The clinical course, early prognosis and coronary anatomy of subendocardial infarction.

The following prospective study was undertaken to observe the clinical course, early prognosis and coronary anatomy of patients with subendocardial infarction. Subendocardial infarction was defined as typical chest apin (greater than 15 minutes), serum enzyme elevation and persistent (greater than 48 hours) new T wave inversion and/or S-T segment depression in the absence of new pathologic Q waves. Fifty consecutive patients were defined, followed in a prospective manner and subjected to early coronary arteriography. A prior history of unstable angina was found in 33 patients (66 per cent); 22 patients (44 per cent) had significant dysrhythmias during the acute hospital phase, and seven patients (14 per cent) had evidence of mild left ventricular failure. Coronary arteriography demonstrated significant lesions (greater than 75 per cent narrowing in at least one vessel) in all 50 patients, with 30 patients (60 per cent) having either double- or triple-vessel disease. Follow-up (mean 10.6 months) revealed that 15 patients (30 per cent) had stable angina, 23 patients (46 per cent) unstable angina and only 12 patients (24 per cent) remained free of angina. Of 28 patients in a medically treated group, acute transmural infarctions developed in six (21 per cent) and one died (3 per cent). We conclude that subendocardial infarction is symptomatically an unstable entity, is associated with severe coronary artery disease and, in a medically treated group, is followed by a significant incidence of early transmural myocardial infarction (21 per cent). Therefore, these patients require in-hospital monitoring, careful follow-up and consideration for early coronary arteriography.     

Coronary lesions due to aortic valve disease. I -- Occurrence and clinical prognosis]

A multicentre retrospective study of 467 cases of operated aortic valve disease was undertaken to define the indications of coronary arteriography in the pre-operative work-up. Significant coronary artery disease was present in 15% of all cases or, more precisely, in 17% of cases with angina and in 8% when investigation was only routine. Coronary artery disease was more frequent in males, in patients with clinical or electrical evidence of previous myocardial infarction, in patients with ST-T wave changes, and when angina was severe (more than one attack per day). None of these factors was specific. It is therefore difficult to limit coronary arteriography to these patients or there would be a risk of missing significant lesions in a small number of cases. It is important to give the surgeon all the necessary information before aortic valve replacement and so coronary arteriography should be widely practiced in this context. However exceptions may be made for young patients and also those in congestive cardiac failure in whom coronary arteriography represents an unnecessary risk before surgery.     

Chronology and incidence of restenosis after coronary angioplasty. Comparison of patients with stable and unstable angina

The aim of this prospective study was to compare the incidence of restenosis after percutaneous transluminal coronary angioplasty (PTCA) in patients with stable and unstable angina before the procedure. Between January 1984 and February 1986, 344 patients with stable angina and 228 patients with unstable angina underwent PTCA. The primary success rate was 86.3 per cent in patients with stable angina (297 patients) and 87.7 per cent in patients with unstable angina (200 patients). The patients were recalled for systematic control coronary arteriography at 30, 60, 90, 120 or 150 days, and was obtained in 83.8 per cent of patients with stable angina and in 86 per cent of patients with unstable angina. The degree of stenosis before and the angiographic changes after PTCA and at control coronary arteriography were evaluated by a computer-assisted automatic contour detection system. The three criteria of restenosis were: 1) over 50 per cent loss of the benefit of PTCA, 2) residual post-PTCA stenosis increasing from less than 50 per cent to more than 50 per cent at control arteriography, 3) a decrease in the minimum intraluminal diameter of at least 0.72 mm with respect to the immediate post-PTCA result. A comparison between the two groups of patients showed that the average age was slightly greater in patients with unstable angina (56 +/- 9 years vs 58 +/- 9 years, p = 0.047). Apart from this difference, the two groups were comparable with regards to the average number of lesions dilated per patient, the date of control arteriography, the severity of the coronary artery disease and previous bypass surgery, angioplasty and infarction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary artery disease in young patients: arteriographic and clinical review of 40 cases aged 35 and under

Coronary arteriography was performed in 60 patients aged 35 or less with suggested coronary artery disease (CAD). Twenty patients (Group 1) had normal coronary arteries and 40 patients (Group 2) had one or more obstructive lesions. The left anterior descending artery was commonly involved followed by the right coronary and left circumflex arteries. The right coronary artery was most commonly completely obstructed. Single-vessel disease (50 per cent or greater obstruction) was found in 60 per cent of the patients, an incidence that is considerably higher than in studies of older patients. A total of 1.6 diseased vessels per patient was present. A hyperlipoproteinemia (HLP) was found in 68 per cent of Group 2 patients. Patients in Group 2 with an HLP had significantly more CAD than Group 2 patients with normal lipoproteins. The incidence of the following clinical features were not significantly different in Groups 1 and 2: typical angina, atypical angina, positive family history, smoking, hypertension, obesity, abnormal electrocardiogram, positive treadmill test, HLP, and diabetes mellitus. A fourth heart sound and a history of a myocardial infarction were significantly common in Group 2. Since almost all of the previously reported cases of myocardial infarction with normal coronary arteries have occurred in young patients, history of a myocardial infarction does not assure the presence of obstructive coronary artery lesions. It is suggested that coronary arteriography is a justifiable procedure in a young patient who presents with a clinical picture that is either compatible with or cannot be clearly distinguished from CAD.     

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.     

Coronary angiography in the preoperative exploration of non-ischemic acquired valve diseases]

One hundred and fifty-nine patients with aortic valve disease (86 cases), mitral valve disease (58 cases) or mitral and aortic disease (15 cases) underwent a pre-operative haemodynamic study, including coronary arteriography either as a routine (age greater than 50 years) or because of chest pains. Coronary arteriography is easy to do during left heart catheterisation and nowadays carries minimal risk. In the cases of chest pains, it showed stenotic lesions of the coronary vessels in 22% of patients with aortic valve disease and in 35% of those with mitral disease. In the absence of angina, coronary arteriography showed no evidence of coronary artery disease in the cases of mitral regurgitation and of aortic valve disease. In contrast, it showed stenotic lesions in three cases of mitral stenosis. In the whole of the series, coronary artery disease proved a contra-indication to surgery in three cases, and was an indication for aorta-coronary by-pass grafting, in addition to valve surgery, in seven other cases. In the absence of angina, coronary arteriography has only a slight influence on the decision to operate. It does however give additional security, which justifies its routine use in patients over 50 years of age, particularly those with mitral valve disease.     

Surgical implications and results of combined aortic valve replacement and myocardial revascularization.

To better define the indications for and results of simultaneous aortic valve replacement and myocardial revascularization, a cohort of 271 patients with angiographically defined coronary anatomy who underwent xenograft bioprosthetic aortic valve replacement were analyzed. Two hundred and twelve patients had predominant aortic stenosis, and 55 had pure aortic regurgitation. Discordance between the clinical assessment of angina and the angiographic assessment of coronary artery disease was apparent in 39 percent of the patients with aortic stenosis and 45 percent of the patients with aortic regurgitation. Thirty-seven percent of patients in the aortic stenosis subgroup without angina and 41 percent of patients in the aortic regurgitation subgroup without angina had hemodynamically significant coronary artery disease. Concomitant coronary artery bypass grafting and aortic valve replacement were performed in 101 patients. The incidence of perioperative myocardial infarction and operative death was significantly greater (P < 0.05) in the subsets of patients with coronary disease than in those without coronary disease (9.9 percent versus 0.7 percent and 8.3 percent versus 2.2 percent, respectively). Late postoperative angina and myocardial infarction also correlated with the preoperative presence of coronary artery disease. Excluding operative mortality, the late actuarial survival rate (mean follow-up, 1.6 years; maximal follow-up, 4.9 years) was not statistically lower for the patients with coronary disease.It is concluded that angina pectoris in patients with aortic valve disease is not a reliable indicator of coronary artery disease and that patients with coronary disease who undergo aortic valve replacement have an increased risk. It is inferred from this study that preoperative coronary arteriography is advisable in most adults undergoing the evaluation of aortic valve disease and that simultaneous aortic valve replacement and myocardial revascularization may provide some protection against late attrition due to the combined effects of coexistent aortic valve and coronary artery disease.     

Should coronary arteriography be performed routinely before valve replacement?

The implication that coronary atherosclerosis is a common cause of complications and death after prosthetic heart valve replacement has resulted in the performance of routine preoperative coronary arteriography in many clinics. A review of 4 years' experience with such studies at the University of Oregon Medical School Hospital indicates that patients with significant coronary obstruction in conjunction with valvular heart disease always had angina pectoris. None of the postoperative deaths or complications were due to demonstrable coronary artery disease without preexisting angina.It is likely that the increased cardiac work load imposed by valvular heart disease increases myocardial oxygen demands. Significant coronary atherosclerosis is therefore unlikely to remain asymptomatic. Coronary arteriography may be safely omitted before valve replacement in many patients with increased myocardial work who have no symptoms of ischemic heart disease, and who lack risk factors known to increase its incidence.     

Significance of angina pectoris in aortic valve stenosis.

Of 60 patients aged 45 to 66 years with aortic valve stenosis, 28 (47 per cent) had angina pectoris. Significant coronary arterial obstruction was shown by selective coronary cineangiography in 14 of them. Systolic pressure gradients across the aortic valve were lower in patients with angina than in those without. In those with angina, systolic gradients were higher in those with normal coronary arteriograms than in those with demonstrable coronary arterial disease. Aortic valve replacement relieved the angina in all patients who had normal coronary arteriograms. When valve replacement was combined with coronary bypass grafting in those with coronary arterial disease, surgical mortality was higher and symptomatic relief less predictable. Incapacitating angina in patients with aortic stenosis was nearly always associated with significant coronary disease. In those with less severe angina it was impossible to predict the state of the coronary arteries. Two patients, who did not have angina and who did not undergo coronary arteriography, died after aortic valve replacement and were found at necropsy to have unsuspected severe coronary disease. We, therefore, suggest that coronary arteriography should be carried out in all patients over the age of 40 years in whom surgery is being considered for aortic stenosis.     

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.     

Significance of angina pectoris in aortic valve stenosis.

Of 60 patients aged 45 to 66 years with aortic valve stenosis, 28 (47 per cent) had angina pectoris. Significant coronary arterial obstruction was shown by selective coronary cineangiography in 14 of them. Systolic pressure gradients across the aortic valve were lower in patients with angina than in those without. In those with angina, systolic gradients were higher in those with normal coronary arteriograms than in those with demonstrable coronary arterial disease. Aortic valve replacement relieved the angina in all patients who had normal coronary arteriograms. When valve replacement was combined with coronary bypass grafting in those with coronary arterial disease, surgical mortality was higher and symptomatic relief less predictable. Incapacitating angina in patients with aortic stenosis was nearly always associated with significant coronary disease. In those with less severe angina it was impossible to predict the state of the coronary arteries. Two patients, who did not have angina and who did not undergo coronary arteriography, died after aortic valve replacement and were found at necropsy to have unsuspected severe coronary disease. We, therefore, suggest that coronary arteriography should be carried out in all patients over the age of 40 years in whom surgery is being considered for aortic stenosis.     

Exercise tests,atrial pacing,and myocardial lactate extraction in relation to coronary arteriography in young patients with angina pectoris

An exercise ECG and atrial pacing with a simultaneous study of myocardial lactate metabolism were used in conjunction with coronary arteriographies for the examination of 33 women and 22 men aged 40 or below whose working capacity was impaired by angina pectoris. Most of the patients fell into the age group 36 to 40. The men with coronary changes had come for examination in a shorter time than other patients. Coronary artery narrowings were found in five women and six men. The findings in other tests were pathological with greater frequency in patients with coronary stenosis. When evaluated on the basis of coronary arteriograms, the exercise and lactate tests proved to be reasonably sensitive (66.6 per cent) and specific (56.3 per cent and 68.8 per cent) in men. In women the sensitivity was high (80 per cent), but the specifivicity low (exercise 35 per cent, pacing 14.3 per cent, and lactates 38.5 per cent, respectively). The pacing ECG was also highly unspecific in men (37.5 per cent). Seven patients gave totally normal findings. The examination did not identify any specific group of patients with changes as indicatives of a constitutional disease of the myocardium. The coronary changes indicated that even in this age it is proper to obtain arteriograms in patients with low working capacity even in the absence of any other changes that angina pectoris itself. There are more false-positive findings in women than in men in exercise tests, and in many situations arteriography assures the best basis for further measures.     

Effects of recent and remote infarction on the predictive accuracy of the ST segment/heart rate slope

The exercise electrocardiographic ST segment/heart rate slope accurately identifies three vessel coronary disease in patients with stable angina, but the method is less accurate in predischarge testing after recent myocardial infarction. To assess the effect of both recent (less than 3 weeks) infarction and remote (greater than 8 weeks) Q wave infarction on the ST segment/heart rate slope, the predictive value of a slope greater than 6.0 microV/beat per min for the identification of three vessel coronary artery disease was evaluated in 113 patients. The 58 patients with stable angina, including 17 with remote Q wave myocardial infarction, were similar to the 55 patients with recent myocardial infarction with respect to age and peak exercise heart rate. In patients with stable angina and no prior Q wave myocardial infarction, an ST segment/heart rate slope greater than 6.0 had a sensitivity of 92% (11 of 12), a specificity of 97% (28 of 29) and a positive predictive value of 92% (11 of 12) for three vessel coronary artery disease. In patients with stable angina and remote Q wave infarction, sensitivity was 83% (5 of 6), specificity was 91% (10 of 11) and positive predictive value was 83% (5 of 6). After recent infarction, test specificity for three vessel disease was preserved at 95% (39 of 41), but test sensitivity was poor (3 of 8). This was confirmed by evaluation of six additional recent patients with infarction and three vessel disease. Among the combined group with recent infarction, test sensitivity for three vessel disease was only 29% (4 of 14), significantly lower than in patients with stable angina (p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical, haemodynamic, and coronary angiographic correlates of angina pectoris in patients with severe aortic valve disease.

Of 88 consecutive patients aged 20 to 77 years with severe symptomatic aortic valve disease requiring surgery, 51 patients had angina pectoris; of these 51, 41 had predominant aortic stenosis and 10 had severe aortic regurgitation. All patients with angina pectoris underwent coronary angiography; significant coronary arterial disease was encounted in 24 per cent of those with aortic stenosis and 20 per cent of those with aortic regurgitation. By contrast, of 37 patients without angina pectoris 19 underwent coronary arteriography; none showed significant coronary artery disease (P smaller than 0.05). Among patients with angina pectoris, 17 per cent of those with aortic stenosis experienced prolonged, rest or nocturnal pain, compared to 70 per cent of those with aortic regurgitation (P smaller than 0.005). At the time of onset of angina pectoris, there were features of heart failure in 34 per cent of those with aortic stenosis, and in 90 per cent of those with aortic regurgitation (P smaller than 0.005). Nitroglycerin promptly relieved angina pectoris in 56 percent of patients with aortic stenosis and in 50 per cent of those with aortic regurgitation (P smaller than 0.05). Neither the pattern of angina pectoris nor the response to nitroglycerin was dependent upon the coexistence of significant coronary artery disease. In patients with aortic stenosis, there was not significant difference between those with angina pectoris, and those without angina with regard to left ventricular end-diastolic volume, end-diastolic pressure, ejection fraction, peak systolic pressure, wall thickness, cardiac index, or the product of these factors. In patients with aortic regurgitation, cardiac index was significantly lower (P smaller than 0.05), left ventricular end-diastolic volume tended to be larger, and ejection fraction tended to be lower in patients with angina pectoris as opposed to those without angina pectoris.     

Relation of angina to coronary artery disease in mitral and in aortic valve disease.

Of 129 patients with either mitral or aortic valve disease angina was present in 55 (42%). It was more frequent in aortic (60%) than in mitral valve disease (33%). The standard 12-lead electrocardiogram was not helpful in distinguishing underlying occlusive coronary artery disease. Coronary arteriography demonstrated coronary artery disease in 26 patients (20%), only 2 of whom had no angina. The incidence of coronary artery disease was almost identical in both the mitral and aortic groups (22% and 17%, respectively), but the percentage of those with demonstrable coronary artery disease accompanying angina was much higher in the mitral group (67% as against 29%). Angina in mitral valve disorders is thus much more likely to be the result of disease of the coronary arteries. Coronary arteriography is mandatory in all patients in both groups who have angina. Otherwise it seems unnecessary as coronary artery disease was found in only 2 patients who did not have angina.     

Relation of angina to coronary artery disease in mitral and in aortic valve disease

Of 129 patients with either mitral or aortic valve disease angina was present in 55 (42%). It was more frequent in aortic (60%) than in mitral valve disease (33%). The standard 12-lead electrocardiogram was not helpful in distinguishing underlying occlusive coronary artery disease. Coronary arteriography demonstrated coronary artery disease in 26 patients (20%), only 2 of whom had no angina. The incidence of coronary artery disease was almost identical in both the mitral and aortic groups (22% and 17%, respectively), but the percentage of those with demonstrable coronary artery disease accompanying angina was much higher in the mitral group (67% as against 29%). Angina in mitral valve disorders is thus much more likely to be the result of disease of the coronary arteries. Coronary arteriography is mandatory in all patients in both groups who have angina. Otherwise it seems unnecessary as coronary artery disease was found in only 2 patients who did not have angina.     

Profile of coronary artery disease in Indian women: correlation of clinical, non invasive and coronary angiographic findings

Clinical and risk factor profile of 101 consecutive female patients subjected to coronary angiography was analysed. Coronary angiography showed single vessel disease (SVD) in 15.8 per cent, double vessel disease (DVD) in 12.9 per cent, triple vessel disease (TVD) in 39.6 per cent and normal coronary arteries (NC) in 30.7 per cent. Risk factor profile in patients with angiographic coronary artery disease (group II) included hypertension (HT) in 52.9 per cent, diabetes mellitus (DM) in 44.3 per cent, post menopausal state in 84.3 per cent, positive family history in 51.4 per cent, obesity in 58.3 per cent, low density and high density lipoprotein ratio (LDL/HDL) more than 3.0 in 58 per cent and smoking in 4.3 per cent. Risk factors in 31 patients with NC (group I) included HT in 29 per cent, DM in 6.5 per cent, positive family history in 45.2 per cent, obesity in 45.2 per cent, post menopausal state in 48.4 per cent, LDL/HDL ratio more than 3.0 in 30 per cent and smoking in none. The clinical presentation in group II was unstable angina in 64.3 per cent, stable angina pectoris in 24.3 per cent, myocardial infarction in 4.3 per cent and atypical chest pain in 2.8 per cent. In group I half the patients presented with atypical chest pain. The other modes of presentation included unstable angina 25.8 per cent, stable angina pectoris in 16.2 per cent and myocardial infarction in 6.5 per cent. Predictive value of exercise electrocardiography (Ex ECG) or exercise radionuclide studies (Ex RNU) was 61.7 and 68.4 per cent respectively. DM, post-menopausal state and LDL/HDL ratio more than 3 were significant risk factors in women.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dipyridamole radionuclide ventriculography for localisation of coronary artery disease

Nineteen consecutive patients who had coronary arteriography underwent dipyridamole stress testing with 0.14 mg/kg/min infusion over 4 minutes during computer assisted radionuclide ventriculography. Global ejection fraction, diastolic function and regional ejection fraction were calculated by a semiautomatic method. There were 17 patients with severe left anterior descending disease of which 12 involved the proximal segment of the LAD, 15 patients with left circumflex disease and 13 patients with right coronary artery disease. Abnormalities in resting or stress induced regional ejection fraction was used for localisation of severe coronary artery disease. The overall sensitivity was 75 per cent with a specificity of 75 per cent, a positive predictive value of 90 per cent and a negative predictive value of 45 per cent. For LAD disease the sensitivity was 94 per cent with a 100 per cent specificity while proximal segment of LAD had a sensitivity of 100 per cent and a specificity of 57 per cent. Identification of left circumflex disease had a sensitivity of 47 per cent and a 100 per cent specificity and right coronary artery had a 85 per cent sensitivity and a 50 per cent specificity. Four patients developed ST changes, 6 developed chest discomfort and 1 patient developed giddiness. All 7 were promptly reversed with intravenous aminophylline. Thus dipyridamole radionuclide ventriculography is a highly sensitive and specific method for localisation of CAD.     

Clinical predictors of angina following myocardial infarction.

To determine if angina following myocardial infarction could be predicted before hospital discharge we prospectively evaluated 219 consecutive patients admitted to the coronary care unit with acute myocardial infarction. Of the 166 who survived to one year, angina was present before infarction in 53 per cent and after infarction in 61 per cent. Angina did not recur postinfarction in 26 per cent of the patients who had angina before infarction. However, in 47 per cent of those without previous angina it developed postinfarction. Although postinfarction angina correlated with the presence of angina before infarction (p < 0.0005), it did not correlate significantly with age, sex, site of infarction, Killip class on admission nor the presence of a previous infarction.To improve our ability to predict angina after infarction we performed exercise tests to 5 metabolic equivalents (METS), or 70 per cent of age-predicted maximal heart rate, before hospital discharge on all patients less than 70 years old who were without chest pain within four days or without overt heart failure. Of the 105 patients exercised, 31 (86 per cent) of the 36 with positive tests had angina during the subsequent year compared to only 25 (36 per cent) of the 69 with negative tests (p < 0.001). Postinfarction angina occurred in 96 per cent (23 of 24) of the patients who had both angina before infarction and a positive test, but in only 26 per cent (10 of 39) of the patients with neither finding (p < 0.001).We conclude that the presence of angina prior to infarction and a positive limited exercise test performed before hospital discharge are predictive of angina following infarction. Myocardial infarction abolishes angina in a quarter of the patients, but angina develops postinfarction in nearly half of the patients who did not have angina previously.     

冠脉痉挛与变异型心绞痛和急性心肌梗死的关系

目的 探讨冠脉痉挛与变异型心绞痛(VA)和急性心肌梗死(AMI)的关系。方法 对30例AMI和14例VA患者施行冠状动脉造影(CAG),以冠脉狭窄>50％为CAG阳性。结果 在30例AMI患者中有4例CAG正常,在14例VA中,CAG正常2例,狭窄程度在50％～90％的12例。结论 本文结果提示,冠脉痉挛在VA和AMI的发病中起着十分重要的作用。冠脉痉挛不仅可以发生在有严重狭窄的冠状动脉,亦可以发生于造影正常的冠状动脉。