Status of the coronary arteries and possibilities of reconstructive surgery in patients with newly developed stenocardia

The state of coronary arteries was assessed by means of angiography, and coronary-bed tendency to spastic response was assessed by the ergometrin test in 76 patients with angina of new onset (several days to 2 months since the first symptoms). It is suggested that coronary spasm as well as the rate and extent of development of collateral anastomoses in response to stenosing events in the coronary arteries are as important as the anatomical factor in the pathogenesis of angina. Aorto-coronary shunting is possible in most of such patients.     

Patterns of coronary artery disease in post-infarction ventricular septal rupture

Cardiac angiography was reviewed in 91 patients with post-infarction ventricular septal rupture. The results were compared with those of 123 stable survivors who had a positive submaximal exercise test early after infarction. Anterior infarction and occlusion of the infarct vessel were more common in those with ventricular septal rupture than in the comparison group. In the group with ventricular septal rupture there was more left ventricular damage, with aneurysm formation in two thirds, and coronary angiography showed more single than triple vessel disease. In the comparison group there was more triple vessel disease than single vessel disease. Angiographically demonstrable collaterals to the infarct territory were not seen or only very faintly seen in 82% of those with septal rupture. Well developed collaterals were seen in two thirds of the comparison group. These patterns of coronary disease suggest that ventricular septal rupture is more likely in patients with coronary occlusion and little or no collateral support to the infarct territory.     

Neurohormonal prediction of post-infarction ventricular dysfunction and coronary disease

Little information is available about the potential role of brain (type B) natriuretic peptide in patients with acute myocardial infarction. We therefore analyzed peptide levels, measured at discharge from our coronary care unit, in 56 patients admitted with a diagnosis of acute myocardial infarction. We examined peptide concentrations in the light of different features in our patients, and found a significant association between natriuretic peptide levels and the two most important prognostic factors: left ventricular ejection fraction, and the severity and extent of coronary disease. Type B natriuretic peptide was a good predictor of these features, and we conclude that concentration of type B natriuretic peptide, measured at discharge from the coronary care unit, provides important clinical and prognostic information in patients with acute myocardial infarction.     

Comparison of the data of 24-hour ECG monitoring and the condition of the coronary bed in patients with the variants of the course of unstable stenocardia]

A total of 232 patients with various clinical types of unstable angina pectoris were examined. All the patients underwent coronary angiographic studies, 24-hour ECG monitoring. In 40.5% of the patients, 24-hour monitoring revealed transient ST segment changes which were not accompanied by pain in 47% of the cases. ST segment changes were equally encountered in patients with one-, two-, and three-vessel disease in the presence or absence of pain. Ischemic ST segment changes generally occurred with an anginal episode in patients with crescendo unstable angina, whereas in those with more prolonged and intensified pain and angina at rest in particular, silent myocardial ischemic episodes were significantly more frequently recorded, which were more common in these patients with multivessel disease.     

Type A personality and risk of post-infarction coronary events

The purpose of this study was to verify the prevalence of Coronary-prone Behaviour Pattern in a group of eighty-eight patients recovering from their first episode of myocardial infarction. These patients were followed for a period of 4 years to verify the eventual appearance of coronary events, after their first myocardial infarction, with high Coronary-prone Behaviour Pattern levels. The results showed that the number of subjects who died from recurrent myocardial infarction was nearly twice as high in type B, non coronary-prone subjects, as in type A subjects. The Authors hypothesize that specific ways of coping with stressful events adopted by type A subjects may constitute a protection factor as regards the risk of death from recurrent myocardial infarction.     

Regression of post-infarction parietal dyskinesia after percutaneous coronary angioplasty

Normalisation of abnormal segmental wall motion is rarely observed after myocardial revascularisation by aorto-coronary bypass when the territory revascularised is the site of post-transmural infarction dyskinesia. In particular, normalisation of segmental wall motion is extremely rare when dynamic tests designed to detect potential for improvement (trinitrin test and post-extrasystolic potentiation) are negative. We present the case of a 41 year old man who had anterior and septal wall dyskinesia 2.5 months after antero-septal infarction which was not improved by trinitrin. Dilatation of the left anterior descending artery by percutaneous coronary angioplasty was undertaken because of recurrent effort angina. Control angiography at 6 months showed almost complete normalisation of left ventricular contraction. This myocardial recovery is paradoxical because the trinitrin test did not show potential for improvement. The case illustrates the possibility of normalisation of segmental abnormalities of left ventricular contraction after revascularisation of the dyskinetic zone by percutaneous coronary angioplasty.     

Long-term outcome of coronary angioplasty in elderly patients with post-infarction angina

The long-term clinical and angiographic outcome of 76 elderly(65 years) patients undergoing coronary angioplasty (PTCA) (83lesions attempted) for post-infarction angina (PIA) (group I)was compared with that of 83 elderly patients undergoing PTCA(105 lesions) for stable angina (group II). Age (70 ±4 years), gender (70% male) and major demographic variableswere similar in both groups. The mean left ventricular ejectionfraction was 56 ± 14% in group I vs 67 ± 14% ingroup II (P<0·01). In group I, PTCA was performedmore frequently for lesions located in the right coronary artery(35% vs 18%, P<0·01) and less frequently in the leftcircumflex artery (12% vs 26%, P<0·05). Although thepercentage of lesions with thrombi was higher in group I (16%vs 2%, P<0·0O1), the rate of angiographic successwas similar in both groups: 94% (78/83 lesions) in group I vs93% (98/105) in group II (ns). PTCA was successful in 67 patients(88%) in group I and in 74 (89%) in group II (ns). The rateof major complications was also similar in both groups (4%).Restenosis occurred in 36% vs 31% of the lesions in groups Iand II respectively (mean time to angiographic follow-up 7 ±2months) (proportion of cases with a repeat angiography: 79%ingroup I and 72% in group II). Restenosis was asymptomatic in57% vs 50% of the patients respectively. Actuarial event-freesurvival (freedom from death, acute myocardial infarction, coronarysurgery, or repeat angioplasty) after successful PTCA (meanfollow-up 22 ± 17 months) was 93%, 84%, 71%, and 54%at 1, 2, 3, and 4 years respectively in group I versus 90%,80%, 74%, and 56% in group II patients (ns). At last follow-up,92% vs 93% of our patients were still alive, and 85% vs 75%were asymptomatic (ns). In conclusion, the clinical indication(PIA versus stable angina) does not seem to affect the shortterm results of PTCA in elderly patients. Moreover, after asuccessful PTCA, elderly patients with PIA appear to have asa good mid-term outcome as those undergoing PTCA for stableangina.     

Patterns of coronary artery disease in post-infarction ventricular septal rupture.

Cardiac angiography was reviewed in 91 patients with post-infarction ventricular septal rupture. The results were compared with those of 123 stable survivors who had a positive submaximal exercise test early after infarction. Anterior infarction and occlusion of the infarct vessel were more common in those with ventricular septal rupture than in the comparison group. In the group with ventricular septal rupture there was more left ventricular damage, with aneurysm formation in two thirds, and coronary angiography showed more single than triple vessel disease. In the comparison group there was more triple vessel disease than single vessel disease. Angiographically demonstrable collaterals to the infarct territory were not seen or only very faintly seen in 82% of those with septal rupture. Well developed collaterals were seen in two thirds of the comparison group. These patterns of coronary disease suggest that ventricular septal rupture is more likely in patients with coronary occlusion and little or no collateral support to the infarct territory.     

Sensitivity to pain in patients with stable stenocardia in relation to the degree of the coronary bed lesion and tolerance to physical exertion (algesimetric data)

Sensitivity to pain, assessed by mechanical algesimetry, was related to the degree of coronary arterial stenosis and physical stress tolerance in patients with stable angina: the higher the degree of stenosis and the lower the stress tolerance threshold, the lower the sensitivity values.     

Clinical characteristics and diagnosis of stenocardia in persons with normal coronary vessels

To date, the clinical pattern and electrocardiographic diagnosis of only one variant of coronary heart disease (CHD) with unchanged coronarogram, Prinzmetal's angina, have been worked out, while the diagnosis of other variants remains undeveloped. Clinical symptoms and possibilities of CHD diagnosis in the presence of intact coronary arteries have been evaluated in 67 coronary patients, the coronarograms being normal in 46 of those. The diagnosis of CHD was verified by means of various instrumental methods, including electrocardiographic tests and myocardial metabolic studies in conditions of frequent atrial stimulations. The results were computerized, using a specifically designed programme. Sets of signs identifying coronary patients with intact coronary arteries at questioning and noninvasive investigation are presented.     

Status of thrombocyte membranes and lipid peroxidation in patients with unstable stenocardia

Platelet and plasma lipid peroxidation (LPO) activity, and possible effect of LPO products on platelet membrane structure were examined in patients with unstable angina, an acute form of coronary disease. All parameters of LPO were increased both in the platelets and the plasma. It was demonstrated by spinning probes that platelet membrane S degree of order was increased significantly, an evidence of increased microviscosity, in patients with unstable angina. There also was a positive correlation between the S value and the level of LPO products. It is suggested that membrane disorders, in which CHD-related platelet hyperreactivity is rooted, may in part be due to PLO activation in the platelets.     

Late coronary reperfusion. A possible etiology of post-infarction angina

Late recanalisation of the infarct Related Artery is possible and may cause post-infarction angina. This was observed in 7 male patients who had complete occlusions of an artery with collateral circulation in the immediate post-infarction period. After a symptom-free period of 17 months, angina recurred and repeat angiography showed recanalisation of the occluded artery with regression of the collateral circulation resulting in myocardial ischemia. Myocardial revascularisation was then required.     

Initial and mid-term results of coronary angioplasty in early post-infarction unstable angina

The aim of this study was to assess the immediate efficacy and the medium-term risks and results of percutaneous transluminal coronary angioplasty (PTCA) in early post-infarction unstable angina. Thirty-six patients were included for a series of 248 consecutive PTCA procedures performed between December 1985 and January 1989. The average age was 56 years (range 35 to 84 years). The initial infarct was anterior (N = 16), inferior (N = 15), lateral (N = 5), without a Q wave (N = 22), transmural (N = 14) and treated by thrombolysis in 42 p. 100 of cases. The interval between initial infarction and PTCA was 16 +/- 3 days. A primary success was obtained in 33 cases (92%). One patient died of electromechanical dissociation at the beginning of the procedure. Two infarcts occurred due to acute coronary occlusions. None of the patients required emergency coronary bypass surgery. The specific risk of PTCA in early post-infarction unstable angina is acute coronary occlusion. This complication was observed in 9 patients (25%) and it required immediate repeat PTCA, associated with thrombolytic therapy in four cases. Coronary occlusion was more common in patients with transmural infarcts than in those without Q-waves (43% vs 14%; p less than 0.01) and in patients treated initially by thrombolysis compared with those not treated by thrombolysis (40% vs 15%; p less than 0.05). No fatalities or reinfarctions occurred during follow-up (average 9 +/- 8 months, range 2 to 35 months). A good clinical result was maintained in 71 per cent of patients treated by PTCA alone. Seven repeat PTCA procedures and 3 coronary bypass operations were performed during follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of reperfusion after coronary artery occlusion on post-infarction scar tissue

Early reperfusion after a coronary occlusion may reduce myocardial infarct size, but late reperfusion into necrotic myocardium may alter post-infarction healing. In rabbits, we compared 1- or 3-week-old scars resulting from permanent coronary occlusion to those resulting from a 1- or 3-hour occlusion followed by reperfusion. Reperfusion at 1 hour post-occlusion did not affect scar mechanical properties assessed at 1 week post-infarction, but at 3 weeks post-infarction, these scars had a tensile strength significantly lower than those not reperfused (78 +/- 11 vs. 158 +/- 15 g/mm2, P less than 0.001). They also were composed of a mixture of fibrous tissue (58 +/- 8%) and myocytes (43 +/- 8%) with a hydroxyproline content of 23 +/- 2.5 mg/g dry weight. The nonreperfused scars had a higher proportion of fibrous tissue (73 +/- 3%) by histological evaluation and a 35% higher hydroxyproline content (31 +/- 2 mg/g dry weight, P less than 0.001) than the scars reperfused after 1 hour. In contrast, 3-week-old scars resulting from "late" reperfusion at 3 hours post-occlusion were similar to nonreperfused scars in fibrous tissue composition and hydroxyproline content. Nonetheless, the tensile strength of these scars reperfused 3 hours post-occlusion was significantly less than that of the nonreperfused scars (72 +/- 5 vs. 158 +/- 15 g/mm2, P less than 0.001). The lower tensile strength was associated with a lower collagen cross-link density in this reperfused group of scars. At physiological stress levels (approximately 3 g/mm2), all groups of reperfused and nonreperfused scars had similar mechanical properties in terms of natural strain, stiffness, creep, and stress relaxation. Thus, although the reperfused scars ruptured more easily at high stresses, when assessed at physiological stresses their mechanical properties were not significantly different from those of nonreperfused scars.     

Preinfarct stenocardia and acute myocardial infarct from the viewpoint of modern coronary surgery]

The results of aorto-coronary shunting in 36 patients with preinfarction angina and of urgent direct myocardial revascularization in 17 patients with acute myocardial infarction are presented. The surgical mortality comprised 28% in the group of patients with preinfarction angina. Twenty-two patients were followed-up for 8 months to 4 years. Good results were obtained in 9 patients, satisfactory--in 7, unsatisfactory--in 4. One patient died of cardiac insufficiency 1 1/2 year after surgery. The diagnosis of preinfarction angina is a direct indication for urgent coronary angiography and aorto-coronary shunting in case suitable coronary arteries are available for anastomosing. The indications for urgent revascularization of the myocardium in cases of infarction included the inefficacy of drug therapy within 2-3 hours of its onset, an unarrested pulmonary oedema and cardiogenic shock in cases of localized proximal occlusion of the coronaries revealed by elective or urgent coronary angiography. Four patients were operated on in the state of cardiogenic shock (one of them after reversing the state of clinical death), and two patients were operated on with pulmonary oedema. All these patients (with the exception of the one with pulmonary oedema) recovered. Four patients died. The follow-up covered a period of 9 months to 3 years. Good results were obtained in 4 patients, satisfactory--in 3, unsatisfactory--in 4. No late mortality cases were observed. The obtained results permit to analyse the preinfarction angina and acute myocardial infarction from the standpoint of modern coronary surgery.