Carotid artery involvement in patients of atherosclerotic coronary artery disease undergoing coronary artery bypass grafting

BACKGROUND: Patients with concomitant critical carotid and coronary artery disease are at risk of major neurological events while undergoing coronary artery bypass grafting. The presence of carotid artery stenosis increases the stroke rate in the perioperative period. In an effort to reduce the stroke rate, many institutions perform routine preoperative noninvasive assessment of the carotid arteries. METHODS AND RESULTS: We analyzed the clinical and laboratory data of 1,200 patients who underwent coronary artery bypass surgery in the last 2 years. Carotid Doppler was normal in 186 patients (15.5%), and showed <30% stenosis in 796 (66.3%), 30%-50% in 110 (9.2%), 50%-70% stenosis in 64 (5.3%) and critical (>70%) stenosis in 44 (3.7%) patients. Conventional risk factors such as hypercholesterolemia, hypertension, smoking and family history were not independent predictors of carotid artery stenosis. However, diabetes as a risk factor had a significant association with carotid artery disease (79.6% v. 43.8%, p<0.02). There was a trend towards increased prevalence of carotid artery stenosis in patients with > or = 2 risk factors (84.3% v. 68.8%). Patients with significant carotid artery stenosis had severe coronary artery disease (triple-vessel disease 93.3%, left main coronary artery disease 12.0%). Out of 44 patients with critical carotid artery stenosis, 27 were subjected to carotid angiography. Doppler findings correlated well with angiography. Seventeen patients underwent carotid artery intervention. None had any perioperative neurological events. A total of 5 (0.4%) patients had a major stroke. Coronary artery bypass grafting was done in 27 patients with critical stenosis without any intervention. The stroke rate (11.1%) was higher in these patients compared to patients with < 70% carotid artery disease or post-carotid intervention (2.5%) patients. Thus, untreated >70% carotid artery stenosis was associated with a higher stroke rate. CONCLUSIONS: Doppler screening of the carotid artery is helpful in detecting the subgroup of patients at increased risk of stroke. Patients with critical carotid artery stenosis should be subjected to angiography. Prophylactic intervention may reduce the occurrence of stroke in the perioperative period.     

心瓣膜病患者颈动脉狭窄的发病情况评估

目的:评估瓣膜病患者颈动脉狭窄的发病率,并对其相关危险因素进行研究。方法:196例超声确诊欲行瓣膜置换术的患者,术前常规冠状动脉造影的同时行颈动脉血管造影。根据造影结果分成两组,单纯瓣膜病组147例(75%),瓣膜病伴发冠心病组49例(25%),分析颈动脉狭窄的发病率。同时将年龄、体质指数、高血压病史、吸烟史及相关生化危险因素作为独立危险因素行多因素逐步Logistic回归分析。结果:瓣膜病伴发颈动脉狭窄总发病率为13%,其中颈动脉狭窄≥70%发生率为7%。单纯瓣膜病组颈动脉狭窄发病率为6%,瓣膜病伴发冠心病组为34%,差异有统计学意义(P<0.01),多因素Logistic回归分析显示,年龄、冠心病史和高血压史与颈动脉狭窄密切相关(P<0.05)。结论:瓣膜病伴发冠心病患者的颈动脉狭窄发病率达34%,术前常规冠状动脉造影的同时,可行颈动脉造影以确诊。     

Prevalence of coronary artery disease in patients with rheumatic heart disease in the current era

BACKGROUND: This study was undertaken to determine the prevalence of coronary artery disease in patients with rheumatic heart disease undergoing valve surgery. METHODS AND RESULTS: Consecutive patients with rheumatic heart disease (n=376) who were above the age of 40 years, and scheduled for valve surgery underwent diagnostic coronary angiogram to delineate coronary arteries. The patients were divided into three groups based on valve involvement (mitral valve, aortic valve, and combined aortic and mitral valve). Significant coronary artery disease was considered to be present if one or more coronaries showed 50% or more luminal stenosis. There were 287 (76.3%) males and 89 (23.7%) females. The mean age of the study population was 51.2+/-8.2 years. Eighty-nine (23.8%) patients had typical chest pain, 116 (30.6%) patients had atypical chest pain and 171 (45.5%) patients had no chest pain. Hypertension was noted in 88 (23.4%) patients, 65 (17.3%) patients had diabetes, 98 (26.1%) patients were smoker, and 66 (17.6%) patients had dyslipidemia, and 15 (4.0%) patients gave past history of myocardial infarction. Of the total 376 patients, 46 (12.2%) patients were found to have significant coronary artery disease. In patients with mitral vale disease the prevalence was 13.5% (13/96), while it was 15.3% (19/124) in patients with aortic valve disease and 9% (14/156) in those with combined mitral and aortic valve disease. CONCLUSIONS: Our results suggest that the overall prevalence of coronary artery disease in a group of patients with rheumatic heart disease undergoing valve surgery in the current era is 12.2%. This prevalence is much lower than the figures reported earlier in the Western literature.     

Incidence of coronary artery disease in patients with valvular heart disease.

The case notes, cardiac catheterisation data, and coronary arteriograms of 239 patients investigated for valvular heart disease during a five year period were reviewed. Angina present in 13 of 95 patients with isolated mitral valve disease, 43 of 90 patients with isolated aortic valve disease, and 18 of 54 patients with combined mitral and aortic valve disease. Significant coronary artery disease was present in 85 per cent of patients with mitral valve disease and angina, but in only 33 per cent of patients with aortic valve disease and angina. Patients with no chest pain still had a high incidence of coronary artery disease, significant coronary obstruction being present in 22 per cent with mitral valve disease, 22 per cent with aortic valve disease, and 11 per cent with combine mitral and aortic valve disease. Several possible clinical markers of coronary artery disease were examined but none was found to be of practical help. There was, however, a significant inverse relation between severity of coronary artery disease and severity of valve disease in patients with aortic valve disease. Asymptomatic coronary artery disease is not uncommon in patients with valvular heart disease and if it is policy to perform coronary artery bypass grafting in such patients, routine coronary arteriography must be part of the preoperative investigation.     

Prevalence of obstructive coronary artery disease in patients with and without prior stroke undergoing coronary angiography for suspected coronary artery disease

This study was conducted to investigate the prevalence and severity of obstructive coronary artery disease (CAD) in 64 men and 38 women (mean age 71+/-9 years) with previous stroke and in 102 age- and gender-matched patients with similar coronary risk factors without previous stroke who underwent coronary angiography for chest pain. Obstructive CAD was present in 100 of 102 patients (98%) with previous stroke and in 84 of 102 (82%) patients without previous stroke (p<0.001). Obstructive 3-vessel CAD was present in 56 of 102 patients (55%) with previous stroke and in 35 of 102 patients (34%) without previous stroke (p<0.005). The prevalence of 2-vessel CAD and of 1-vessel CAD was not significantly different between patients with and without previous stroke. In conclusion, patients with previous stroke have a significantly higher prevalence of obstructive CAD and of obstructive 3-vessel CAD than age- and gender-matched patients with similar coronary risk factors without previous stroke who undergo coronary angiography for chest pain.     

Prevalence of significant coronary heart disease in valvular heart disease in Indian patients

Records of 326 patients were analysed to determine the prevalence of coronary heart disease (CHD) in patients with valvular heart disease (VHD) and to identify the group in whom coronary arteriography is essential. Significant CHD (60% or more luminal narrowing) was found in 7 per cent of cases, and its prevalence was 3 per cent in mitral, 10 per cent in aortic, and 6 per cent in combined mitral and aortic valve disease. Angina was present in 14 per cent of patients with mitral, 39 per cent with aortic, and 21 per cent with combined mitral and aortic valve disease. Seventy-three per cent of patients with CHD had angina whereas only 19 per cent with angina had CHD. The prevalence of CHD was higher in patients above 50 years (13%) and in males (98%) as compared to those below 50 years (3%) and females (none). We conclude that the prevalence of CHD is low in our patients with VHD. Routine coronary arteriography is recommended only in males over the age of 50 years.     

Frequency of coronary artery disease in patients undergoing peripheral artery disease surgery

The prevalence of coronary artery disease (CAD) in patients with peripheral arterial disease (PAD) varies widely in published reports. This is likely due at least in part to significant differences in how PAD and CAD were both defined and diagnosed. In this report, the investigators describe 78 patients with PAD who underwent preoperative coronary angiography before elective peripheral revascularization and provide a review of published case series. Among the patients included, the number with concomitant CAD varied from 55% in those with lower-extremity stenoses to as high as 80% in those with carotid artery disease. The number of coronary arteries narrowed by ≥50% was 1 in 28%, 2 in 24%, and 3 in 19%; 28% did not have any angiographic evidence of CAD. The review of published research resulted in the identification of 19 case series in which a total of 3,969 patients underwent preoperative coronary angiography before elective PAD surgery; in the 2,687 who were described according to the location of the PAD, 55% had ≥1 epicardial coronary artery with ≥70% diameter narrowing. The highest prevalence of concomitant CAD was in patients with severe carotid artery disease (64%). In conclusion, despite sharing similar risk factors, the prevalence of obstructive CAD in patients with PAD ranges widely and appears to differ across PAD locations. Thus, the decision to perform coronary angiography should be based on indications independent of the planned PAD surgery.     

Prevalence and clinical predictors of atherosclerotic coronary artery disease in asymptomatic patients undergoing coronary multidetector computed tomography

OBJECTIVE: We examined the prevalence and clinical predictors of atherosclerotic coronary artery disease in asymptomatic patients undergoing multidetector computed tomography BACKGROUND: In recent years multidetector computed tomography imaging has taken a leading role in the detection of subclinical atherosclerosis, even before its clinical manifestation. We examined the prevalence and clinical predictors of atherosclerotic coronary artery disease in asymptomatic patients undergoing multidetector computed tomography of the coronary arteries. METHODS: A total of 244 consecutive asymptomatic patients (190 men and 54 women aged 53.8+/-7.9 years) with at least one atherogenic risk factor underwent multidetector computed tomography angiography of the coronary arteries. The severity and extent of coronary atherosclerosis were graded and evaluated against clinical and laboratory parameters. RESULTS: Multidetector computed tomography identified significant obstructive coronary artery disease (>50% luminal stenosis) in 13 patients (4.9%), mild or moderate nonobstructive disease (<50% stenosis) in 124 patients (50.8%), and no atherosclerosis in 108 patients (44.3%). On multivariate logistic regression analysis, significant independent clinical predictors of coronary artery disease were male sex (odds ratio, 1.6, P<0.0047), family history of coronary artery disease (odds ratio, 1.4, P<0.0099), low-density lipoprotein cholesterol >130 mg/dl (OR 1.3, P<0.027), hypertension (odds ratio, 1.27, P<0.05), and noninsulin-dependent diabetes mellitus (odds ratio, 1.6, P<0.006). On the basis of the multidetector computed tomography results, pharmacological treatment was initiated or intensified in 40% of patients (statins in 31% and aspirin in 9%). Twenty-two patients (9%) were referred for complementary exercise testing and five (2%) for catheterization. CONCLUSIONS: (i) Occult atherosclerosis is not uncommon in asymptomatic patients with a risk profile for coronary artery disease. (ii) Conventional risk factors independently correlate with imaging findings of coronary atherosclerosis. (iii) Risk management could be intensified in a significant proportion (approximately 40%) of patients based on the multidetector computed tomography findings. (iv) In approximately 5% of patients at clinical risk, multidetector computed tomography might detect obstructive atherosclerosis that mandates further investigation.     

Carotid stenosis and peripheral artery disease in Japanese patients with coronary artery disease undergoing coronary artery bypass grafting.

The combination of a change in lifestyle toward Western habits and an aging society, has led to a steady increase in the incidence of atherosclerotic diseases in the Japanese population. Coronary artery disease (CAD), carotid stenosis (CS), and peripheral artery disease (PAD) are major manifestations of generalized atherosclerosis and increase the risk of cardiovascular events. However, the incidence of CS and PAD in Japanese patients with CAD is not well known, so the present study investigated this in 380 consecutive patients with CAD undergoing elective coronary aorta bypass grafting (CABG) at Kishiwada Tokushukai Hospital between October 1999 and October 2001. The coexistence of CS and PAD in all patients was preoperatively evaluated by duplex ultrasonography and the ankle - brachial index (ABI). The average age of the study population was 66.09.1 years (range, 42-87). The number of male patients was 293 (77.1%). The incidence of CS was 13.7% and 15.3% for PAD. Multivariate logistic regression analysis demonstrated that no particular traditional atherosclerotic risk factor, such as hypertension, hyperlipidemia, diabetes mellitus, and smoking, was able to predict either CS or PAD, but CS and PAD were independent predictors of each other. The results of the study suggest that CS and PAD were not only highly prevalent but also strongly associated with each other in this cohort of CAD patients. Accordingly, extracoronary atherosclerotic disease should be assessed in Japanese CAD patients.     

Prevalence of coronary artery disease in patients with symptomatic peripheral vascular disease.

BACKGROUND: Prevalence of coronary artery disease has been reported to be quite high in patients with peripheral vascular disease in western literature. Therefore, it is important to study the coronary anatomy in patients with symptomatic peripheral vascular disease. METHODS AND RESULTS: Fifty-three patients presenting with symptoms of peripheral vascular disease underwent peripheral angiography in our institute during the last 2 years. The total number of vessels involved in these patients was 117. Fifteen patients had involvement of the upper limb vessels, 46 patients had involvement of the lower limb vessels and 6 patients had involvement of the carotid/vertebral arteries. Coronary arteriography was done in all the patients. Only 8 (15%) patients were found to have coronary artery disease with involvement of 11 arteries. Eighty-four (72%) peripheral vessels out of the 117 vessels involved showed total occlusion, whereas only 2 (18%) coronary arteries out of 11 vessels involved showed total occlusion. CONCLUSIONS: This study shows that the majority of patients with symptomatic peripheral vascular disease have normal coronaries, the extent of their involvement being low despite severe peripheral vascular disease.     

Prevalence of left main coronary artery disease,of three- or four-vessel coronary artery disease,and of obstructive coronary artery disease in patients with and without peripheral arterial disease undergoing coronary angiography for suspected coronary artery disease

Data from the present investigation showed that the prevalence of current cigarette smoking, current or ex-cigarette smoking, systemic hypertension, diabetes mellitus, and dyslipidemia was significantly higher in patients with peripheral arterial disease (PAD) than in patients without PAD. The present report also showed that compared with patients without PAD undergoing coronary angiography for suspected coronary artery disease (CAD), patients with PAD undergoing coronary angiography for suspected CAD had a higher prevalence of left main CAD (18% vs <1%), a higher prevalence of 3- or 4-vessel CAD (63% vs 11%), and a higher prevalence of obstructive CAD (98% vs 81%).     

Angina, coronary risk factors and coronary artery disease in patients with valvular disease. A prospective study

The relationship between coronary risk factors and coronaryartery disease in patients with valvular heart disease was studiedprospectively in 387 consecutive patients undergoing routinecoronary arteriography prior to valve replacement. Coronary artery disease was as common in patients with mitralvalve disease (31.9%) as in those with aortic valve disease(26.8%) Although it occurs more frequently in patients withangina (45.7%) significant coronary artery disease is foundin 19.2% (47 of 245) of those without angina (P<0.001), suggestingthat the presence of angina alone is an unreliable indicatorof significant coronary disease. The prevalence and severityof significant coronary artery disease increases progressivelyas the number of coronary risk factors also increase (P<0.001)but the prevalence is low (3%) in patients in whom both anginaand coronary risk factors are absent. These findings suggestthat preoperative coronary arteriography might be omitted inthis latter group of patients.     

Valvular heart disease: undiagnosed valvular involvement, concomitant coronary artery disease and systemic embolization

The clinical and operative findings were correlated with postmortem findings in 259 patients who died during or shortly after open heart surgery for valvular disease. In 114 patients with clinically diagnosed isolated aortic valve disease, 72 had morphologic abnormalities of the mitral valve, and in 13 these changes were hemodynamically significant. In 28 of 81 patients with clinically diagnosed isolated mitral valve disease, 28 showed aortic valve abnormalities, but the changes were significant in only 1. Fifty-five patients showed abnormalities of the tricuspid valve. All had concomitant mitral valve disease, 44 had aortic valve disease and 2 had changes of the pulmonic valve as well. In 8 the tricuspid valve disease was hemodynamically significant; in 4 of the 8, the lesion was clinically recognized.     

Angina pectoris and coronary artery disease in patients with severe aortic valvular disease

We studied the clinical, hemodynamic, and angiographic findings of 90 consecutive patients with significant symptomatic aortic valve disease, 40 years of age or older, to evaluate the prevalence of angina pectoris in relation to coronary artery disease and the effect upon cardiac function.The prevalence of chest pain was 66% (typical angina, 39%; atypical chest pain, 27%), and the prevalence of coronary artery disease was 39%. The prevalence of coronary artery disease in patients with typical angina was 77%, in contrast to 25% in patients with atypical chest pain $\text{(}\text{P}\text{= 0.001)}$. Only two of the 35 patients (6%) with coronary artery disease were free of chest pain. Although the incidence of coronary artery disease in patients with aortic stenosis was slightly higher than in patients with aortic regurgitation or aortic stenosis-aortic regurgitation, it was not statistically significant.Patients with aortic regurgitation and coronary artery disease had significantly lower ejection fraction than patients with aortic stenosis and coronary artery disease. There were no significant differences between ejection fraction in patients without coronary artery disease in the different groups. Patients with aortic stenosis and coronary artery disease tend to have lower mean pressure gradients than those without coronary artery disease. Patients with coronary artery disease in aortic regurgitation and aortic stenosis-aortic regurgitation tend to have higher left ventricular end-diastolic pressure.This study indicates that although patients with aortic valve disease and typical angina are most likely to have associated coronary artery disease, it is not possible to predict this disorder with accuracy by means of clinical or hemodynamic findings.Since the presence or absence of coronary artery disease in patients undergoing aortic valve replacement has prognostic and therapeutic significance, we recommend that coronary arteriography be performed in all patients with significant aortic valve disease undergoing cardiac catheterization when they present with any form of chest pain, or in patients over the age of 40 years even if no chest pain is present. Coronary arteriography would also rule out anomalous aortic origin of the coronary arteries.