Detection of transplant coronary artery disease using multidetector computed tomography with adaptative multisegment reconstruction.

OBJECTIVES: This study sought to determine whether multidetector computed tomography (MDCT) may be able to detect occlusive coronary disease in transplanted hearts. BACKGROUND: In heart transplant recipients, asymptomatic coronary disease requiring frequent surveillance commonly develops. Recent advancements in MDCT allow for noninvasive assessment of the coronary vessels. METHODS: Electrocardiogram-gated contrast-enhanced MDCT scans (16 x 0.75-mm detectors, 420 ms rotation, 100 ml contrast) with multisegment reconstruction were performed on 54 transplant recipients within 6 +/- 11 days of quantitative coronary angiography (QCA). Heart rate at the time of the scan was 90 +/- 11 beats/min. Coronary arterial segments >1.5 mm in diameter were analyzed by independent investigators. RESULTS: There was a good correlation between MDCT and QCA percent stenosis (r = 0.75, p < 0.01, SEE = 15%). Of the 791 segments identified by QCA, 754 (95%) were analyzable by MDCT. The sensitivity, specificity, and positive and negative predictive values of MDCT compared with QCA for the detection of segments with significant (>50%) stenosis were 86%, 99%, 81%, and 99%, respectively. The MDCT correctly identified 15 of the 16 (94%) transplant patients classified by QCA as having occlusive coronary artery disease and 29 of the 37 patients without significant stenosis (78%). In 1 patient who received intravenous beta-blockers, transient bradycardia requiring temporary pacing developed, but there were no other complications. CONCLUSIONS: Detection of occlusive coronary disease in heart transplant recipients with elevated resting heart rate by MDCT is feasible using multicycle reconstruction. The need for surveillance invasive coronary angiography in transplant recipients might be mitigated by use of MDCT.     

Accuracy of multislice computed tomography in the preoperative assessment of coronary disease in patients with aortic valve stenosis.

OBJECTIVES: To evaluate multislice computed tomography (MSCT) as an alternative to coronary angiography, we prospectively studied its diagnostic accuracy for the detection of significant coronary artery lesions in patients with significant aortic valve stenosis undergoing valve surgery. BACKGROUND: In patients with aortic valve stenosis, coronary angiography is still recommended before surgery. Multislice computed tomography is a promising noninvasive technique for the detection of significant coronary artery lesions. METHODS: Fifty-five consecutive patients scheduled for coronary angiography in the preoperative assessment of aortic valve stenosis underwent 16-slice MSCT 24 h before coronary angiography. We analyzed coronary lesions, image quality, and arterial calcium score. RESULTS: The sensitivity of the MSCT-based strategy in detecting significant stenosis was 100%, and its specificity 80%. The positive and negative predictive values were respectively 55% and 100%. For calcium scores <1,000 (77% of patients), MSCT detected all patients without coronary artery disease, enabling conventional coronary angiography to be avoided in 35 of 55 cases (80%). For calcium scores >1,000, MSCT enabled conventional coronary angiography to be avoided in only 6% of cases, either because significant stenosis was found with a possible indication of revascularization, or because the examination was not interpretable. CONCLUSIONS: The results of this initial experience in relatively few patients suggest that MSCT-based coronary angiography may serve as an alternative to invasive coronary angiography to rule out significant coronary artery disease in patients scheduled for elective aortic valve replacement. Larger studies are necessary to fully explore the potential of coronary MSCT to improve preoperative risk stratification.     

463例心脏瓣膜病冠状动脉造影分析

目的　观察心脏瓣膜病患者的冠状动脉病变的发生率。方法　对 46 3例心脏瓣膜病患者术前临床资料和选择性冠状动脉造影的结果进行综合分析。结果　心脏瓣膜病并发冠状动脉病变发生率为 16 8% ,其中无症状占 88 3%。结论　年龄大于 5 0岁者 (有冠心病危险因素者提前到 45岁 ) ,心脏瓣膜置换术前应常规行选择性冠状动脉造影检查 ,以减少手术并发症 ,确保瓣膜置换术后复跳成功     

Head-to-head comparison of three-dimensional navigator-gated magnetic resonance imaging and 16-slice computed tomography to detect coronary artery stenosis in patients

OBJECTIVES: The purpose of this research was to compare the diagnostic accuracy of three-dimensional navigator-gated magnetic resonance (MR) imaging and 16-slice multidetector row computed tomography (MDCT) versus quantitative coronary angiography (QCA) for the detection of coronary artery stenosis in patients. BACKGROUND: Both MR and MDCT are novel non-invasive tests, which have been proposed for noninvasive detection of coronary artery disease. Yet their diagnostic accuracy has not been directly compared in the same population. METHODS: Fifty-two patients underwent coronary MR and 16-slice MDCT before invasive coronary angiography. Diameter stenosis (DS) severity in vessels >1.5-mm reference diameter were graded visually and measured quantitatively on both MR and MDCT images. Diagnostic accuracy of both methods was compared using QCA as the reference test. RESULTS: According to QCA, 81 of 452 (18%) coronary segments with >1.5 mm diameter had >50% DS. By visual analysis, MR and MDCT had similar sensitivity (75% vs. 82%, p = NS), specificity (77% vs. 79%, p = NS), and diagnostic accuracy (77%, vs. 80%, p = NS) for detection of >50 % DS. Quantitative measures of DS by MR (r = 0.60, p < 0.001) and MDCT (r = 0.75, both p < 0.001) correlated well with QCA. Receiver-operating characteristic analysis demonstrated that quantification of DS severity improved the diagnostic accuracy of MDCT (area under curve [AUC] 0.81 vs. 0.92, p < 0.001) but not that of MR (AUC 0.78 vs. 0.83, p = NS). CONCLUSIONS: Visual assessment of coronary diameter stenosis severity by MR or MDCT allows identification of significant coronary artery disease with a similar high diagnostic accuracy. Quantitative analysis significantly further improves the diagnostic accuracy of MDCT but not that of MR.     

Comparison of the degree of coronary stenoses by multidetector computed tomography versus by quantitative coronary angiography

Sixteen-slice multidetector computed tomography (MDCT) and quantitative coronary angiography (QCA) were performed in 29 patients. Quantification of the degree of luminal narrowing and lesion length measurements were performed independently on MDCT and QCA at 42 sites with sufficient computed tomographic image quality. The correlation between MDCT and QCA for quantifying the degree of stenosis was excellent (r2 = 0.93), although a systematic overestimation was observed by MDCT (bias 4% +/- 8%). The correlation between MDCT and QCA was moderate with respect to lesion length (r2 = 0.54). In the absence of severe calcifications or motion artifacts, MDCT permits noninvasive quantification of coronary stenosis.     

主动脉瓣疾病冠脉造影分析

目的　观察主动脉瓣疾病患者合并冠状动脉病变的发生情况。方法　对 10 5例主动脉瓣疾病不合并二尖瓣病变的患者术前临床资料和选择性冠状动脉造影的结果进行综合分析。结果　 10 5例患者中 5 1例有心绞痛症状 ,心绞痛发生率为 48 6% ,但冠脉造影显示只有 7例诊断冠心病。主动脉瓣狭窄病变为主者心绞痛的发生率为 68 2 % ,以主动脉瓣关闭不全病变为主者 ,心绞痛的发生率为 3 2 0 % ,两者比较有统计学差异 (P <0 0 1)。但是 ,两者冠心病的发病率无统计学差异。主动脉瓣退行性变组合并冠心病率(3 3 3 % )显著高于风心病组和先天性二叶瓣组 (P <0 0 1)。结论　在单纯主动脉瓣病变中以心绞痛预测冠心病的敏感性、特异性、准确率低。而主动脉瓣退行性变合并冠心病的发病率大于风心病和先天性的主动脉瓣病变。在单纯主动脉瓣病变者明确有无合并冠心病 ,冠脉造影是必要的 ,尤其是主动脉瓣退行性变病人     

Contrast enhanced multi-detector computed tomography coronary angiography versus conventional invasive quantitative coronary angiography in acute coronary syndrome patients-correlation and bias

BACKGROUND: Previous studies that compared multi-detector computed tomography (MDCT) non-invasive coronary angiography with conventional coronary angiography, did not assessed the ability of MDCT to detect stenotic lesions correctly in acute coronary syndromes (ACS) patients. The aim of the present study was to assess prospectively the correlation and bias between 16-slice MDCT coronary angiography and quantitative coronary angiography analysis (QCA) in these patients. METHODS: Patients underwent electrocardiogram-gated, 16-slice MDCT coronary angiography and routine invasive percutaneous coronary angiography with quantitative coronary angiography (QCA) analysis blinded to MDCT results. The correlation and the bias between the results of MDCT and QCA were assessed in segments observed by both modalities in vessels > or = 2 mm in diameter. RESULTS: 59 patients (81% male, age 56 +/- 11 years), admitted due to ACS, underwent MDCT and invasive coronary angiography. 544 segments were analyzed. The correlations between MDCT and QCA observed for the left anterior descending coronary artery (LAD), the left circumflex coronary artery (Cx), the right coronary artery (RCA) and for all analyzed segments were 0.74 (P < 0.0001), 0.54 (P < 0.009), 0.72 (P < 0.0001) and 0.70 (P < 0.0001), respectively. By Bland-Altman analysis, a small overestimation of the lesion severity with MDCT of 4.8% for the LAD, 5.9% for the Cx, and 3.3% for the RCA was observed. CONCLUSIONS: In ACS patients, MDCT contrast-enhanced coronary angiography provides good quantification of the luminal diameter as compared to coronary angiography, and it is characterized by a small overestimation bias.     

Aortic atheroma: not a sensitive indicators for coronary artery disease in patients with mitral valve disease

Aortic atheroma detected by transoesophageal echocardiography has been reported to be a good prognostic marker for coronary disease on angiography. The value of this detection in valvular heart disease would be to avoid preoperative coronary angiography in asymptomatic patients. The aim of this study was to assess the prognostic value of aortic atheroma in a population with a low prevalence of coronary artery disease in whom transoesophageal echocardiography was systematically performed. In addition, calcification of the aortic knuckle, a marker of atherosclerosis, was analysed by simple chest X-ray. One hundred and ninety two patients (103 men, 89 women; mean age: 63.1 +/- 15 years), operated for mitral valve replacement, underwent transoesophageal echocardiography, angiography, within 6 months, and chest X-ray. The cardiovascular risk factors, presence of aortic atherome, angiographic coronary artery disease and aortic calcification were studied. Aortic atheroma was observed in 72 patients (37.5%), usually in the descending thoracic aorta (73.6%). Coronary stenosis was observed in 36 patients (18.7%). On univariate analysis, aortic atherome predicted coronary stenosis with a sensitivity of 53%, specificity of 66% and positive predictive value of 26% and negative predictive value of 86%, compared with chest X-ray: 71%, 65%, 33% and 90%, respectively. In multivariate analysis, only hypercholesterolaemia, smoking and age predicted the presence of coronary artery disease. The presence of aortic atheroma was not predictive (p = 0.3). The authors conclude that aortic atheroma does not predict the presence of coronary artery disease in a patient population with mitral valve disease and a low prevalence of coronary artery disease. Simple chest X-ray has almost the same diagnostic value. The association of these two investigations does not give sufficient negative predictive values to avoid coronary angiography.     

血管内超声、64层螺旋CT及定量冠状动脉造影对不稳定性心绞痛患者冠状动脉病变的评价

目的 应用血管内超声(rvos)探讨不稳定性心绞痛(UAP)低、中及高危组患者动脉粥样硬化斑块的特点,评价定量冠状动脉造影(QCA)和64层螺旋CT(MDCT)的诊断价值.方法 采用IVUS、MDCT和QCA分析61例UAP患者(低危组17例,中危组33例,高危组11例)71支病变血管.分析比较3组患者斑块的形态学特点.根据IVUS斑块回声的强度,将斑块分为软斑块、纤维斑块、钙化斑块、混合斑块,计算最小面积处斑块负荷,并分为≤50%、51%～74%及≥75%3类病变.以IVUS结果为标准,评价QCA计算血管狭窄程度的可信性,MDCT诊断3类病变的敏感性和特异性,及对斑块成分诊断的可靠性.结果 QCA可估计低危组和中危组患者的斑块负荷(低危组r=0.768,P<0.01;中危组r=0.721,P<0.01).高危组患者血管重构明显(冠状动脉重构指数=1.21±0.31),QCA低估了IVUS的斑块负荷[分别为(67±14)%、(75±16)%,r=0.551,P<0.01].MDCT对冠状动脉病变有较高的阴性预测值(87.8%-96.3%),但无法区分典型粥样硬化斑块内的纤维帽(kappa=0.245)及脂质核(kappa=0.235).3组患者IVUS斑块特点分析结果表明,随着危险度程度的增加,软斑块比例、血管正性重构程度、血管外弹力膜面积、最小管腔面积、斑块负荷、斑块破裂及血栓发生率逐渐增加.结论 QCA可以相对准确地评价UAP低危和中危组患者的冠状动脉狭窄程度,同时会低估高危组患者的病变程度.MDCT对于冠心病的诊断有非常高的阴性预测值可用于排除冠心病,但是无法可靠地区分粥样硬化斑块内的纤维帽及脂质核.IVUS检查显示软斑块、正性血管重构和最小管腔面积<4mm~2者可能为UAP高危组患者.     

定量多层螺旋CT冠状动脉成像与定量冠状动脉造影的对比研究

目的通过与同期定量冠状动脉造影(QCA)作对照,评价定量冠状动脉多层螺旋CT(QCT)成像对冠状动脉疾病的诊断价值。方法选择冠心病患者78例,利用QCA和QCT测量同一病变的最小管腔直径、最小管腔面积、参考直径、参考面积、靶病变长度、直径狭窄率、面积狭窄率等指标,比较2种方法结果的相关性及一致性。结果 78例患者中,存在明显冠状动脉病变62例(79.49%),QCT和QCA一致认为重度狭窄(>75%)的节段共为47段,其中右冠状动脉1 5段,前降支27段,回旋支5段。QCT和QCA测量的最小管腔面积、面积狭窄率比较,差异有统计学意义(P<0.05),2种测量最小管腔直径、参考直径、参考面积、靶病变长度和直径狭窄率的比较,差并均无统计学意义(P>0.05)。QCT和QCA测量最小管腔直径,靶病变长度,参考直径,参考面积,直径狭窄率一致性较好(0.5≤r_c≤0.85),最小管腔面积、面积狭窄率则一致性不佳(r_c<0.5)。结论 QCT检查能良好评价冠状动脉病变.可用于术前即可指导对经皮冠状动脉介入治疗中球囊和支架的选择。     

Clinical significance of the coronary calcification score by multidetector row computed tomography for the evaluation of coronary stenosis in Japanese patients.

BACKGROUND: The coronary artery calcification (CAC) score measured by multidetector row computed tomography (MDCT) has emerged as a marker for predicting coronary artery disease (CAD). To evaluate the clinical significance of the CAC score, coronary artery stenosis as assessed by coronary angiography (CAG) was compared with the CAC score determined by MDCT, risk factors and medications. METHODS AND RESULTS: Subjects included 374 consecutive patients who underwent ECG-gate CT angiography using MDCT. The accuracy in patients with a CAC score >or=400 was 84%, and significantly lower than that in patients with a CAC score =0. In addition 92 patients (68 males, 24 females; mean age, 63+/-11 years) who underwent both MDCT and CAG within a 1-month period were selected for further investigation. Patients with significant coronary stenosis had a significantly higher CAC score than those without stenosis. In addition, a higher number of stenosed vessels was associated with a higher CAC score. The subjects were divided into 3 groups according to the CAC score: low (0-12), intermediate (13-444) and high (>or=445). The CAC score was significantly associated with age, and plasma levels of total cholesterol and hemoglobinA1c, and logistic regression analysis revealed that significant coronary stenosis as assessed by CAG was most closely correlated with the CAC score (p=0.03). CONCLUSIONS: The CAC score determined by MDCT can predict CAD independent of other factors, such as age, metabolic diseases and medications, when coronary stenosis can not be diagnosed because of severe calcification.     

Serial quantitative coronary angiography and coronary events

BACKGROUND: Although assessment of progression of atherosclerosis by quantitative coronary angiography (QCA) is used as a surrogate for coronary events, no validation study has compared the several QCA measures used. METHODS AND RESULTS: The Cholesterol Lowering Atherosclerosis Study was a clinical trial testing the efficacy of colestipol-niacin on the progression of coronary atherosclerosis. Baseline/2-year coronary angiograms were obtained on 156 men with prior coronary artery bypass graft surgery. Changes in percent diameter stenosis and minimum lumen diameter (both measured in coronary lesions and segments) and coronary segment measures of average diameter, percent involvement, and vessel edge roughness were measured by QCA. Coronary events ascertained over 12 years of follow-up included myocardial infarction (MI), coronary death, and coronary artery revascularizations. Proportional hazards models evaluated the relation between QCA change measures and coronary events. Changes in percent diameter stenosis and minimum lumen diameter of coronary artery lesions were significantly related to the risk of MI/coronary death. All QCA measures were significantly related to the risk of any coronary event. Relative risks for each QCA measure were of similar magnitude when estimated separately within each treatment group. Change in minimum lumen diameter of lesions was the only measure independently associated with the risk of coronary events. CONCLUSIONS: All QCA measures of progression of coronary artery disease were related to all coronary events (including revascularizations). Only QCA measures of lesion progression were related to MI/coronary death. QCA measures of lesion change may be better surrogate end points for "hard" coronary events than measures of change in coronary segments.     

风心病患者瓣膜置换术前颈动脉超声检查的临床意义

目的探讨颈动脉粥样硬化与冠状动脉粥样硬化的相关性以及颈动脉内膜—中膜厚度(IMT)对风心病患者是否合并冠心病的预测价值。方法117例风心病患者根据冠状动脉造影结果分为冠心病组和对照组,用B超检测颈动脉病变情况。结果颈动脉IMT增厚和斑块检出率对冠心病预测的敏感性为81.82%(9/11),特异性为75.47%(80/106),阳性预测值为25.71%(9/35),阴性预测值为97.56%(80/82)。IMT异常与冠状动脉硬化程度积分呈显著正相关(r=0.55,P<0.01)。结论B超检测颈动脉粥样硬化对风心病患者是否合并冠心病具有预测价值。     

Prevalence and predictors of significant coronary artery disease in Turkish patients who undergo heart valve surgery

BACKGROUND AND AIMS OF THE STUDY: The presence of significant atherosclerotic coronary artery disease (CAD) in patients with valvular heart disease is an important predictor of perioperative mortality. The prevalence of CAD in patients undergoing valvular heart surgery is 20-40% in industrialized countries. The study aim was to determine CAD prevalence in Turkish patients undergoing valvular heart surgery, and to identify predictors of its presence. METHODS: A total of 760 patients (357 males, 403 females; mean age 54.4+/-18.1 years) who underwent coronary angiography before valvular surgery between 1995 and 2000 was enrolled retrospectively. Single- and multi-valve involvement was present in 46% and 54% of patients, respectively. Patients with ischemic mitral regurgitation were excluded from the study. Significant CAD was defined as the presence of > or =50% diameter stenosis anyone of the coronary arteries. The presence of angina pectoris, and of risk factors (e.g. hypertension, smoking, diabetes mellitus (DM), hyperlipidemia, family history of CAD) were sought in all patients. Predictors of CAD were identified by logistic regression analysis. RESULTS: Significant CAD was present in 15.8% of patients (24% males, 9% females) (p <0.001); the highest prevalence was in those with aortic stenosis (p <0.05). CAD was not seen in young patients (aged <45 years) with none of the above-mentioned risk factors. The highest correlation between CAD and risk factors was family history of CAD, followed by DM, hyperlipidemia, hypertension and smoking, in decreasing order. CONCLUSION: The study results showed that CAD in patients with valvular heart disease was less prevalent in Turkey than in industrialized countries. The incidence of coronary lesions rises notably from the age of 50 years in both males and females. Coronary angiography before valvular heart surgery could be omitted in young patients (age <45 years) with none of the coronary risk factors, or without angina.     

Study of Coronary Artery Disease in Single Aortic Valvular Disease

Objectives To analyze the results of coronary angiographies (CAG) in patients with single aortic valvular heart disease; To study the relationship between aortic valve diseases and coronary artery disease (CAD). Methods 105 patients with single aortic valvular heart disease before surgery underwent angiography. The data of clinical characteristics and angiographies were analyzed. Results 51 patients had symptoms of angina pectoris among 105 patients with single aortic valvular heart disease. Seven of them were confirmed coronary artery disease by angiographies. Although the incidence of angina in aortic valve stenosis group was significantly higher than that in aortic valve regurgitation, the probability of combination of CAD in aortic valve stenosis group was similar to the later. However, the probability of combination of CAD in degenerative aortic valve group was significantly higher than the groups of rheumatic, congenitally bicuspid aortic valves, and other causes (p < 0.01 ). Conclusions Angina pe     

血管内超声在冠状动脉临界病变中的应用研究

目的:研究传统冠状动脉定量分析方法(QCA)与血管内超声(IVUS)在冠状动脉临界病变中的应用。方法:共入选经过冠状动脉造影(至少4体位造影)证实病变狭窄处于临界病变的患者150例。将入选者分为:常规冠状动脉造影组90例(QCA),血管内超声组60例(IVUS)。通过QCA和血管内超声定量分析方法分析2组最小管腔直径、参考血管直径、直径狭窄率及最小管腔面积等参数指标;将相关数据建立直线回归分析方程,分析二者之间是否具有线性关系;采用Cox回归模型分析2组免于心血管事件方面差异,观察2组术后住院期间、30d、3个月、6个月、9个月和12个月主要心血管事件。结果:血管内超声组分别采用QCA和IVUS分析,参考血管直径2者具有正相关性分别为(3.28±0.19)mmvs.(3.17±0.21)mm,R=0.627。最小管腔直径分别为(2.04±0.18)mmvs.(2.0±0.17)mm,R=0.782。比较2组之间的参数:QCA组通过计算得出直径狭窄率,与IVUS管腔面积狭窄率之间无相关性(R20.05,P=0.222),IVUS最小管腔面积(4.7±0.67)mm2。通过COX回归模型显示2组在免于心血管事件方面的差异,可见QCA组发生心血管事件率具有较高的趋势。结论:对于临界病变的患者,采用IVUS的方法能够检测出更严重狭窄的发生率,传统冠状动脉造影判定结果往往低估真正的病变情况。对于临界病变的患者,采用IVUS进行测量分析,具有减低心血管事件风险的趋势。     

Association of aortic valve sclerosis and coronary artery disease in patients with severe nonischemic mitral regurgitation

BACKGROUND: The presence of aortic valve sclerosis accounts for a higher rate of ischemic events and increased cardiovascular mortality. It may reflect coronary artery disease (CAD) because of a shared pathologic background. HYPOTHESIS: We aimed to analyze whether the presence of aortic valve sclerosis might help in identifying patients with coronary atherosclerosis among those with severe nonischemic mitral regurgitation (MR), who undergo coronary angiography before surgery for screening, and not because of suspected ischemic heart disease. METHODS: In all, 84 patients (mean age 64 +/- 9 years; 71% men) with mitral valve prolapse and severe regurgitation underwent echocardiography and coronary angiography. Aortic valve sclerosis was defined as focal areas of increased echogenicity and thickening of the leaflets without restriction of leaflet motion on echocardiography. Coronary artery disease was defined by the presence/absence of atherosclerotic plaques, independent of the degree of stenosis. RESULTS: Coronary artery disease was diagnosed in 47.6% of patients with and 15.8% of those without aortic valve sclerosis (p = 0.008). On logistic regression analysis, the presence of aortic valve sclerosis predicted CAD (odds ratio 3.3, 95% confidence interval 1.03-10.5; p = 0.04) independent of age. In female patients, the risk ratio for CAD in the presence of aortic valve sclerosis was 9. CONCLUSIONS: Coronary artery atherosclerosis and aortic valve sclerosis are closely associated in patients with severe nonischemic MR.     

Prediction of coronary artery disease by left ventricular regional wall motion abnormalities in patients with stenosis of the aortic valve

To identify predictive factors for coronary artery disease in patients with stenosis of the aortic valve the clinical histories, haemodynamic measurements, biplane contrast left ventriculograms, and coronary angiograms of 83 consecutively catheterised patients with valvar aortic stenosis were examined retrospectively. The mean (SD) age was 66.4 (9.1) years and 78% were men. Fifty five patients had significant coronary artery disease (greater than or equal to 50% diameter narrowing). Forty five (82%) of 55 patients with and 23 (82%) of 28 patients without coronary disease had angina. Heart failure occurred in a third of the patients; these patients were on average older, were more likely to be female, and had lower ejection fractions and cardiac outputs than patients in whom failure did not occur. Calculated valve area, transvalvar gradient, and left ventricular end diastolic pressure did not discriminate between patients with and without coronary disease. Syncope was less common than angina and heart failure and was associated with significantly lower valve areas and higher gradients than those found in patients without syncope. Left ventricular regional wall motion abnormalities were equally common in the groups with and without angina and predicted coronary artery disease with 94% accuracy. The absence of regional wall motion abnormality was an insensitive marker of normal coronary arteries as 45% of such patients had coronary disease. Five of the 83 patients had significant coronary disease without angina or regional wall motion abnormality. In patients with aortic stenosis angina did not predict the presence of coronary artery disease; therefore, it is advisable to have the results of coronary angiography before aortic valve replacement in a population such as this. Two of the patients with heart failure and severe aortic stenosis had regional wall motion abnormality with normal coronary arteries. Thus in some patients left ventricular failure produced by increased afterload may itself be a cause of left ventricular regional wall motion abnormality.     

Prediction of coronary artery disease by left ventricular regional wall motion abnormalities in patients with stenosis of the aortic valve.

To identify predictive factors for coronary artery disease in patients with stenosis of the aortic valve the clinical histories, haemodynamic measurements, biplane contrast left ventriculograms, and coronary angiograms of 83 consecutively catheterised patients with valvar aortic stenosis were examined retrospectively. The mean (SD) age was 66.4 (9.1) years and 78% were men. Fifty five patients had significant coronary artery disease (greater than or equal to 50% diameter narrowing). Forty five (82%) of 55 patients with and 23 (82%) of 28 patients without coronary disease had angina. Heart failure occurred in a third of the patients; these patients were on average older, were more likely to be female, and had lower ejection fractions and cardiac outputs than patients in whom failure did not occur. Calculated valve area, transvalvar gradient, and left ventricular end diastolic pressure did not discriminate between patients with and without coronary disease. Syncope was less common than angina and heart failure and was associated with significantly lower valve areas and higher gradients than those found in patients without syncope. Left ventricular regional wall motion abnormalities were equally common in the groups with and without angina and predicted coronary artery disease with 94% accuracy. The absence of regional wall motion abnormality was an insensitive marker of normal coronary arteries as 45% of such patients had coronary disease. Five of the 83 patients had significant coronary disease without angina or regional wall motion abnormality. In patients with aortic stenosis angina did not predict the presence of coronary artery disease; therefore, it is advisable to have the results of coronary angiography before aortic valve replacement in a population such as this. Two of the patients with heart failure and severe aortic stenosis had regional wall motion abnormality with normal coronary arteries. Thus in some patients left ventricular failure produced by increased afterload may itself be a cause of left ventricular regional wall motion abnormality.     

Frequency of angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis

A consecutive series of 192 patients (121 men and 71 women, mean age 59 years, range 28 to 82) with isolated, severe valvular aortic stenosis was with isolated, severe valvular aortic stenosis was analyzed retrospectively to determine the relation of angina pectoris and coronary risk factors to angiographically significant coronary artery disease (CAD). Significant CAD (diameter reduction greater than or equal to 50%) was found in 47 patients (24%). Angina was present in 83% of them, but it was also found in 61% of the non-CAD patients. This symptom had as a result a low positive predictive value (31%). Of the patients without angina (n = 65) 12% had significant CAD. The negative predictive value of angina alone was thus 88%. By using multivariate logistic regression, a risk score could be calculated based on angina, age and sex, which increased the negative predictive value to 95%. It was concluded that coronary arteriography can only be omitted in severe aortic valvular stenosis, when patients have no angina and when they are less than 40 years of age for men and less than 50 years for women. For all other cases, coronary arteriography should be recommended.