腺苷负荷心肌灌注显像正常女性中心电图呈缺血改变35例分析

目的:探讨腺苷负荷心电图(ECG)呈缺血性改变而核素心肌灌注显像(MPI)正常的女性患者,MPI和冠状动脉CT(CTCA)结果对冠心病(CAD)诊断的临床价值。方法:回顾性分析2008年5月至2011年11月疑诊冠心病行腺苷负荷/静息MPI的4 142例女性患者资料,将其中35例〔年龄39～76岁,平均年龄(55.74±9.43)岁〕腺苷负荷ECG呈缺血改变,但MPI正常者作为研究对象,35例患者均利用SPECT/CT行MPI和同机CTCA检查,其中1例患者在1个月内行冠状动脉造影(CAG)检查。结果:35例患者静息状态ECG均正常,腺苷负荷ECG则出现ST段水平或下斜型下移≥0.1 mV,停止负荷1 min后ECG恢复正常,提示心肌缺血改变,随后的负荷/静息MPI均未见心肌缺血改变。同机CTCA结果示:27例冠状动脉正常(27/35,77.1%),7例冠状动脉粥样硬化性改变(7/35,20.0%),1例(2.9%)为3支冠状动脉狭窄性病变,程度均≥50%,其CAG显示:LAD近段狭窄75%,LCX中段狭窄90%,RCA近中段狭窄95%。结果提示:此组患者中97.1%的冠状动脉是正常或仅呈硬化性改变,而无心肌缺血存在。结论:女性患者易出现负荷ECG"假阳性";负荷MPI是评价此类患者有无冠心病的重要手段;同机CTCA则是避免冠状动脉3支病变而MPI"假阴性"的弥补手段,因此,利用SPECT/CT施行同机MPI/CTCA是对此类患者进行冠心病筛查的准确性较高的无创性评价手段。     

Relationship between noninvasive coronary angiography with multi-slice computed tomography and myocardial perfusion imaging.

OBJECTIVES: The aim of this study was to perform a head-to-head comparison between multi-slice computed tomography (MSCT) and myocardial perfusion imaging (MPI) in patients with an intermediate likelihood of coronary artery disease (CAD) and to compare non-invasive findings to invasive coronary angiography. BACKGROUND: Multi-slice computed tomography detects atherosclerosis, whereas MPI detects ischemia; how these 2 techniques compare in patients with an intermediate likelihood of CAD is unknown. METHODS: A total of 114 patients, mainly with intermediate likelihood of CAD, underwent both MSCT and MPI. The MSCT studies were classified as having no CAD, nonobstructive (<50% luminal narrowing) CAD, or obstructive CAD. Myocardial perfusion imaging examinations were classified as showing normal or abnormal (reversible and/or fixed defects). In a subset of 58 patients, invasive coronary angiography was performed. RESULTS: On the basis of the MSCT data, 41 patients (36%) were classified as having no CAD, of whom 90% had normal MPI. A total of 33 patients (29%) showed non-obstructive CAD, whereas at least 1 significant (> or =50% luminal narrowing) lesion was observed in the remaining 40 patients (35%). Only 45% of patients with an abnormal MSCT had abnormal MPI; even in patients with obstructive CAD on MSCT, 50% still had a normal MPI. In the subset of patients undergoing invasive angiography, the agreement with MSCT was excellent (90%). CONCLUSIONS: Myocardial perfusion imaging and MSCT provide different and complementary information on CAD, namely, detection of atherosclerosis versus detection of ischemia. As compared to invasive angiography, MSCT has a high accuracy for detecting CAD in patients with an intermediate likelihood of CAD.     

Predictive values of Framingham risk and coronary artery calcium scores in the detection of obstructive CAD in patients with normal SPECT

A subgroup of patients with normal stress myocardial perfusion imaging (MPI) have obstructive coronary artery disease (CAD) on coronary computed tomographic angiography (CCTA). A retrospective study was performed to identify factors associated with obstructive CAD in patients with normal MPI. Bivariate differences between patients with obstructive (>50% stenosis) and nonobstructive (<50% stenosis) CAD were assessed. Of the 105 patients with normal MPI, 42 (40%) had obstructive CAD on CCTA. After a multivariable logistic regression analysis increased Framingham risk scores ([FRS] ≥10%) and coronary artery calcium scores ([CACS] >100 Agatston Units [AU]) were independently associated with obstructive CAD (P = .006 and P < .0001, respectively). Patients with normal MPI had 13 times and 98 times higher odds of having obstructive CAD if they had a FRS ≥10% versus <10% and CACS >100 AU versus ≤100 AU, respectively. Increased FRS and CACS may stratify patients who may benefit from further evaluation for significant CAD despite normal MPI.     

Factors associated with failure to identify the culprit artery by the electrocardiogram in inferior ST-elevation myocardial infarction

Background

Right and left circumflex coronary artery occlusions cause inferior myocardial infarction. To improve the targeting of diagnostic and therapeutic measures individually, factors interfering with identification of the culprit artery by the electrocardiogram (ECG) were explored.

Methods

Patients with inferior preinfarction syndrome (n = 266) were included to the Danish Trial in Acute Myocardial Infarction-2 substudy. The culprit vessel was predicted by the ECG, and findings were correlated with angiography. Factors associated with false identification of the culprit artery by the ECG were examined.

Results

Electrocardiogram criteria for right coronary artery occlusion to predict coronary angiography findings had sensitivity, specificity, and positive and negative predictive values of 95%, 52%, 84%, and 81%. For left circumflex coronary artery occlusion, the corresponding values were 51%, 93%, 70%, and 85%, respectively. False ECG identification of the culprit artery was independently associated with left coronary dominance (P < .001; odds ratio [OR], 22.0; 95% confidence interval [CI], 7.2-67.0), multivessel disease (P = .035; OR, 2.2; 95% CI, 1.1-4.7), and absence of proximal occlusion pattern in the ECG (P = .003; OR, 4.0; 95% CI, 1.6-9.8).

Conclusions

Left coronary artery dominance, multivessel disease, and absence of ECG signs of proximal culprit lesion are associated with failure to predict the culprit artery of inferior myocardial infarction by the 12-lead ECG.     

Cocaine-using patients with a normal or nondiagnostic electrocardiogram: single-photon emission computed tomography myocardial perfusion imaging and outcome

Background:

Few trials have examined the outcomes of patients who use cocaine with chest pain and who have a normal or nondiagnostic electrocardiogram (ECG) and the use of single‐photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI).

Hypothesis:

We sought to compare the characteristics and overall outcomes in cocaine users vs non‐cocaine users presenting to the emergency department with a normal/nondiagnostic ECG and to assess the value of rest MPI in both of these populations.

Methods:

Patients with symptoms compatible with myocardial ischemia, suspected acute coronary syndrome (ACS), and a normal/nondiagnostic ECG were enrolled in the Emergency Room Assessment of Sestamibi for Evaluation of Chest Pain (ERASE Chest Pain) trial, a randomized controlled trial designed to evaluate the impact of rest MPI on triage decisions. Cocaine users (n = 294) were compared to non‐cocaine users (n = 2180). Cocaine users were younger than non‐cocaine users, and 72% were male.

Results:

Among the cocaine users, 2.4% had a myocardial infarction, 1.4% required percutaneous coronary intervention, and none of the patients underwent coronary artery bypass graft surgery. Among cocaine users with a final diagnosis of not ACS, randomization of patients to rest SPECT MPI resulted in an appropriate reduction in hospital admissions in both the cocaine users (P = 0.011) and the non‐cocaine users (P < 0.001), suggesting improved triage when MPI was used.

Conclusions:

Cocaine users with a normal/nondiagnostic ECG are at low risk of cardiac events. Even though cocaine users are at low risk of cardiac events, SPECT MPI remains effective in the risk stratification and improves triage management decisions resulting in lower admission rates and more discharges to home. Clin. Cardiol. 2011 DOI: 10.1002/clc.21977 This work was supported by grant number RO1‐HS09110 from the Agency for Healthcare Research and Quality, and in part by the General Clinical Research Centers at Tufts Medical Center (MO1‐RR00054), Northwestern Memorial Hospital (MO1‐RR00048), and Boston Medical Center (MO1‐RR00533), funded by the NIH National Center for Research Resources. The authors have no other funding, financial relationships, or conflicts of interest to disclose.     

The relationship between glycosylated hemoglobin and myocardial perfusion imaging

Background:

The relationship between long‐term glucose control (measured by glycosylated hemoglobin [HgbA1C]) and myocardial perfusion imaging (MPI) abnormalities in symptomatic diabetic patients has not been studied.

Hypothesis:

We hypothesized that diabetic patients with poorly controlled HgbA1C would have more abnormal MPI compared to both patients without diabetes and diabetic patients with tighter glycemic control.

Methods:

This was a retrospective evaluation of 1037 consecutive patients referred for MPI. All patients completed a 1‐day MPI protocol. The electronic medical records were accessed for demographics and relevant medical history.

Results:

Diabetic patients had a higher risk of abnormal MPI (including ischemia, infarction, and mixed ischemia/infarction) compared to nondiabetic patients (relative risk [RR] = 1.77). The populations with suboptimal (HgbA1C ≥7%) and poor (HgbA1C ≥8%) glycemic control had significantly higher risk of abnormal MPI (RR = 1.78 and 2.17, respectively) compared to nondiabetic patients. Coronary angiography supported the MPI results; 66% of diabetic patients had coronary artery disease (CAD), which was higher than the 53% of patients without diabetes found to have CAD.

Conclusions:

The importance of strict glycemic control to reduce cardiovascular complications in diabetic patients is well known. Our study shows a significantly higher risk of abnormal MPI and CAD in diabetic patients with suboptimal and poor long‐term glycemic control, further emphasizing the need for aggressive risk factor modification to minimize vascular complications from DM. Clin. Cardiol. 2012 doi: 10.1002/clc.22028 The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Accuracy of stress Tc-99m tetrofosmin myocardial perfusion tomography for the diagnosis and localization of coronary artery disease in women.

BACKGROUND: Earlier studies have suggested a modest accuracy of stress thallium 201 myocardial perfusion imaging (MPI) for the diagnosis of coronary artery disease (CAD) in women. The accuracy of stress MPI with technetium 99m tetrofosmin has not been studied in women. The aim of this study was to assess the accuracy of stress Tc-99m tetrofosmin MPI for the diagnosis and localization of CAD in women. METHODS AND RESULTS: We studied 88 women who underwent exercise or dobutamine stress Tc-99m tetrofosmin tomography and coronary angiography within 3 months. Significant CAD was defined as a stenosis 50% or greater in diameter in at least 1 major epicardial coronary artery. Myocardial perfusion abnormalities were detected in 44 of 53 patients with significant CAD and in 7 of 35 patients without significant CAD (overall sensitivity, 83% [95% confidence interval (CI), 73%-93%]; specificity, 80% [95% CI, 67%-93%]; and accuracy, 82% [95% CI, 74%-90%]). The sensitivity was 72% (18/25) in patients with single-vessel CAD and 93% (26/28) in patients with multivessel CAD. Perfusion abnormalities were detected in 2 or more vascular distributions in 20 of 28 patients with multivessel CAD and in 4 of 60 patients without multivessel CAD (sensitivity for the identification of multivessel CAD, 71% [95% CI, 55%-88%]; specificity, 93% [95% CI, 86%-98%]; and accuracy, 86% [95% CI, 79%-93%]). The sensitivity, specificity, and accuracy were 82%, 84%, and 83%, respectively, for the diagnosis of CAD in the left anterior descending artery; 77%, 84%, and 81%, respectively, for CAD in the right coronary artery; and 74%, 80%, and 78%, respectively, for CAD in the left circumflex artery. CONCLUSION: Stress Tc-99m tetrofosmin MPI is an accurate noninvasive technique for the diagnosis and localization of CAD in women.     

Prediction of multivessel coronary artery disease and prognosis early after acute myocardial infarction by exercise electrocardiography and thallium-201 myocardial perfusion scanning

Exercise electrocardiography and thallium scanning were performed a mean of 24 days after uncomplicated acute myocardial infarction in 103 patients, aged 36 to 60 years, who also underwent coronary angiography. The purpose of the study was to determine the ability of the noninvasive tests to predict multivessel coronary artery disease (CAD) and prognosis. Patients were followed up to document medical complications (incidence 12%: 3 deaths, 1 resuscitated cardiac arrest, 4 recurrent infarctions, 4 admissions with unstable angina) and combined events (medical events or bypass surgery, incidence 23%). The sensitivity, specificity and predictive accuracy for predicting multivessel CAD were 64%, 77% and 64% for a positive exercise electrocardiographic (ECG) response, 64%, 88% and 80% for a remote thallium defect, and 42%, 96% and 88% for a combination of the 2 tests. With 2 tests yielding negative findings the probability of multivessel CAD was 13%. No variable (positive exercise ECG response, remote thallium defect and presence of multivessel CAD) predicted medical events, although there were nonsignificant trends to more events in patients with any of those findings. The relative risk of combined events was 2.5 (p less than 0.05) for a positive exercise ECG response; 1.8 (NS) for a remote thallium defect; 2.6 (p less than 0.05) for multivessel CAD; and 3.1 (p less than 0.025) for both positive ECG response and remote defect. A combination of exercise electrocardiography and thallium scanning early after acute myocardial infarction helps to identify subsets of patients with high and low probabilities of multivessel CAD and combined medical or surgical events.     

Discrepancy between stress electrocardiographic changes and nuclear myocardial perfusion defects in the prognostic assessment of patients with chest pain

ObjectivesThe aim of the present study was to determine the long-term prognostic value provided by the exercise electrocardiographic (ECG) response to nuclear myocardial perfusion imaging (MPI) in the evaluation of patients with chest pain, focusing on patients with a discrepancy between the two tests.MethodsA total of 1460 consecutive patients (777 female; 62.6±11.4 years) undergoing exercise myocardial single-photon emission computed tomography (SPECT) were included. The endpoint was the occurrence of acute coronary syndrome, heart failure or cardiac death during follow-up.ResultsIschemic ECG changes were observed during stress testing in 271 patients (18.5%) and 362 patients (24.7%) had positive (abnormal) exercise MPI results. There was a discrepancy between ECG and SPECT findings in 471 patients (32.2%). During the follow-up period (14.0-39.6 months), 224 patients (15.3%) presented cardiac events. The hazard ratios (HR) of ECG and MPI results to predict events were 1.506 (95% CI: 1.113-2.039) and 10.481 (95% CI: 7.799-14.080), respectively. In patients with negative MPI, the ECG response did not predict events (HR 1.214 [95% CI: 0.646-2.282]), the same as in patients with positive MPI (HR 1.203 [95% CI: 0.848-1.705]). Only in hypertensive patients with positive SPECT did the ECG show significant prognostic value (HR 1.937 [95% CI: 1.030-3.642]). In multivariate analysis, positive MPI proved an independent long-term prognostic factor (HR 10.536 [95% CI: 7.759-14.308]), but not ECG (HR 1.356 [95% CI: 0.994-1.850]).ConclusionMPI results (normal vs. abnormal) had strong predictive value and discrepant ECG results had no significant additive prognostic value.     

Prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction and non-significant coronary artery disease

Background and purpose

We aimed to study the prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction (STEMI) and non-significant coronary artery disease (CAD).

Methods

From January to October 2012 we consecutively included patients admitted with suspected STEMI and non-significant CAD (coronary artery stenosis diameter < 50%). Patients were diagnosed with acute cardiac disorder in the presence of elevated cardiac biomarkers (troponin T > 50 ng/l or creatine kinase MB > 4 μg/l) or dynamic ECG changes (ST-segment changes or T-wave inversion).

Results

Of the 871 patients admitted with suspected STEMI, 11% (n = 95) had non-significant CAD. Of these, 67% (n = 64) had elevated cardiac biomarkers or dynamic ECG changes and were accordingly diagnosed with acute cardiac disorders. In the remaining 33% (n = 31) of patients, cardiac biomarkers were normal and ECG changes remained stationary.

Conclusions

Acute cardiac disorders were diagnosed in two thirds of patients with suspected STEMI and non-significant CAD.     

New parameters in the interpretation of exercise testing in women: QTc dispersion and QT dispersion ratio difference

BACKGROUND: It has been reported that the increase of QT dispersion (QTD) that occurs due to increased inhomogeneity of the ventricular repolarization because of transient ischemia obtained by standard 12-lead electrocardiogram (ECG), the changes during exercise, and the differences between exercise and rest increase the accuracy of exercise test in the diagnosis of coronary artery disease (CAD). HYPOTHESIS: This study was designed to investigate the value of QTD parameters, which are reported to increase the diagnostic accuracy of exercise test in women. METHODS: Ninety-seven women who had undergone coronary angiography and exercise test were evaluated for diagnosis of chest pain. QT dispersion was calculated using the measurements of the highest and lowest values of QT interval obtained by ECG during peak exercise. The QTc using Bazett's equation, and the QTD ratio (QTDR) using QT/RR were calculated, and QTcD and QTD ratios were obtained. The difference between QTcD and QTDR was determined by extracting the rest values from the exercise values. RESULTS: The groups with normal coronaries (n = 48), single-vessel CAD (n = 24), and multivessel CAD (n = 25) were compared. The obtained QTD parameters at peak exercise and their differences between exercise and rest were found to be significantly increased in patients with CAD (p <0.001). Furthermore, these parameters were found to be higher in the patients with multivessel CAD than in those with single-vessel disease (p < 0.05). With the parameters QTcD > 60 ms and QTDR > 10%, greater sensitivity and specificity were obtained compared with ST-segment depression. The highest diagnostic accuracy was obtained with the QTD parameters calculated from the differences between rest and exercise values. The diagnostic accuracy of the difference of QTcD > 15 ms and the difference of QTDR > 5% was relatively higher than the other parameters (sensitivity, specificity, and negative and positive predictor values are 84, 88, 84, 87% and 84, 96, 85, 95%, respectively). CONCLUSION: The use of QTD parameters as variables of ECG, which is easily obtainable in the evaluation of exercise ECG in women, increases the diagnostic accuracy of the exercise test. In addition, the evaluation of QTD variables may provide information about the incidence of CAD.     

Carotid intima–media thickness is a predictor of coronary artery disease in South African black patients

Background

Several studies have shown that increased carotid intima–media thickness (CIMT) confers risk of future coronary artery disease (CAD) and stroke. The present study aimed at investigating whether CIMT is a predictor of CAD in South African black patients.

Methods and Results

This was a prospective study of 53 patients, 41 men and 12 women, with ages ranging from 30 to 70 years. All patients had undergone coronary angiography for suspected CAD. B-mode ultrasound measurement of the carotid intima–media thickness was carried out in all patients, the operator being blinded to the coronary angiography findings. Twenty-nine of the 38 (76%) subjects with established CAD had increased CIMT, with an average mean CIMT of 1.13 mm. Single-vessel disease was present in 12 people, double-vessel disease in 11 and triple-vessel disease in 12. There was a significant positive linear trend between CIMT and the number of involved coronary vessels (p < 0.0001, r = 0.44).

Conclusions

Increased CIMT correlated with evidence of angiographically proven CAD. The median percentile scores showed a progressive increase as the number of vessels involved increased. CIMT could be useful as a screening tool for the presence of CAD in the South African black population.     

Randomized Comparison of Clinical Effectiveness of Pharmacologic SPECT and PET MPI in Symptomatic CAD Patients

ObjectivesThis study compared the clinical effectiveness of pharmacologic stress myocardial perfusion imaging (MPI) plus positron emission tomography (PET) with single-photon emission computed tomography (SPECT) in patients with known coronary artery disease (CAD) presenting with symptoms suggestive of ischemia.BackgroundAlthough PET MPI has been shown to have higher diagnostic accuracy in detecting hemodynamically significant CAD than SPECT MPI, whether this impacts downstream management has not been formally evaluated in randomized trials.MethodsThis study consisted of a single-center trial in which patients with known CAD and suspected ischemia were randomized to undergo PET or attenuation-corrected SPECT MPI between June 2009 and September 2013. Post-test management was at the discretion of the referring physician, and patients were followed for 12 months. The primary endpoint was diagnostic failure, defined as unnecessary angiography (absence of ≥50% stenosis in ≥1 vessel) or additional noninvasive testing within 60 days of the MPI. Secondary endpoints were post-test escalation of antianginal therapy, referral for angiography, coronary revascularization, and health status at 3, 6, and 12 months.ResultsA total of 322 patients with an evaluable MPI were randomized (n = 161 in each group). At baseline, 88.8% of patients were receiving aspirin therapy, 76.7% were taking beta-blockers, and 77.3% were taking statin therapy. Diagnostic failure within 60 days occurred in only 7 patients (2.2%) (3 [1.9%] in the PET group and 4 [2.5%] in the SPECT group; p = 0.70). There were no significant differences between the 2 groups in subsequent rates of coronary angiography, coronary revascularization, or health status at 3, 6, and 12 months of follow-up (all p values ≥0.20); however, when subjects were stratified by findings on MPI in a post hoc analysis, those with high-risk MPI on PET testing had higher rates of angiography and revascularization on follow-up than those who had SPECT MPI, whereas those undergoing low-risk PET studies had lower rates of both procedures than those undergoing SPECT (interaction between randomized modality 1high-risk MPI for 12-month catheterization [p = 0.001] and 12-month revascularization [p = 0.09]).ConclusionsIn this contemporary cohort of symptomatic CAD patients who were optimally medically managed, there were no discernible differences in rates of diagnostic failure at 60 days, subsequent coronary angiography, revascularization, or patient health status at 1 year between patients evaluated by pharmacologic PET compared with those evaluated by SPECT MPI. Downstream invasive testing rates with PET MPI were more consistent with high-risk features than those with SPECT MPI. (Effectiveness Study of Single Photon Emission Computed Tomography [SPECT] Versus Positron Emission Tomography [PET] Myocardial Perfusion Imaging; NCT00976053)     

Angiographic prevalence and pattern of coronary artery disease in women

Background

There are not many studies describing the prevalence and pattern of “coronary artery disease” (CAD) in women undergoing “coronary angiography” (CAG). Hence, uncertainty thrives with regard to the angiographic prevalence and pattern of CAD in women.

Objective

Our objective was to study the prevalence and pattern of CAD among women undergoing CAG.

Methods

Data of 500 women who underwent CAG for suspected CAD over 3 years were retrospectively analyzed. They were classified into young group (age < 55 years) and elderly group (age ≥ 55 years). Angiographic profile of “left main disease” (LMD) was also studied.

Results

There was greater prevalence of obstructive CAD especially double vessel disease and triple vessel disease in elderly group while normal coronaries were more prevalent in young group. There was equal distribution of non-significant lesions and intermediate lesions between the two groups. The prevalence of LMD is 3.4%, obstructive CAD is 45.4%, and multivessel disease is 28%. The prevalence of LMD and multivessel disease is 31.4%. The pattern of involvement of coronary arteries was same between the two groups; left anterior descending artery is the most commonly affected vessel. Chronic total occlusion mostly involved right coronary artery. Bifurcation lesion involving distal left main coronary artery is the most prevalent pattern of LMD.

Conclusion

There has been a change with regard to clinical presentation and onset of risk factors for CAD at young age, but the load of atherosclerotic burden and pattern of involvement of coronary arteries have not changed in women.     

Role of coronary spasm for a positive noninvasive stress test result in angina pectoris patients without hemodynamically significant coronary artery disease

BACKGROUND: A positive noninvasive stress test result is often considered as a false-positive indicator of coronary artery disease (CAD) when coronary angiography reveals no hemodynamically significant CAD. METHODS: From January 2001 through December 2004, 5474 patients scheduled to undergo exercise electrocardiogram (ECG) [exercise ECG without imaging or exercise ECG with thallium-201 (201Tl) single photon emission tomography (SPECT)] or dipyridamole 201Tl tomography at our outpatient clinic because of chest oppressive sensation were included in this prospective study. Coronary angiography was performed when a noninvasive test result was positive for ischemia or when ischemic chest pain was suspected. Intracoronary methylergonovine testing was performed when spastic angina was suspected and coronary angiography showed no hemodynamically significant CAD. RESULTS: Noninvasive stress testing was positive in 113 (67%) patients with coronary spasm. Of the 53 patients who had positive exercise ECG (exercise ECG with or without imaging), ST depression was found in 50 patients and ST elevationin in 3 patients. Multivessel spasm was found in 6 (15%), 6 (15%), and 7 (21%) of the patients with a positive result on exercise ECG without imaging, exercise ECG with 201Tl SPECT, and dipyridamole 201Tl SPECT, respectively. There was no significant difference in the results of noninvasive stress testing and the number of vessels with coronary spasm (1-vessel spasm versus multivessel spasm) among these 3 noninvasive stress testing groups. CONCLUSION: Intracoronary ergonovine testing induced coronary spasm in over 50% of patients who had suspected ischemic chest pain, a positive noninvasive stress test, and no hemodynamically significant CAD.     

老年肾动脉狭窄与冠状动脉病变的关系及其相关因素

目的 在冠状动脉造影（CAG）的老年患者中观察并发肾动脉狭窄(RAS)的发生率,并分析并发RAS的影响因素。方法 CAG同时行肾动脉造影（RAG）患者277例,分析动脉粥样硬化的危险因素与RAS发生的关系。结果 经CAG证实冠心病患者212例,RAS发生率19%,CAG正常患者RAS发生率8%,冠脉多支病变组中RAS发生率明显高于单支病变组及冠状动脉正常组（P<0.01）,多因素分析,独立预测因子为冠状动脉病变程度（OR=1.89,95%可信区间:1.35-2.65,P<0.01）。结论 冠心病患者有较高RAS发生率,发现冠状动脉多支病变患者应常规行RAG检查。     

Valvular and thoracic aortic calcium as a marker of the extent and severity of angiographic coronary artery disease

Background

The presence of calcified extracoronary structures as a useful indicator of underlying coronary artery disease (CAD) has not yet been established. The purpose of this study was to evaluate whether valvular and thoracic aortic calcification is associated with obstructive CAD.

Methods

We evaluated 99 patients who underwent both coronary angiography and electron beam tomography (EBT) coronary scanning. We identified the presence, absence, and amount of calcification in the aortic valve (AVC), mitral annulus (MAC), descending aorta (DAC), and ascending aorta (AAC). The extent of CAD was graded according to the number of vessels diseased (VD).

Results

Patients with multivessel disease (MVD) had a higher proportion of DAC. The presence of DAC significantly increased the specificity of EBT to detect CAD (58% with a calcium score >0 to 88% for calcium score>0 and DAC >0, P < .001). Both AAC and DAC were associated with a significantly higher rate of MVD in women (DAC, 63% in MVD vs 19% without, P < .01.; AAC, 65% vs 22%, P < .05). MAC had no relationship to either stenosis severity or the presence of obstructive CAD. AVC was the strongest predictor of the severity of CAD and predicted the presence of 3-vessel disease.

Conclusion

AVC and thoracic aortic calcification as detected with EBT are associated with the angiographic extent and severity of CAD and add incremental diagnostic value to the coronary artery calcium score. MAC does not add incremental value. (Am Heart J 2003;145:xxx-xxx.)     

Efficacy of Patient Selection for Diagnostic Coronary Angiography in Suspected Coronary Artery Disease

Background

Guidelines recommend that in suspected stable coronary artery disease (CAD), a clinical (non-invasive) evaluation should be performed before coronary angiography.

Objective

We assessed the efficacy of patient selection for coronary angiography in suspected stable CAD.

Methods

We prospectively selected consecutive patients without known CAD, referred to a high-volume tertiary center. Demographic characteristics, risk factors, symptoms and non-invasive test results were correlated to the presence of obstructive CAD. We estimated the CAD probability based on available clinical data and the incremental diagnostic value of previous non-invasive tests.

Results

A total of 830 patients were included; median age was 61 years, 49.3% were males, 81% had hypertension and 35.5% were diabetics. Non-invasive tests were performed in 64.8% of the patients. At coronary angiography, 23.8% of the patients had obstructive CAD. The independent predictors for obstructive CAD were: male gender (odds ratio [OR], 3.95; confidence interval [CI] 95%, 2.70 - 5.77), age (OR for 5 years increment, 1.15; CI 95%, 1.06 - 1.26), diabetes (OR, 2.01; CI 95%, 1.40 - 2.90), dyslipidemia (OR, 2.02; CI 95%, 1.32 - 3.07), typical angina (OR, 2.92; CI 95%, 1.77 - 4.83) and previous non-invasive test (OR 1.54; CI 95% 1.05 - 2.27).

Conclusions

In this study, less than a quarter of the patients referred for coronary angiography with suspected CAD had the diagnosis confirmed. A better clinical and non-invasive assessment is necessary, to improve the efficacy of patient selection for coronary angiography.     

The relation between coronary artery disease severity and fragmented QRS complex in patients with left bundle branch block

Background

The diagnosis of coronary artery disease (CAD) in patients with LBBB represents a clinical challenge. The presence of fragmented QRS (fQRS) complex on surface ECG may be related to myocardial ischemia, scarring or fibrosis.

Cardiac syndrome X: Clinical characteristics revisited

Background

Cardiac syndrome X includes a heterogenous group of patients with angina but normal epicardial coronaries in angiography.

Objective

Our objective was to study the clinical characteristics of patients with cardiac syndrome X.

Methods

Data of patients who underwent coronary angiography over a period of one year was retrospectively analyzed. Those with normal or non-obstructive coronaries in angiography with chest pain were included in this study.

Results

1203 patients underwent coronary angiography during the study period. 105 (8.7%) patients fulfilled the inclusion criteria. There were 52 (49.5%) males and 53 (50.5%) females including 31 (29.5%) postmenopausal women. Many patients had atherosclerotic risk factors. Typical angina and atypical chest pain were reported by 63 (60%) and 42 (40%) patients, respectively. ECG was normal in 46 (43.8%) and abnormal in 59 (56.2%) patients. The most common abnormal finding in ECG was ST-T changes seen in 49 (46.7%) patients. Regional wall motion abnormality with mild left ventricular systolic dysfunction was seen in 4 (3.8%) patients while 101 (96.2%) patients had normal ventricular function in echocardiography. TMT was positive for inducible ischemia in 35 (33.3%) patients and inconclusive in 10 (9.5%) patients. Angiography showed normal epicardial coronaries in 85 (80.9%) patients.

Conclusions

Cardiac syndrome X constitutes a significant subset of patients undergoing coronary angiography. It is essential to identify and treat them specifically for microvascular angina. Many of them have atherosclerotic risk factors but their presentation is different from those with obstructive coronaries.