Localization of coronary artery disease with exercise electrocardiography: correlation with thallium-201 myocardial perfusion scanning

In 61 patients with single vessel coronary artery disease (70 percent or greater obstruction of luminal diameter in only one vessel) and no previous myocardial infarction, the sites of ischemic changes on 12 lead exercise electrocardiography and on thallium-201 myocardial perfusion scanning were related to the obstructed coronary artery. The site of exercise-induced S-T segment depression did not identify which coronary artery was obstructed. In the 37 patients with left anterior descending coronary artery disease S-T depression was most often seen in the inferior leads and leads V₄ to V₆, and in the 18 patients with right coronary artery disease and in the 6 patients with left circumflex artery disease S-T depression was most often seen in leads V₅ and V₆. Although S-T segment elevation was uncommon in most leads, it occurred in lead V₁ or aVL, or both, in 51 percent of the patients with left anterior descending coronary artery disease. A reversible anterior defect on exercise thallium scanning correlated with left anterior descending coronary artery disease (probability [p] < 0.0001) and a reversible inferior thallium defect correlated with right coronary or left circumflex artery disease (p < 0.0001).In patients with single vessel disease, the site of S-T segment depression does not identify the obstructed coronary artery; S-T segment elevation in lead V₁ or aVL, or both, identifies left anterior descending coronary artery disease; and the site of reversible perfusion defect on thallium scanning identifies the site of myocardial ischemia and the obstructed coronary artery.     

Clinical studies of patients with coronary spasm

Coronary artery spasm may cause myocardial ischemia in patients without severe coronary atherosclerotic obstruction. Spontaneous rest angina, particularly at night, is the predominant symptom; most patients are smokers. Ergonovine tests have high sensitivity and specificity for the diagnosis of coronary spasm, but should be used when vasospasm is suspected but no electrocardiogram was recorded during spontaneous angina. Arterial constriction measured during ergonovine testing suggests that the arterial hypersensitivity to vasoconstrictors at sites of atherosclerotic lesions is independent of the severity of the lesion. Coronary vasospasm may also be provoked by exercise, possibly through an alpha-adrenergic mechanism. Both spontaneous and exercise-induced attacks of vasospasm are prevented by calcium-antagonist drugs that remain effective during longer-term treatment. The cyclic nature of the condition is demonstrated when successful therapy is discontinued without recurrence of symptoms and may be due to alteration of arterial hypersensitivity.     

Differentiation between right and circumflex coronary artery disease on thallium myocardial perfusion scanning

Thallium defects in the inferior and lateral walls of the heart were correlated with right and circumflex coronary artery disease (CAD) in 405 patients who underwent coronary arteriography. In the 102 patients with either single right or left circumflex (LC) CAD, inferior segment defects (anterior view) were associated with right CAD, and both lateral segment defects (40 ° left anterior oblique view) and posteroinferior defects (60 ° left anterior oblique view) were associated with LC CAD. In all 405 patients, inferior segment defects had a sensitivity of 65%, a specificity of 92%, and a predictive accuracy of 89% for right CAD, and lateral segment defects had a sensitivity of 52%, a specificity of 96%, and a predictive accuracy of 90% for LC CAD. Posteroinferior defects had a low predictive accuracy for narrowing in either artery. The presence or absence of concomitant anterior defects did not alter these results. Narrowing in both right and LC coronary arteries was best identified by a combination of inferior and lateral segment defects (sensitivity 30%, specificity 96%, predictive accuracy 72% ). Narrowing in only 1 of these 2 arteries was best identified by a combination of inferior segment without lateral segment defects for right CAD (sensitivity 63%, specificity 86%, predictive accuracy 55%) and lateral segment without inferior segment defects for LC CAD (sensitivity 45%, specificity 92%, predictive accuracy 57%). Thallium scanning identifies significant narrowing in the right and LC coronary arteries, and these may be separated by the pattern of defects.     

Prognosis after an initial non-Q-wave myocardial infarction related to coronary arterial anatomy

Eighty-six consecutive hospital survivors (aged less than or equal to 60 years) of a first non-Q-wave acute myocardial infarction (MI) were followed up prospectively. Coronary arteriography was performed a median of 2 weeks after MI. The size of the MI was small (as judged by a mean peak creatine kinase level of 906 IU/liter); 90% were in Killip class I, and the mean left ventricular ejection fraction was 60 +/- 11% (+/- standard deviation). Forty-nine patients had 1 vessel significantly narrowed by disease (greater than or equal to 70% luminal diameter reduction), 19 had 2-vessel, 2 had 3-vessel, 3 had left main (greater than or equal to 50% luminal diameter reduction), and 13 minimal or no coronary artery disease (CAD). Complete occlusion of the MI-related vessel was present in 33 patients. All 33 and an additional 5 patients had collateral vessels to the MI area. During a mean follow-up of 25 months, 1 cardiac death and 4 recurrent infarcts (3 with non-Q-wave MI) occurred. Angina occurred in 53 patients (62%) and responded medically in all but 7 who underwent coronary artery surgery. Angina after MI occurred frequently in patients with severe proximal left anterior descending CAD (greater than or equal to 90%), and in those with CAD (greater than or equal to 50%) in a vessel supplying collaterals to the infarct area. Because angina can be managed medically in most patients and the outcome is good, routine coronary angiography is not indicated in asymptomatic survivors less than or equal to 60 years of a first non-Q-wave MI.     

Abnormal left ventricular response to isometric exercise in pure, isolated aortic regurgitation: beneficial effects of nifedipine

To examine the effects of nifedipine on the left ventricular (LV) functional response to isometric exercise in patients with aortic regurgitation (AR), 20 patients with isolated, moderate to severe AR performed 3 minutes of handgrip exercise at 33% of their maximal voluntary contraction, before and after administration of 20 mg of sublingual nifedipine. Although handgrip exercise produced similar increases in heart rate and systolic blood pressure before and after nifedipine treatment, heart rate was higher and systolic blood pressure lower with handgrip exercise during nifedipine treatment. LV end-diastolic volume index was not different during the control period and nifedipine handgrip exercise, but the increase in end-systolic volume index was smaller and the ejection fraction was higher during nifedipine handgrip exercise. Nifedipine reduces afterload and ameliorates handgrip exercise-induced LV dysfunction in patients with AR.     

Coronary and left ventricular angiographic anatomy and prognosis of survivors of first acute myocardial infarction

To relate coronary anatomy and left ventricular function to prognosis, 197 of 269 consecutive survivors of a first myocardial infarction (MI) ≤ 60 years old underwent prospective cardiac catheterization a median of 2 weeks after admission and were followed up for a median of 24 months (range 12 to 61). Seventy-two patients were excluded from angiography because of early death (9), severe noncoronary disease (44), MI complications (6), or patient refusal (13). The prevalence of multivessel disease was low (30%) and unrelated to the site of MI or presence of Q waves but was increased in patients with previous angina pectoris (p = 0.05) or those in Killip class II or III (p = 0.02). There were only 8 deaths from heart disease. The survival rate at 12 months was 97 ± 1% and at 24 and 36 months, 95 ± 2%. Nineteen patients underwent coronary revascularization surgery. As the number of deaths was small, the differences in survival between patients with single or multivessel disease and normal or depressed ejection fractions failed to reach significance. Survivors of a first MI ≤ 60 years old have a low prevalence of multivessel disease and a good prognosis.     

Influence of heart rate and atrial transport on left ventricular volume and function: relation to hemodynamic changes produced by supraventricular arrhythmia

The response of the left ventricle to pacing-induced changes in heart rate and the atrioventricular (A-V) relation was examined with equilibrium gated radionuclide ventriculography in 20 patients who had normal ventricular function after surgery for recurrent supraventricular tachycardia. In 10 patients count-derived left ventricular ejection fraction, end-diastolic volume and stroke volume were measured during sinus rhythm and during atrial pacing at 120, 140 and 160 beats/min. In the other 10 patients similar determinations were made during sequential A-V and simultaneous ventricular and atrial (V/A) pacing, both at rates of 100 and 160 beats/min. Left ventricular ejection fraction did not change significantly with atrial pacing (from 0.65 +/- 0.02 [mean +/- standard error of the mean] at a baseline sinus rate of 91 +/- 3 beats/min to 0.62 +/- 0.03 at 160 beats/min) despite a progressive decrease in end-diastolic volume. The percent reduction in end-diastolic volume (% delta EDV) and stroke volume (+ delta SV) from the baseline values was linear and related to change in heart rate (delta HR) as % delta EDV = -0.60 delta HR + 5.19 (r = 0.71; p less than 0.01) and % delta SV = -0.62 delta HR + 5.03 (r = 0.76; p less than 0.001). Left ventricular ejection fraction with baseline sequential A-V pacing at 100 beats/min was 0.67 +/- 0.03 and not significantly altered by either sequential A-V or simultaneous V/A pacing at 160 beats/min. At 100 beats/min, loss of atrial transport with simultaneous V/A pacing resulted in a small reduction in end-diastolic volume from a baseline value of -9.0 +/- 1.9 percent (p less than 0.01) and a nonsignificant reduction in stroke volume of -3.7 +/- 1.6 percent. During simultaneous V/A pacing at 160 beats/min, the reduction in end-diastolic and stroke volumes from the baseline value was -26.6 +/- 3.8 percent and -28.8 +/- 4.3 percent, respectively (both p less than 0.01), but was significantly smaller (-16.1 +/- 3.6 percent and -19.2 +/- 4.1 percent, respectively [p less than 0.05]) when atrial transport was maintained during sequential A-V pacing at the same heart rate. During simultaneous V/A pacing at 160 beats/min, two thirds of the reduction in end-diastolic and stroke volumes from the baseline value was due to the increment in heart rate as assessed from sequential A-V pacing and the other third was due to loss of atrial transport. The data indicate that the hemodynamic consequences of supraventricular tachyarrhythmias in patients with normal ventricular function are due primarily to decreases in ventricular volume as heart rate is increased and atrial contribution is lost rather than to any changes in left ventricular ejection fraction.     

Verapamil in stable effort angina: Effects on left ventricular function evaluated with exercise radionuclide ventriculography

A double blind placebo-controlled study was performed in 12 patients with stable angina pectoris to evaluate the effects of oral verapamil (320 mg/day) on left ventricular function, as measured at rest and during exercise with gated equilibrium radionuclide ventriculography. On verapamil, patients had a lower heart rate-blood pressure product at each work load than with placebo. Anginal threshold increased by 28 ± 19 watts (p < 3.005), and maximal exercise capacity increased by 20 ± 14 watts (p < 0.001) with verapamil, but the rate-pressure product at the onset of angina and at maximal exercise was unchanged. Left ventricular ejection fraction at rest during verapamil therapy was the same as with placebo therapy. On exercise during placebo therapy, the ejection fraction decreased from 40 ± 9 to 35 ± 11 percent (p < 0.025) because end-systolic volume increased disproportionately compared with end-diastolic volume. On exercise during verapamil therapy, the ejection fraction did not decrease (44 ± 8 versus 45 ± 12 percent) and was significantly higher at identical work loads than on placebo because of a smaller increase in end-systolic volume. Oral verapamil is effective treatment for effort angina and may prevent the decrease in left ventricular ejection fraction due to exercise-induced ischemia.     

Calcium channel blocking drugs for chronic, stable angina. Verapamil

Verapamil is effective primary therapy for angina pectoris at a dosage of about 120 mg three times a day. In equal doses it has the same antianginal effect as propranolol although the mechanism of action is different. Long-term therapy is effective and well tolerated. Side effects are few and if required, verapamil may be given with nitrates or beta-blockers.     

The QRS scoring system for estimating myocardial infarct size: clinical, angiographic and prognostic correlations

The relation between a QRS score derived from the routine electrocardiogram and left ventricular function was investigated in 181 patients after myocardial infarction. Patients with left ventricular hypertrophy and conduction defects were excluded. The QRS score correlated closely with the severity of wall motion abnormalities and left ventricular ejection fraction. The more severe the dyssynergy, the higher the QRS score (hypokinesia = 3.0; akinesia = 5.4; dyskinesia = 9.1). The left ventricular ejection fraction (percent) = 66 - (3.3 x QRS score) (correlation coefficient [r] = -0.81, probability [p] less than 0.001). With use of this regression equation, the QRS score predicted angiographic left ventricular ejection fraction to within 12% of the angiographic ejection fraction in 29 of 30 additional patients studied prospectively. The QRS score was also related to clinical functional class. The worse the clinical manifestation of left ventricular dysfunction, the higher the QRS score (Killip class I = 3.5; class II = 6.5; class III = 7.1). A QRS score greater than or equal to 7 had a specificity of 97% and a sensitivity of 59% for predicting an ejection fraction of less than 45%. Patients with a QRS score of 7 or greater had severe wall motion abnormalities, higher peak serum creatine kinase levels, higher prevalence of multivessel coronary disease, poor clinical functional class and an unfavorable outcome. The QRS score provides an inexpensive, clinically useful estimate of left ventricular function after myocardial infarction and can identify patients at high risk.     

The effect of high-dose intravenous nitroglycerin on cardiovascular hemodynamic features and left ventricular function at rest and during exercise in patients with exertional angina

Intravascular pressures, cardiac output and left ventricular function were measured at rest and during exercise in 14 patients with stable angina pectoris before and during an intravenous nitroglycerin infusion. Nitroglycerin was infused at a rate sufficient to reduce mean arterial pressure at rest by 15 to 25 mm Hg.At rest, the end-diastolic volume index decreased from 57 ± 13 to 39 ± 3 ml/m², stroke volume index from 32 ± 6 to 24 ± 5 ml/m² and mean arterial pressure from 112 ± 16 to 91 ± 14 mm Hg. The cardiac output was maintained by an increase in heart rate from 73 ± 9 to 92 ± 37 beats/min. The left ventricular ejection fraction increased from 57 ± 7 to 62 ± 9% because the stroke volume decreased less than the end-diastolic volume.All 14 patients were limited by angina in the prenitroglycerin exercise study, and the mean ST-segment depression at maximal work load was 2.2 ± 1.2 mm. At identical work loads in the nitroglycerin study, only 4 patients had angina, and the mean ST-segment depression was 0.3 ± 0.5 mm. Ten of the 14 patients improved their exercise performance by at least 30 W.Comparing the 2 exercise studies at the maximal work load achieved in the prenitroglycerin study, the mean pulmonary artery wedge pressure was decreased from 23 ± 6 to 6 ± 4 mm Hg, the end-diastolic volume index from 38 ± 15 to 27 ± 12 ml/m², and the mean arterial pressure from 132 ± 8 to 114 ±13 mm Hg. The stroke volume index and the heart rate were not significantly altered and the ejection fraction increased from 56 ± 8% to 66 ± 8%.Thus, in the high dose administered, nitroglycerin decreased left ventricular filling pressure, heart size, and stroke volume at rest and increased the ejection fraction. During exercise, nitroglycerin decreased myocardial ischemia and improved exercise tolerance. An increase in exercise ejection fraction was associated with an increase in the ratio of systolic pressure to end-systolic volume, suggesting that there was an improvement in contractile performance.     

Anterolateral ST segment depression in acute inferior myocardial infarction: angiographic and clinical implications

We examined the relationship between coronary anatomy and anterolateral ST segment depression during inferior acute myocardial infarction (AMI) in 84 consecutive survivors of inferior AMI, who underwent prospective coronary angiography a median time of 2 weeks after AMI. Multivessel disease was defined as two or more significantly (greater than 70%) stenosed vessels. A QRS scoring system was used to estimate myocardial infarct size. Patients with ST depression had more multivessel disease compared to patients with no ST depression (53% vs 6%, p less than 0.01), more left anterior descending stenoses (36% vs 10% p less than 0.05), and higher QRS scores (5.8 +/- 3.2 vs 2.6 +/- 1.8, p less than 0.01) indicating larger infarcts. Patients with ST depression and one-vessel disease (47%) still had higher QRS scores compared to patients with no ST depression (4.8 +/- 2.9 vs 2.6 +/- 1.8, p less than 0.001) and had an increased prevalence of infarct-related vessels with a terminal branch supplying the left ventricular lateral wall or apex. We conclude that anterolateral ST depression during inferior AMI may indicate the presence of additionally stenosed vessels or that the infarct-related vessel has a large vascular territory. The absence of ST depression virtually precludes multivessel disease.     

Stimulation of protein synthesis in isolated hepatocytes by somatomedin

Insulin (1 mU/ml) stimulated the incorporation of 14C-leucine into trichloroacetic acid-precipitable material by isolated hepatocytes from normal and hypophysectomized adult rats and 12-day-old rabbits. Somatomedin (200 ng/ml) purified from human plasma had an insulinlike effect in hepatocytes from hypophysectomized rats and baby rabbits but not from normal rats. This study suggests that, as well as being a site of somatomedin synthesis, the liver may be a target organ for this hormone.     

The effect of fasting on liver receptors for prolactin and growth hormone

The effects of 3 day fasting on liver prolactin and growth hormone receptors have been investigated in male and female rats. Fasting caused a significant fall in serum immunoreactive insulin (67% decrease), while receptor-reactive somatomedin fell by 82% when measured in whole serum and by 72% when measured in serum fractions following gel chromatography at low pH. Tracer ovine prolactin binding to liver microsomal membranes was reduced by 55% on fasting in females, but unchanged in males. Tracer bovine growth hormone binding fell significantly in both sexes. Analysis of competitive binding curves showed the decreased binding to be due to a loss of prolactin receptors in females, and of high affinity (but not low affinity) growth hormone receptors in males and females. Significant correlations were seen between serum insulin and tracer prolactin (females) and growth hormone (males and females) binding to liver membranes. Correlations between serum insulin and liver high affinity growth hormone binding sites were particulary significant (r = 0.899 in females, r = 0.910 in males). It is proposed that the hypoinsulinemia of fasting causes a loss of high affinity growth hormone receptors in the liver, which could result in a relative hepatic resistance to growth hormone and a decreased hepatic generation of somatomedin.     

Changes in rat liver prolactin binding sites in diabetes are sex dependent

The effect of streptozotocin-induced diabetes (100 mg/kg) on lactogenic binding sites, measured by iodinated ovine prolactin (PRL) binding, has been studied in liver microsomal membranes from males and female rats. In females, specific binding was reduced in diabetes from 13% to 4.5% of total tracer, while in males specific binding increased from 0.5% to 2.5%. Similar results were obtained using iodinated human growth hormone as tracer, through overall binding was higher. Scatchard plots of binding curves in females showed that changes in binding were due to changes in receptor concentration, while affinity remained unchanged at 2 X 10(9) M-1. In diabetes, serum PRL and estradiol levels fell by 60% in males but showed no significant change in females, and could therefore not account for receptor changes. In contrast, mean testosterone levels fell in diabetic males from 9.0 to 3.9 nM, and rose in diabetic females from 2.1 to 5.8 nM. Estrogen treatment of male rats caused a marked induction of binding in nondiabetic animals, and a change from the male to the female response to diabetes. Testosterone treatment of nondiabetic females suppressed binding, although not to the male levels, and diabetes caused further suppression. These results are consistent with a role for testosterone in regulating PRL receptors in experimental diabetes, but suggest that other hormonal influences are also involved.     

Perioperative coronary arterial spasm: Long-term follow-up

Six patients who survived episodes of coronary arterial spasm occurring immediately after coronary bypass grafting were followed up for 15 to 30 (mean 20) months after operation. In all patients coronary spasm occurred in an unobstructed dominant right coronary artery and caused inferior transmural ischemia. Sudden circulatory collapse occurred in five of the six patients as a consequence of acute coronary spasm. All patients were treated with nitroglycerin followed by nifedipine. No patient has had recurrent angina or other evidence of spontaneous coronary spasm since surgery. Cardiac catheterization studies, including ergonovine maleate testing, were repeated 3 to 12 months after surgery in five of the six patients. The right coronary artery and all bypass grafts were patent in all five. Four patients had new inferior wall motion abnormalities. Ergonovine provoked focal right coronary arterial spasm in one patient.It is concluded that manifestations of coronary spasm after myocardial revascularization range from asymptomatic S-T segment elevation to severe hypotension. These episodes of perioperative spasm may cause myocardial necrosis. Coronary spasm has not recurred in patients who survived perioperative spasm, but some patients may have a continued predisposition to development of coronary spasm late after surgery.     

Effects of verapamil on the electrophysiologic properties of the accessory pathway in patients with the Wolff-Parkinson-White syndrome

The effects of intravenous verapamil on the electrophysiologic properties of the accessory pathway in 12 patients with symptomatic Wolff-Parkinson-White syndrome were studied using intracardiac electrical recordings. In 11 of the 12 patients it was possible to induce a reentrant supraventricular tachycardia with programmed atrial or ventricular pacing. After verapamil it was still possible to induce supraventricular tachycardia in 6 of the 11 patients; however, the mean cycle of length of the tachycardia increased from a control value of 330 ± 20 ms (mean ± standard error of mean) to 369 ± 21 ms (p < 0.05). Although verapamil had no significant effect on the anterograde refractory period of the accessory pathway as measured by the extrastimulus technique, it significantly increased maximal 1:1 atrioventricular (AV) conduction through the accessory pathway to incremental high rate atrial pacing in 10 of the 12 patients (control value 227 ± 10 beats/min, value after verapamil 258 ± 14 beats/min, p < 0.001). In 4 patients in whom episodes of atrial fibrillation could be compared before and after verapamil, the drug decreased the average R-R interval from a control value of 327 ± 27 ms to 282 ± 28 ms (p < 0.05) and decreased the shortest R-R interval between preexcited beats from a control value of 237 ± 21 ms to 209 ± 18 ms (p < 0.05).

It is concluded that in patients with symptomatic Wolff-Parkinson-White syndrome, verapamil may increase the ventricular response through the accessory pathway if atrial fibrillation occurs. This finding, which is of potential clinical significance, could not have been predicted from conventional anterograde refractory period estimations.     

Early and long-term results of coronary artery bypass grafting with severely depressed left ventricular performance

The effects of coronary artery bypass grafting (CABG) on ventricular performance and long-term clinical status were studied in 18 consecutive patients with disabling angina pectoris and severely depressed left ventricular (LV) performance (ejection fraction [EF] 27 +/- 9%). All patients survived CABG, although 1 patient had a perioperative myocardial infarction. There was no change in LVEF at rest, 29 +/- 12%, in the other 17 patients. However, LVEF during peak exercise increased from 22 +/- 7% to 27 +/- 14% (p less than 0.05). The 17 patients were separated into 2 groups: those who increased their peak exercise LVEF by at least 10% (group A, 8 patients) and those who increased it by less than 10% (group B, 9 patients). Preoperatively, patients in group A had a higher LVEF at rest (p less than 0.001) and smaller end-systolic and end-diastolic volumes at rest (p less than 0.001) and during exercise (p less than 0.005). Preoperatively, the LVEF in group A decreased with exercise, from 36 +/- 4% to 27 +/- 5% (p less than 0.01), but was unchanged in group B (19 +/- 3% vs 17 +/- 4%, difference not significant). After CABG, patients in group A had a smaller increase in end-systolic volume with exercise than those in group B (13 +/- 7 vs 34 +/- 22 ml/m2, p less than 0.05), but the changes in end-diastolic volume with exercise were not significantly different. At 27 +/- 5 months after CABG, 5 of 8 patients in group A were asymptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary artery surgery in Australia. Report from the Committee of the National Heart Foundation Coronary Artery Surgery Register

Clinical data on all patients who have undergone coronary artery surgery in Australia are collected, audited, and published each year by the National Heart Foundation of Australia. These data from 1971 to 1980 are summarized and show the indications for operation, the variation in numbers of patients operated on in each state and unit, and the overall increase in number of operations during the decade.     

Technetium brain scanning in the diagnosis and management of cerebral abscess

Eighteen patients with intracranial abscess were investigated over a 3 year period. Each patient was subjected to cerebral scanning with technetium-99m pertechnetate within 10 days of admission to the hospital. The scan accurately localized each lesion present.Brain scanning was found to be the most sensitive and accurate investigation in the early diagnosis and localization of intracranial abscess. When scans were performed and interpreted in careful clinical context, their accuracy approached 100 percent.Serial scanning with the low energy, gamma emitting radio-pharmaceutical technetium-99m pertechnetate was a sensitive and convenient means of monitoring the patients' response to therapy.The brain scan abnormality in cerebral abscess is due to focal breaches in the blood brain barrier, which occur at the cellular level and which are therefore not dependant upon the presence of an accumulation of macroscopic pus of sufficient size to displace vessels or ventricles. A cerebral scan should be performed whenever cerebral abscess is suspected. In this context it should precede the diagnostically ineffective and potentially dangerous lumbar tap.With careful clinical correlation, the brain scan should reduce the present high mortality rate in patients with cerebral abscess.