心律失常和心肌缺血与冠状动脉造影的临床对照研究

为了解不明原因心律失常与冠状动脉病变的关系，并探讨心电图心肌缺血部位与冠脉病变间的相关性，对４８例心律失常患者行冠状动脉造影。结果２２例心律失常不伴典型心绞痛和心电图缺血改变者，冠脉病变阳性率１３６％，２６例心律失常伴典型心绞痛和心电图缺血改变者，冠脉病变阳性率９２３％。前壁缺血的心电图预测左前降支病变敏感性７８５％，特异性９１６％，下壁缺血的心电图预测右冠脉病变敏感性７５％，特异性７５％。提示典型心绞痛和心肌缺血作为临床诊断冠心病较心律失常更为重要。     

中老年心律失常患者冠状动脉造影的临床分析

目的:分析心律失常患者冠状动脉造影(CAG)特点,以探讨其与冠脉病变的相关性。方法:回顾性分析60例心律失常患者冠状动脉造影的资料。结果:26例心律失常不伴典型心绞痛和心电图心肌缺血者,冠脉病变阳性率11.5％。34例心律失常伴典型心绞痛和心电图缺血改变者,冠脉病变阳性率91.1％;其中左前降支病变易发生快速性心律失常,右冠状动脉病变易发生缓慢性心律失常。两组冠脉造影阳性率有非常显著差异(P<0.01)。结论:心律失常伴典型心绞痛或心肌缺血者很可能是冠心病。     

心律失常患者48例冠状动脉造影结果分析

48例心律失常患者行冠脉造影,结果23例心律失常不伴典型心绞痛和心电图缺血改变者,冠状动脉阳性率13%;25例心律失常伴典型心绞痛和心电图缺血改变者,冠脉病变阳性率92.3%。前壁缺血的心电图预测左前降支病变敏感性为78.5%,特异性为91.6%,下壁缺血的心电图预测右冠脉病变敏感性为75%,特异性为75%。认为典型心绞痛和心肌缺血诊断冠心病较心律失常更为可靠。     

老年心律失常患者冠状动脉病变的分析

目的探讨老年患者不明原因的心律失常与冠状动脉病变的关系。方法对108例老年心律失常伴（A组）或不伴（B组）心绞痛及缺血性心电图改变者的冠状动脉造影（CAG）结果进行分析。结果A组冠状动脉病变率77%,双支、三支病变占58.14%;B组冠状动脉病变率19.2%,单支病变占80%。A组冠状动脉病变阳性率明显高于B组（P〈0.001）。结论心律失常伴典型心绞痛或心肌缺血者诊断冠心病的可能性大。     

258例心律失常患者冠脉病变的临床分析

目的分析心律失常患者的冠状动脉造影结果，研究心律失常与冠脉病变的相关性。方法回顾性分析258例合并有心律失常的疑诊冠心病患者冠状动脉造影结果，对其心律失常与冠脉病变的关系进行分析。结果冠脉病变阳性组134例，其中心律失常伴心绞痛者104例（77．6％），不伴心绞痛30例（22．4％）。冠脉病变阴性组124例，心律失常伴心绞痛者6例（4．8％），不伴心绞痛118例（95．2％）。结论心律失常伴心绞痛诊断冠心病可能性大，而仅以心律失常诊断冠心病可能性较小。     

心律失常、心电图心肌缺血与冠状动脉造影的对比分析

目的 通过选择性冠状动脉造影的对比分析，评估心律失常、心电图心肌缺血与冠状动脉病变的相关性。方法患者根据典型、不典型的心绞痛与无症状的心电图心肌缺血分为A、B和C三组进行选择性冠状动脉造影。结果A组33例有冠状动脉病变，占91．67％；B组仅5例有冠状动脉病变，占14．29％；C组20例有冠状动脉病变，占62．50％；右冠状动脉(RCA)病变在心电图上易出现下壁部位心梗，22／30占73．33％；左冠状动脉回旋支(LCX)病变时主要在心电图上表现下壁与正后壁部位，分别为11／19占57．89％与7／19占36．84％；左前降支(LAD)病变在心电图导联以前壁多见29／36占80．56％。结论心律失常虽然是一个判断因素之一，但无典型心绞痛或心电图心肌缺血改变，其冠心病发生率低；而无症状性心肌缺血临床易忽视，识别与及早治疗是减少心脏事件的重要手段。     

245例冠状动脉造影在冠心病诊断中的价值

为了探讨冠状动脉造影在冠心病诊断中的价值，将245例选择性冠状动脉造形分为心肌梗塞组（101例）、心绞痛组（76例）、不典型心绞痛组（45例）和非冠心病组（23例）进行分析观察，其中224例有满意的左室造影可供分析。结果发现164树冠状动脉造影显示阳性改变，其利心肌梗塞组阳性率96．1%，心绞痛组71．1％，不典型心绞痛组28.9％，非冠心病组无一例阳性．共查出病变冠状动脉血管290支，依次分布于前降支130支、左回旋支80支、右冠状动脉67支、左冠状动脉主干13支．224例在室造影阳性表现为节段运动异常或室壁瘤，心肌梗塞组阳性率86．5％、心绞痛组55．2％、不典型心绞痛组34．1％、非冠心病组5％．结果提示冠状动脉造影仍是显示冠状动脉病变的最直接、有效的方法．     

12导联动态心电图ST段压低诊断冠心病的价值

目的探讨24h12导联动态心电图ST段压低诊断冠心病的临床意义。方法将163例12导联动态心电图检查有缺血性ST段压低伴或不伴典型胸痛患者分为两组（A组ST段压低伴典型胸痛者88例，B组ST段压低不伴典型胸痛或无症状者75例），并与冠状动脉造影进行对比分析。结果A组88例冠状动脉造影明显狭窄79例，其中单支病变44例，双支病变25例，3支病变10例，而B组75例冠状动脉造影明显狭窄15例。以冠状动脉造影阳性为标准，A组对冠心病的诊断阳性率为89．77％，特异性为80．00％，准确度为85．28％。而B组阳性率仅为20．00％，两组阳性率差异有非常显著性意义（χ^2=80．75，P〈0．01）。结论12导联动态心电图检查缺血性ST段压低伴有典型胸痛，诊断冠心病的价值要优于仅有ST段改变者，前者阳性率和准确度较高，具有重要的临床应用价值。     

90例选择性冠状动脉造影分析

目的：探讨选择性冠状动脉造影在冠心病诊断及治疗中的价值。方法：对心肌梗塞、典型心绞痛、不典型心绞痛患者共90例进行选择性冠状动脉造影，并对结果进行分析。结果：冠脉造影阳性率：心肌梗塞组占100％，典型心绞痛组占79．2％，不典型心绞痛组占37．5％。心肌梗塞组及典型心绞痛组与不典型心绞痛组比较，冠脉造影阳性率差异非常显著（P〈0．01），心肌梗塞组与典型心绞痛组比较阳性率无显著差异（P〉0．05）。结论：冠状动脉造影不仅是诊断冠心病的“金标准”，而且有益于冠心病的分型和指导治疗。     

95例拟诊冠心病心绞痛患者冠状动脉造影分析

目的:总结95例临床拟诊冠心病心绞痛患者的冠状动脉造影结果,分析其临床症状及其心电图ST-T改变与冠状动脉造影确诊冠心病的相关性。方法:从发作性胸痛、胸闷为主诉或伴心电图ST-T改变的患者中,筛选出符合或疑似心绞痛,并经心脏超声、胸片检查排除了其他心脏病患者95例,其中典型心绞痛36例;疑似心绞痛的非典型胸痛59例;伴有ST-T改变者87例(缺血型改变25例、非特异性改变62例)。分别接受选择性冠状动脉造影。血管内径狭窄≥50%为造影阳性,诊断冠心病的依据。结果:95例患者造影阳性的45例,其中36例典型心绞痛造影者阳性34例(伴ST-T典型缺血型改变23例、非特异性改变者10例、无改者1例),阳性率94.44%;59例非典型胸痛造影阳性11例(伴非特异性ST-T改变),阳性率18.64%。两组阳性率有显著差异(P<0.01)。结论:典型心绞痛患者冠脉造影诊断冠心病相关性高,非典型胸痛或心电图非特异性ST-T改变患者冠脉造影诊断冠心病阳性率低。     

Application and safety of outpatient ergonovine testing in accurately detecting coronary spasm in patients with possible variant angina

We analyzed the results of 61 consecutive outpatient ergonovine provocation tests to determine the safety and efficacy of such outpatient testing for detecting coronary artery spasm (CAS). Criteria for outpatient testing included: clinical history suggestive of variant angina, noncritical coronary artery disease documented by coronary arteriography, normal exercise treadmill test, no symptomatic arrhythmias, and no history of recent myocardial infarction. All antianginal medications were tapered and stopped. Ergonovine maleate was given as a bolus at 3-minute intervals in consecutive doses of 0.05, 0.10, and 0.25 mg. A positive test was defined as chest pain accompanied by > 0.1 mV ST segment elevation on 12-lead ECG. If pain and ST-segment elevation occurred, intravenous and sublingual nitroglycerin were immediately administered for rellef of myocardial ischemia. Of the 61 patients studied, 10 had positive tests; there were no complications. Follow-up of the 51 patients with negative studies has not revealed cardiac etiology for their chest pain. We conclude that outpatient ergonovine testing is a safe and accurate diagnostic test for identifying CAS in a highly selected population of patients with possible variant angina when performed under carefully controlled conditions.     

QRS prolongation on the signal-averaged electrocardiogram versus st-segment changes on the 12-lead electrocardiogram: Which is the most sensitive electrocardiographic marker of myocardial ischemia?

BACKGROUND: ST-segment changes and QRS prolongation are electrocardiographic (ECG) markers of myocardial ischemia. HYPOTHESIS: This study was undertaken to investigate the appearance of QRS duration changes with or without concomitant ST-segment changes during a typical anginal episode. METHODS: For this purpose, 126 patients underwent 12-lead surface ECG and signal-averaged electrocardiogram (SAECG) during typical anginal pain as well as at the time the patient was asymptomatic. In both periods, QRS duration and ST-segment changes were evaluated. All patients underwent cardiac catheterization. RESULTS: Of the 126 patients, 108 (86%) had coronary artery disease (CAD), whereas the remaining 18 (14%) patients had normal coronary arteriograms. During typical anginal pain, 75 of the 108 (70%) patients with CAD and 2 of the 18 (11%) patients with normal coronary arteriograms developed QRS prolongation, whereas 60 of the 108 (56%) patients with CAD and 2 of the 18 (11%) patients with normal coronary vessels developed ST-segment changes. Thus, the sensitivities of QRS prolongation measured by SAECG and of ST-segment changes on the surface ECG for the detection of myocardial ischemia were found to be 70 and 56%, respectively, (p < 0.01), whereas the specificities were both found to be 89% (p = NS). CONCLUSIONS: During typical anginal pain, QRS prolongation on the SAECG is more sensitive than are ST-segment changes on the ECG for the detection of myocardial ischemia.     

Evaluation of Non-ST Segment Elevation Acute Chest Pain Syndromes with a Novel Low-Profile Continuous Imaging Ultrasound Transducer

Background: This investigation was designed to test the hypothesis that continuous cardiac imaging using an ultrasound transducer developed in our laboratory (ContiScan) is superior to electrocardiogram (ECG) monitoring in the diagnosis of coronary artery disease (CAD) in patients with acute non-ST segment elevation chest pain syndromes. Methods: Seventy patients with intermediate to high probability of CAD who presented with typical anginal chest pain and no evidence of ST segment elevation on the ECG were studied. The 2.5-MHz transducer is spherical in its distal part mounted in an external housing to permit steering in 360 degrees. The transducer was placed at the left sternal border to image the left ventricular short-axis view and recorded on video tape at baseline, during and after episodes of chest pain. Two ECG leads were continuously monitored. The presence of CAD was confirmed by coronary arteriography or nuclear or echocardiographic stress testing. Results: Twenty-four patients had regional wall motion abnormalities (RWMA) on their initial echo which were unchanged during the period of monitoring. All had evidence of CAD. Twenty-eight patients had transient RWMA. All had evidence of CAD. Eighteen patients had normal wall motion throughout the monitoring period, 14 of these had no evidence of CAD, and four had evidence of CAD. These four patients did not have chest pain during monitoring. The sensitivity, specificity, and accuracy of echocardiographic monitoring for diagnosing non-ST elevation myocardial infarction was 88%, 100%, and 91% respectively. The sensitivity, specificity, and accuracy of the ECG for diagnosis of CAD were 31%, 100%, and 52%, respectively. Echocardiography was superior to ECG (P < 0.001). Conclusions: The data indicate that continuous cardiac imaging is superior to ECG monitoring for the diagnosis of CAD in patients presenting with acute non-ST segment elevation chest pain syndromes. This technique could be a useful adjunct to ECG monitoring for myocardial ischemia in the acute care setting.     

Demonstration of carotid plaque in Takayasu arteritis by multislice computed tomography

A 60-year-old woman was admitted to cardiology clinic because of typical chest pain. The presenting electrocardiography (ECG) revealed sinus rhythm and T wave inversion on inferolateral wall. Her chest pain relapsed at second day of admission and electrocardiogram recorded during chest pain had ECG changes consistent with Wolf Parkinson White (WPW) syndrome. She underwent cardiac catheterization and borderline lesion was detected in proximal of left anterior descending artery and direct stent implantation was performed. This is the first case report in which acute ischemia may induce typical ECG changes of WPW in a patient with concealed WPW syndrome. We concluded that acute coronary ischemia may manifest concealed WPW syndrome.     

Right precordial and posterior electrocardiographic leads do not increase detection of ischemia in low-risk patients presenting with chest pain

BACKGROUND: A number of innovative approaches have been investigated for their value in the early detection of acute ischemia or infarction in patients presenting to the emergency department (ED) with chest pain suggestive of a cardiac origin. Prior investigations have demonstrated the utility of adding right precordial and posterior chest leads to the standard 12-lead electrocardiogram (ECG) for identifying right ventricular and posterior wall infarctions in the ED. HYPOTHESIS: To assess the utility of additional ECG leads in low-risk patients presenting to the ED with symptoms suggestive of acute coronary syndromes who are managed in a chest pain evaluation unit (CPEU). METHODS: We studied low-risk patients who presented to the ED with chest pain compatible with myocardial ischemia. Low-risk patients were identified by a normal 12-lead ECG, no arrhythmias or hemodynamic instability, and one negative serum cardiac troponin I. Patients were admitted to the CPEU where a 16-lead ECG was recorded by the addition of 2 right-sided precordial leads (V4R, V5R) and 2 posterior leads (V8, V9) to the standard 12-lead ECG. RESULTS: The 16-lead ECG system was applied to 316 consecutive patients. The study group was a middle-aged population with equal numbers of men and women and an average of 2 cardiac risk factors per patient. The 16-lead ECG demonstrated evidence of myocardial injury in only 1 patient and no evidence of ischemia in any of the 316 patients. CONCLUSION: In patients presenting to the ED with chest pain and evidence of low clinical risk by our criteria, the addition of both right-sided precordial and posterior chest leads to the standard 12-lead ECG did not provide additional information for risk stratification.     

Ventricular arrhythmias in patients with rest angina: correlation with ST segment changes and extent of coronary atherosclerosis

Major ventricular arrhythmias occurring concurrently with myocardial ischemia are presumed to be the most frequent mechanism for sudden cardiac death. Two hundred eighteen catheterized patients with angina pectoris at rest were reviewed to identify clinical, ECG, and arteriographic features that might correlate with the presence of serious ventricular arrhythmias occurring during episodes of rest pain. Ventricular arrhythmias during episodes of rest pain were significantly more common in patients who manifested transient ST segment elevation in the anterior leads and in patients with marked transient ST segment shifts (greater than 5 mm). Ventricular arrhythmias during episodes of rest pain were not more common in patients with extensive coronary artery disease.     

Use of coronary calcium scanning for predicting inducible myocardial ischemia: Influence of patients' clinical presentation.

BACKGROUND: The selection of patients for cardiac stress tests is generally based on assessment of chest pain symptoms, age, gender, and risk factors, but recent data suggest that coronary artery calcium (CAC) measurements can also be used to predict inducible myocardial ischemia. However, the potential influence of clinical factors on the relationship between CAC measurements and inducible ischemia has not yet been investigated. METHODS AND RESULTS: We prospectively performed CAC scanning in 648 patients undergoing exercise myocardial perfusion single photon emission computed tomography. The frequency of ischemia on myocardial perfusion single photon emission computed tomography was assessed according to CAC magnitude after dividing patients according to chest pain symptom class and Bayesian likelihood of angiographically significant coronary artery disease (ASCAD). Estimates of ASCAD likelihood and CAC scores were poorly correlated. The frequency of inducible myocardial ischemia was very low among patients with a low ASCAD likelihood if CAC scores were less than 400. By contrast, the threshold for increasing ischemia occurred at low CAC scores among patients with a high ASCAD likelihood. When characterized by chest pain classification, asymptomatic and nonanginal chest pain patients had a low frequency of ischemia if CAC scores were less than 400, whereas lower CAC scores did not exclude ischemia among typical angina or atypical angina patients. CONCLUSIONS: CAC scores predict myocardial ischemia, with a threshold score of greater than 400 among patients with a low likelihood of ASCAD and those who are asymptomatic or have nonanginal chest pain. These data appear to extend the pool of patients for whom CAC scanning may be useful in ascertaining the need for cardiac stress testing.     

Angina pectoris with angiographically normal coronary arteries: a clinical, hemodynamic, and metabolic study

Seventy-six patients with anginalike chest pain (ALCP) and angiographically normal coronary arteries (NCA) had a study of the myocardial metabolism at rest and during maximal atrial pacing. The results were compared with pain characteristics, electrocardiogram, left ventricular, and coronary hemodynamic data. Coronary blood flow (CBF) was measured by continuous thermodilution. At maximal paced heart rate, the study of the myocardial metabolism distinguished two groups: (1) a first group of 50 patients whose lactate extraction coefficient was equal to or exceeded 9% and was considered as normal (Gr. I, K greater than or equal to 9%); (2) a second group of 26 patients whose lactate extraction coefficient was below 9% (Gr. II, K less than 9%), significant of myocardial ischemia. In group I (K greater than or equal to 9%), chest pain was usually atypical (typical in only 25% of cases) and rapid atrial pacing most often caused neither pain nor ECG changes. The hemodynamic and angiographic study showed minor alterations of the left ventricular cavity in 50% of cases. In group II (K less than 9%), chest pain was typical in 50% of the patients and maximal atrial pacing most often caused chest pain (85%) and ST-segment depression (80%). In almost every case, the left ventricular and the coronary angiograms were normal. Only in this group, which had clinical, electrical, and metabolic signs of myocardial ischemia, could the diagnosis of angina pectoris with angiographically normal coronary arteries be upheld.(ABSTRACT TRUNCATED AT 250 WORDS)     

高血压病伴胸痛患者冠状动脉造影结果分析

目的探讨高血压患者胸痛与冠状动脉狭窄和心肌缺血之间的关系。方法对119例因胸痛入院的高血压病患者的冠状动脉造影结果分析以及收集患者临床资料与冠状动脉造影结果对比分析。结果119例高血压病伴胸痛的患者中诊断心肌缺血101例,73例存在冠状动脉狭窄,阳性率为61.3%,冠状动脉迂曲、僵硬、血流减慢。结论长期高血压而出现心肌缺血临床表现的患者可无冠状动脉狭窄病变,但可出现冠状T波、运动试验性阳性,应进一步提高对高血压病和冠心病复杂临床表现的认识。     

Study of silent myocardial ischemia using exercise stress test among diabetic and non-diabetic patients with documented coronary artery disease

IntroductionProspective studies have documented an increased likelihood of sudden cardiac death and unrecognized myocardial infarction in patients with diabetes.Aim of the workTo study silent myocardial ischemia using exercise stress test among diabetic and non-diabetic patients with angiographically documented coronary artery disease.Patients and methodsPatients with contra-indications to exercise test were excluded.All patients were subjected to treadmill test using modified Bruce protocol & were considered to have silent ischemia if ECG shows ischemic changes without chest pain.StatisticsData were collected & analyzed statistically.ResultsThe study included 80 patients with CAD (40 diabetics & 40 non-diabetics).Their mean age was 58 years old, including males (73.8%).According to stress test patients were classified:

• 1-Group 1: 28 patients (35%), showed no ST depression no chest pain during exercise test, 10 patients of them (35.7%) were diabetic.
• 2-Group 2: two patients (2.5%) who were diabetic showed chest pain without stress induced ST depression (only pain).
• 3-Group 3: 26 patients (32.5%) showed stress ST depression without chest pain (silent ischemia), 18 patients of them (69.2%) were diabetic.
• 4-Group 4: 24 patients (30%) showed ST depression and chest pain during exercise test (symptomatic ischemia), 10 patients of them (41.7%) were diabetic.

All patients underwent coronary angiography (100%) and all of them had significant coronary artery disease (more than 50% stenosis).ConclusionDiabetics with coronary artery disease have a higher prevalence of silent myocardial ischemia than non-diabetics.