary angiograms, 25% had evidence of left ventricular systolic dysfunction, 20% had evidence of diastolic dysfunction, and 11% had evidence of both systolic and diastolic dysfunction. The results suggest that smoking may be associated with left ventricular regional wall motion abnormalities.     

Myocardial strain analysis by 4D-speckle tracking echocardiography for prediction of coronary artery disease severity in patients with stable angina pectoris

ObjectiveWe sought to evaluate the myocardial strain by four-dimensional speckle-tracking echocardiography (4D-STE) in patients with stable angina pectoris (SAP) to determine the severity of coronary artery disease (CAD) based on the Gensini score.MethodsThe present study comprised of 150 patients with SAP. Patients with history of SAP, normal left ventricular ejection fraction, and without regional wall motion abnormalities (RWMA) were scheduled for elective coronary angiography. Based on Gensini score, there were two groups: non-critical stenosis group [Gensini score (0–19), n = 117] and critical stenosis group [Gensini score ≥20, n = 33]. Correlation between Gensini score and 4D-STE strain parameters were investigated.ResultsOut of 150 patients, critical stenosis group had significantly depressed values of all 4D-STE strain parameters than non-critical stenosis group (p < 0.001), except global radial strain (GRS) parameter. Significant positive correlation was found between Gensini score and 4D global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS) with Spearman's correlation coefficient (ρ) as 0.626, 0.548, and 0.631, respectively (p < 0.001), whereas significant negative correlation was found between Gensini score and GRS (ρ = −0.433, p < 0.001). A 4D GLS value of ≥ −17 had 84.9% sensitivity and 97.4% specificity, GAS ≥ −31 (90.9% sensitivity, 78.6% specificity), GCS ≥ −17 (69.7% sensitivity, 92.3% specificity), and GRS <47 (sensitivity 72.7%, specificity 76.1%) to detect critical CAD described by Gensini score ≥20.ConclusionThe 4D-STE can aid in the assessment of severe CAD stenosis with good sensitivity and specificity in the patients with SAP without RWMA on traditional echocardiography.     

Pacing-induced angina pectoris and induction of ventricular arrhythmias in coronary artery disease

Ischemia caused by rapid pacing during electrophysiologic study could facilitate induction of ventricular arrhythmias. The results of extrastimulation were retrospectively analyzed in 32 patients with coronary artery disease (CAD) without a history of symptomatic arrhythmia. These patients were studied at cardiac catheterization for angina pectoris refractory to medical therapy. Eleven patients (group I) had typical angina during trains of rapid right ventricular pacing (repeated trains of 8 stimuli [mean cycle length (CL) 473 +/- 47 ms]) but were asymptomatic during slower trains (CL 800 +/- 100 ms). Twenty-one patients (group II) had no symptoms with either rapid (CL 448 +/- 51 ms) or slow (CL 688 +/- 105 ms) trains, despite comparable left ventricular function, CAD severity and medication. Effective refractory periods (S1S2) after rapid drive were shorter in group I than in group II patients (225 +/- 9 vs 240 +/- 14 ms, p less than 0.002), but refractory periods during slow pacing were similar (251 +/- 12 vs 253 +/- 17 ms, difference not significant). No patient in either group had sustained arrhythmia (more than 15 beats) induced by single and double ventricular extrastimuli, decrementally applied at the right ventricular apex. The number of extra beats provoked in group I when rapid trains caused angina (4.3 +/- 3.6) was similar to that induced by extra-stimulation after slower pacing without angina (4.4 +/- 3.5) and to that obtained with rapid or slow pacing in group II (3.1 +/- 3.3 and 2.8 +/- 2.2).(ABSTRACT TRUNCATED AT 250 WORDS)     

血清TSLP与稳定型心绞痛患者内皮功能和冠状动脉病变的关系

目的 研究血清胸腺基质淋巴细胞生成素（TSLP）水平与稳定型心绞痛（SAP）患者肱动脉内皮功能及冠状动脉病变的关系。方法 连续收集2017年5~11月在我院心血管内科经冠状动脉造影确诊的SAP患者279例和非冠心病者75例（对照组）;术前空腹留取血清待检TSLP和应用超声无创性检测肱动脉血流介导的内皮依赖性血管舒张功能（FMD）以评估血管内皮功能。应用改良Gensini积分评估冠状动脉病变的严重程度,根据结果进一步将SAP患者分为重度、中度和轻度病变亚组。结果 与对照组比较,SAP组FMD显著降低[(7.5±3.1)%比(13.2±3.8)%,P<0.01],而血清TSLP水平则显著升高[(258.2±59.2)pg/mL比(153.7±48.4)pg/mL,P<0.01]。在SAP三个亚组间比较,随冠状动脉病变由轻到重,FMD逐渐降低（P<0.01）,血清TSLP逐渐升高（P<0.05）;Logistic回归分析显示,血清TSLP是冠状动脉重度病变的独立危险因素（OR=1.707,95%CI: 1.334~2.184,P<0.01）。血清TSLP与FMD呈直线负相关（r=-0.402,P<0.01）;进一步多因素分析排除其他心血管危险因素的干扰后,前述两者之间仍存在负相关关系（β′=-0.311,P<0.01）。结论 SAP患者血清TSLP水平与肱动脉内皮功能和冠状动脉病变严重程度密切关系,提示TSLP可能参与了冠心病的病理生理过程。     

Comparison of clinical characteristics and prognosis in Taiwanese patients with coronary vasospastic angina pectoris without significant fixed coronary artery disease versus patients with significant fixed coronary artery disease and either stable angina pectoris or acute coronary syndromes

BACKGROUND: Limited information is available comparing the clinical characteristics and prognosis for patients with coronary vasospastic angina in the absence of hemodynamically significant coronary artery disease (CAD) (defined as >50% stenosis) versus patients with significant fixed CAD presenting with either stable angina pectoris (SAP) or acute coronary syndromes (ACS). METHODS: Patients who underwent cardiac catheterization for suspected ischemic heart disease between August 1999 and February 2003 were followed clinically. For patients without hemodynamically significant CAD, a provocation test for coronary vasospasm was undertaken using a step-wise dose of intracoronary ergonovine administration. RESULTS: A total of 1134 patients were enrolled in the final analysis and stratified into 4 diagnostically distinct groups: control group (n = 239; mild CAD without coronary vasospasm); vasospasm group (n = 284; coronary vasospastic angina pectoris without hemodynamically significant CAD); SAP group (n = 110; hemodynamically significant CAD with SAP); ACS group (n = 501; hemodynamically significant CAD with ACS). Comparison of these 4 groups revealed that the ACS patients were more likely to be male, current smokers, and have hypercholesterolemia. In addition, this group had a significantly higher incidence of typical angina pectoris, 3-vessel CAD, and lower left ventricular ejection fraction. Between-group comparison revealed that vasospasm patients had a significantly higher incidence of early morning angina pectoris. Multivariate analysis showed that current smoking was the most independent risk factor associated with the diagnosis of coronary vasospastic angina pectoris in patients without hemodynamically significant CAD. During a median follow-up period of 49 months, recurrent angina pectoris was noted in patients from the control (n = 6; 3%), SAP (n = 9; 8%), vasospasm (n = 30, 11%), and ACS groups (n = 92; 18%); with nonfatal myocardial infarction identified during follow-up in the SAP (n = 5; 5%), vasospasm (n = 3; 1%), and ACS groups (n = 37; 7%). In addition, 29 and 3 cardiac deaths occurred in the ACS and SAP groups, respectively, whereas there were no such mortalities in the control and vasospasm groups. CONCLUSIONS: Early morning angina pectoris and cigarette smoking were the most common clinical characteristics in patients with coronary vasospasm. These patients had an excellent prognosis despite the possibility of recurrences of vasospastic angina pectoris.     

Left ventricular dysfunction in patients with angina pectoris and normal coronary angiograms.

Left ventricular function was assessed in 201 patients who presented with angina pectoris and who were subsequently found to have completely normal coronary angiograms. Left ventricular angiograms from 187 patients were suitable for analysis of systolic regional wall motion; 121 were found to be normal and 66 had a total of 115 hypokinetic segments. Patients with hypokinesia had a significantly higher left ventricular end systolic volume and a significantly lower left ventricular ejection fraction and exercise capacity than those in whom regional wall motion was normal. Thirty one per cent of patients with normal wall motion and 30% of those with hypokinesia had a resting left ventricular end diastolic pressure greater than 15 mm Hg. There were significantly more smokers in the group with hypokinetic segments. Thus of patients with angina and normal coronary angiograms, 25% had evidence of left ventricular systolic dysfunction, 20% had evidence of diastolic dysfunction, and 11% had evidence of both systolic and diastolic dysfunction. The results suggest that smoking may be associated with left ventricular regional wall motion abnormalities.     

The correlation between speckle tracking echocardiography and coronary artery disease in patients with suspected stable angina pectoris

BackgroundTo examine the value of speckle tracking echocardiography to detect the presence, extent and severity of coronary artery affection in patients with suspected stable angina pectoris.MethodsTwo hundred candidates with suspected stable angina pectoris and normal resting conventional echocardiography were subjected to speckle tracking echocardiography and coronary angiography. Global and segmental longitudinal peak systolic strain were assessed and were correlated to the results of coronary angiography for each patient.ResultsThere was a statistically significant difference in the mean of global longitudinal peak systolic strain between normal coronaries and different degrees of coronary artery disease (CAD) (−20.11 ± 0.8 for normal, −18.34 ± 2.52 for single vessel, −16.14 ± 2.85 for two vessels, −14.81 ± 2.12 for three vessels, −13.01 ± 2.92 for left main disease). GLPSS showed high sensitivity for the diagnosis of single vessel CAD (90%, specificity 95.1%, cutoff value: −18.44, AUC: 0.954); two vessels disease (90%, sensitivity 88.9%, cutoff value −17.35, AUC: 0.906) and for three vessels CAD (cutoff value −15.33, sensitivity 63% and specificity 72.2% AUC 0.681) segmental LPSS also showed statistical significance for localization of the affected vessel for left anterior descending, left circumflex and right coronary artery (ρ = 0.001) and inverse correlation with syntax score that was significant with high and intermediate score (ρ = 0.001) and insignificant for low syntax score (ρ value 0.05).ConclusionTwo-dimensional speckle tracking echocardiography has good sensitivity and specificity to predict the presence, extent and severity of CAD.     

Dental pain threshold and angina pectoris in patients with coronary artery disease

One hundred eight consecutive patients with proved coronary artery disease and reproducible exercise-induced myocardial ischemia were studied. During repeated exercise testing, 52 patients (Group I) had myocardial ischemia in the absence of pain (silent ischemia) whereas 56 patients (Group II) experienced anginal symptoms in the presence of electrocardiographic signs of ischemia. A pulpal test was carried out in all patients using an electrical dental stimulator commonly used in dentistry. Electrical current was delivered in increasing intensity from 10 to 500 mA, and the dental pain threshold and the reaction of the patients to maximal stimulation were determined. During the pulpal test, 71.2% of the patients in Group I did not experience pain, even at maximal stimulation (threshold 0), 11.5% were sensitive at threshold I (10 to 200 mA) and 17.3% felt pain at threshold II (210 to 500 mA). In Group II, 69.7% of the patients complained of dental pain at the low intensity test current (threshold I), 10.7% at threshold II and 19.6% at threshold 0. In Group I, 71.2% of patients did not have discomfort (reaction -), even at maximal stimulation, 21.1% had a mild reaction (reaction +) and 7.7% had an intense painful reaction (reaction ++). In Group II, 80.4% of patients were sensitive to the pulpar test (67.9% reported intense painful sensation at maximal stimulation, 12.5% had a mild reaction); 19.6% of patients had no reaction. The two groups of patients were similar with respect to age, sex and angiographic features.(ABSTRACT TRUNCATED AT 250 WORDS)     

Lipid markers, coronary score and coronary artery disease of stable angina pectoris type

In 120 middle aged male patients with stable angina pectoris and coronarographically documented CAD all examined serum lipid markers differed significantly in comparison with 30 male subjects with vertebro-cardial syndrome and negative coronaro-angiogram (p less than 0.001). The low mean overall coronary score values (4.017 +/- 2.376) reflect the low extent of the coronary atherosclerosis. The coronary score values were significantly positively correlated to the serum levels of cholesterol, triglyceride, LDL-cholesterol, VLDL-cholesterol and negatively correlated to the serum concentration of HDL-cholesterol and HDL-cholesterol/total cholesterol ratios in all examined subjects (CAD and n-CAD groups) (p less than 0.001). In contrast, no significant correlation between coronary score and the examined lipid markers was exhibited in the CAD group of patients when comparing subjects with low and middle coronary score values. According to our results the ratio HDL-cholesterol/total cholesterol represents the best single indicator of the presence and also discriminator of the severity of the coronary athero-sclerosis in the patients with stable angina pectoris.     

依那普利对冠心病人左室舒张功能的影响

应用依那普利治疗冠心病心绞痛患者４０的，１２周后，临床总有效率为９２．５％，心电图总有效率为７２．５％。依那普利尚有降低血压、改善左室舒张功能的作用，适合于心绞痛伴轻、中度高血压病人的治疗。     

N-terminal B-type natriuretic peptide predicts extent of coronary artery disease and ischemia in patients with stable angina pectoris

Background

B-type natriuretic peptide (BNP) and its N-terminal fragment (NT-proBNP) are elevated in patients with acute coronary syndromes and are closely linked to prognosis. Because there is only a small amount of data available concerning NT-proBNP in patients with stable angina pectoris, we aimed to determine whether NT-proBNP is of additional diagnostic value in these patients.

Methods and results

Ninety-four patients with stable angina pectoris were prospectively included. All patients underwent exercise testing and coronary angiography, and 91 patients received thallium-201 single-photon emission computed tomography myocardial scintigraphy. NT-proBNP was analyzed at rest and after exercise testing. NT-proBNP was elevated in patients with inducible myocardial ischemia shown by single-photon emission computed tomography (396 ± 80 pg/mL vs 160 ± 101 pg/mL; P < .01) closely linked to the extent of coronary artery disease (CAD) (no CAD, 148 ± 29 pg/mL; 1- or 2-vessel disease, 269 ± 50 pg/mL; 3-vessel disease 624 ± 186 pg/mL; P < .01). In a multivariate analysis, NT-proBNP was an independent predictor for CAD. The area under the curve of the receiver operating characteristic curve was 0.72 for NT-proBNP to predict CAD. Using an optimized cut off level of 214 pg/mL, CAD can be predicted with high accuracy. The total test efficiency of exercise testing can be improved from 1.46 to 1.52 when combined with NT-proBNP measurement.

Conclusion

NT-proBNP is elevated in patients with stable angina pectoris and has a close correlation to disease severity. Combining the measurement of NT-proBNP with exercise testing, the test accuracy for predicting severe CAD can be improved. Our data show an incremental value of NT-proBNP in the diagnostic process of stable angina pectoris.