Electrocardiographic predictors of proximal left anterior descending coronary artery occlusion

Proximal occlusion of the left anterior descending coronary artery (LAD) results in a less favorable prognosis in coronary angiography. Therefore, it is important to determine whether there are significant lesions in LAD by electrocardiography (ECG) before coronary angiography. Twelve-lead ECG was compared in 130 patients with significant lesions (≥70% stenosis) confined to proximal part of the LAD (P LAD group) and 492 patients with normal coronary angiography (control group). Fifty-nine patients in the P LAD group and 18 patients in the control group had signs of anterior myocardial infarction as shown by ST elevation (≥1.0 mV) in two consecutive pericardial leads or the presence of a pathological Q wave. An inverted U wave (biphasic T wave) in leads V₁ to V₄ had a sensitivity of 49.3% (35/71) in P LAD patients without signs of anterior myocardial infarction (MI) and 96.6 % (57/59; specificity, 66.6%; positive predictive value, 90.9 %) in the P LAD patients with signs of anterior MI. In the P LAD patients with signs of anterior MI, T inversion in V₄–V₅ had a lower sensitivity (67.0% [40/59]) than an inverted U wave. ST depression in inferior leads and ST depression in V5 were not useful markers of proximal LAD occlusion. In conclusions, an inverted U wave in V₁ to V₄ (or in each of these leads) and T inversion in V4–V₅ are the best predictors of significant proximal LAD lesion, especially in patients with ECG findings of anterior MI.     

Effects of pinacidil on myocardial blood flow and infarct size after acute left anterior descending coronary artery occlusion and reperfusion in awake dogs with and without a coexisting left circumflex coronary artery stenosis

To determine whether partial stenosis of a second major coronary artery promoted vasodilator-induced coronary steal and increased infarct size after acute coronary artery occlusion, we produced acute myocardial infarction by 4-h left anterior descending coronary artery occlusion and 20-h reperfusion in awake dogs with and without a mild to moderate stenosis (33-72%) of the proximal left circumflex coronary artery. Dogs were randomized to receive intravenous (i.v.) normal saline or pinacidil, a new antihypertensive agent with a marked coronary dilator property, beginning 40 min after onset of coronary artery occlusion and continuing throughout the occlusion and the first hour of reperfusion. Pinacidil was titrated to decrease mean aortic pressure 25 mm Hg, which resulted in an increase in heart rate (HR), cardiac output (CO), and left ventricular (LV) dP/dt and LVdP/dt/P. Saline infusion had no effects. Blood flows to ischemic and remote myocardium did not differ between dogs with and without coronary stenosis. Pinacidil increased blood flow threefold in normal myocardium, but had no effect on infarct zone myocardial blood flow or infarct size (58 +/- 4% of region at risk vs. 56 +/- 4% in animals receiving normal saline) in dogs without coronary stenosis. In contrast, similar administration of pinacidil in dogs with coronary stenosis reduced infarct size zone myocardial blood flow and increased infarct size (69 +/- 3% vs. 55 +/- 5% in the saline group, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of different beta adrenoceptor ligands in mice with permanent occlusion of the left anterior descending coronary artery

1. We have studied the effects of three betaAR ligands (carvedilol, alprenolol, and ICI-118551) with different pharmacological profiles and negative efficacy at the beta2AR on cardiac in vivo, in vitro, biochemical and gene expression parameters in mice with permanent occlusion of the left anterior descending coronary artery. 2. Cardiac in vivo parameters were determined using Doppler studies. Mitral-wave E peak velocity (EPV) and aortic peak velocity (AoPV) decreased in the first 2 weeks postocclusion. After 3 weeks of drug treatment, EPV was improved in the carvedilol group to preocclusion values; however, a further reduction in EPV in the alprenolol and control permanent occlusion group was measured and there was no change after ICI-118551 treatment. AoPV was unchanged between weeks 2 and 5 in all groups. 3. The left atria were isolated to record isometric tension responses to isoprenaline. Permanent occlusion significantly reduced the maximum isoprenaline response to 30% of control and carvedilol increased the maximum response to isoprenaline significantly to 60%. 4. The biochemical and gene expression studies revealed different effects of the three betaAR ligands. Most notably, carvedilol reduced gene expression of myosin heavy chain beta. 5. These results indicate that chronic treatment with carvedilol is beneficial in a mouse model of myocardial damage resulting from ischaemia. We hypothesise that these beneficial effects of the drug may be because of the negative efficacy at the beta2AR, combined with beta1AR antagonism.     

Cicletanide improves outcome after left circumflex coronary artery occlusion-reperfusion in the dog

The possible antifibrillatory effect of cicletanide, a new diuretic antihypertensive drug, was investigated at random in 50 anesthetized dogs subjected to left circumflex coronary artery ligation for 60 min and later reperfused. In this model, standard electrocardiographic leads 2 and 3 were continuously registered to measure delta R wave percent changes, to count the number of ventricular premature beats, and to document the onset of ventricular fibrillation; aortic pressure was recorded; 6-keto PGF1 alpha and TXB2 plasma levels were determined. Cicletanide significantly reduced early (Phase 1a) postischemic ventricular fibrillation (5 of 25 vs. 12 of 25, p = 0.036) but failed to reduce the incidence of global ischemia-induced ventricular fibrillation. On the other hand, the incidence of postreperfusion ventricular fibrillation was lower in the cicletanide group (1 of 14 vs. 5 of 9, p = 0.04). In addition, the total survival rate was improved in cicletanide treated dogs (p = 0.0257). While the rate-pressure product was lowered by the drug independent of the presence of ischemia, delta R% changes after occlusion were less in treated dogs than in controls. Moreover, the drug reduced significantly the number of ventricular premature beats in the early (Phase 1a) postischemic period. Finally, the drug increased (mean two-fold) the plasma levels of 6-keto PGF1 alpha as compared with controls; however, this increase was less than that achieved (mean 20-fold) after 100 ng/kg/min epoprostenol (prostacyclin) given in a further series of animals. Thus, improved outcome follows 10 mg/kg i.v. cicletanide administration in this model.     

Verapamil in a new model of severe local myocardial ischaemia due to combined coronary occlusion and stenosis

The effect of verapamil was studied in a new canine model of local myocardial ischaemia. In this model in addition to the critical construction of the left circumflex coronary artery, the left anterior descending branch was suddenly occluded. Experiments were performed in the anaesthetized, thoracotomized and artificially respired dog. The model represents a severe form of myocardial ischaemia and mimics the clinical situation in which usually more than one coronary artery is involved in the stenotic process. Verapamil (0.15 mg kg -1 i.v.) moderated the extent of the ischaemic changes (indicated by the ST segment elevation in the epicardial and endocardial ECG) as well as their consequences e.g. the incidence and severity of early postocclusion and reperfusion arrhythmias. This beneficial effect was probably due to the drug-induced favourable haemodynamic action (reduction of left ventricular end-diastolic pressure and slight increase in left ventricular dP/dtmax) and to the electrophysiological effects (e.g. decreased inhomogeneity of electrical activation, diminution of extrasystolic activity) and blood flow changes (enhanced blood supply to the ischaemic subepicardium).     

Influence of cinepazide, a vasoactive substance, on canine coronary circulation after acute constriction of the left anterior descending coronary artery.

The left anterior descending coronary artery was variably constricted mechanically in nine dogs. Blood flow in the left anterior descending (LAD) and circumflex coronary arteries (CCA), aortic pressure and peripheral, i.e. post-stenotic coronary pressure were measured. Myocardial perfusion was determined from the clearance of radioactive xenon injected at a depth of 7 mm into the underperfused area supplied by the LAD artery. The vasoactive drug 1-(pyrrolidinyl-1-carbonyl)-methyl-4-(3,4,5-tri-methoxycinnamoyl)piperazine-maleate (cinepazide) was given at doses of 5-10 mg/kg by i.v. route. 1. Blood flow in the LAD was decreased stepwise to 50% of its initial value. There was practically no more coronary reserve. After drug injection, diastolic aortic pressure, that normally falls, was kept constant by clamping. Heart rate, perfusion pressure, post-stenotic pressure, and blood flow and resistance in the LAD showed practically no change. In the CCA, blood flow increased significantly (p less than 0.005) and flow resistance decreased (p less than 0.001). 133Xe clearance showed an increased myocardial perfusion (p less than 0.02) in the territory supplied by the LAD artery. 2. The lumen of the LAD was narrowed by 53%, i.e., coronary reserve was decreased. This constriction was followed by no haemodynamic reaction. After injection of cinepazide, mean and diastolic aortic pressure (p less than 0.02) and post-stenotic coronary pressure (p less than 0.005) decreased. Blood flow increased by 41% in the CCA and by 31% in the LAD. Coronary resistance in these vessels decreased (p less than 0.001 and 0.005, respectively). Here, too, the 133Xe clearance curve showed an increase in myocardial perfusion in the territory supplied by the LAD artery (+78%).     

The effects of propranolol and acebutolol on left ventricular function and coronary haemodynamics in the conscious dog with myocardial ischaemia.

1 The cardiovascular effects of the beta-adrenoceptor blocking drugs, propranolol and acebutolol, on regional coronary blood flow and left ventricular function have been investigated in the conscious dog with developing myocardial infarction. 2 Propranolol (1 to 1.5 mg/kg) or acebutolol (4 to 5 mg/kg) were administered intravenously 2 to 3 h after occlusion of the left anterior descending coronary artery. 3 Propranolol or acebutolol administration resulted in a relative increase in flow to the ischaemic area of the myocardium, particularly to the subendocardium. 4 Propranolol produced a greater reduction in heart rate and myocardial contractility than acebutolol. 5 These results demonstrate that beta-adrenoceptor blocking drugs reduce myocardial oxygen consumption and increase coronary flow to the ischaemic area of the myocardium after coronary artery occlusion in the conscious dog.     

A case of type I dual left anterior descending coronary to pulmonary artery fistula

We report a case of Type I dual left anterior descending coronary artery (LAD) giving rise to a pulmonary artery fistula via a short LAD branch, causing symptoms of typical angina. This rare coronary artery anomaly is importance to classify; it shows features of both intrinsic coronary artery anatomy anomaly and coronary drainage anomaly.     

Brugada-like early repolarization pattern misdiagnosed as acute anterior myocardial infarction in a patient with myocardial bridging of the left anterior descending artery

The diagnosis of acute coronary syndrome in patients presenting to the emergency department with chest pain is still challenging. Since the symptoms and electrocardiographic abnormalities of patients with acute myocardial infarction can be indistinguishable from those of patients with other conditions that lead to ST-segment elevation, a high clinical index of suspicion is needed to avoid an incorrect diagnosis and subjecting the patient to unwarranted thrombolytic therapy. Our report concerns a 53-year-old male with myocardial bridging of the left anterior descending artery. He presented with the combined electrocardiographic abnormality of the Brugada-like or early repolarization pattern, which was misdiagnosed as acute anterior myocardial infarction.     

Quality of life in patients with severe left ventricle dysfunction due to coronary artery disease

Background  

The majority of randomized trials comparing surgical treatment with percutaneous coronary intervention exclude patients with severe left ventricle dysfunction, resulting in the lack of a clear strategy for treatment.     

Cardiovascular effects of acebutolol following coronary artery occlusion and reperfusion in anaesthetized dog.

1 The effects of 5 mg/kg acebutolol given intravenously were investigated in anaesthetized dogs after (a) ligation of the left anterior descending coronary artery and (b) coronary reperfusion following 60 min of ligation of the anterior descending coronary artery. 2 Coronary artery ligation produced, after 4 to 6 h, persistent multiple ventricular ectopic beats and abnormalities of R and T waves and of the S-T segment. Administration of acebutolol, after the development of persistent ventricular arrhythmias, restored normal sinus rhythm within 5 min of injection. Electrocardiographic abnormalities were also reduced. 3 Coronary artery reperfusion (following 60 min of ligation) resulted in multiple ventricular ectopic beats, ventricular tachycardia and/or ventricular fibrillation. Pretreatment with acebutolol, 15 min before starting reperfusion, markedly reduced the arrhythmias. 4 Acebutolol did not affect peak inspiratory airway pressure. 5 Acebutolol produced significant bradycardia and slight, transient, hypotension. It was without effect on left ventricular systolic pressure, left ventricular end-diastolic pressure, cardiac output or pulmonary arterial pressure. 6 These results suggest beneficial effects of acebutolol in myocardial ischaemia and coronary reperfusion, without any significant risk of cardiodepression or bronchospasm.     

Mechanisms responsible for the in vitro relaxation of ligustrazine on porcine left anterior descending coronary artery

In this study, we have evaluated the underlying mechanisms responsible for the relaxation response of ligustrazine (2,3,5,6-tetra-methyl-pyrazine; 2,3,5,6-MP) and its structural analogues (2-methyl-pyrazine (2-MP); ethyl-pyrazine (EP); 2,3-di-methyl-pyrazine (2,3-MP); 2,5-di-methyl-pyrazine (2,5-MP); 2,6-di-methyl-pyrazine (2,6-MP) and 2,3,5-tri-methyl-pyrazine (2,3,5-MP)) in porcine left anterior descending coronary artery (tertiary branch, O.D. 2,3,5-MP>EP>2,5-MP>/=2,6-MP>/=2,3-MP>2-MP. Besides, salbutamol and forskolin caused an endothelium-independent relaxation. The relaxation response of ligustrazine, salbutamol and forskolin was blunted in the presence of cis-N-(2-phenylcyclopentyl) azacyclotridec-1-en-2-amine (MDL 12330A) (10 microM, an adenylate cyclase inhibitor) and N-[2-((bromocinnamyl)amino)ethyl]-5-isoquinoline-sulphonamide (H-89, a protein kinase A inhibitor, 3 microM). Patch-clamp, whole-cell electrophysiological studies using single smooth muscle cells of the left anterior descending coronary artery revealed that ligustrazine (300 microM), salbutamol (30 microM) and forskolin (1 microM) inhibited the nifedipine-sensitive L-type Ca(2+) channels, and the inhibitory effect was eradicated by MDL 12330A (10 microM) and H-89 (1 microM). However, neither the Ca(2+)-dependent K(+) channel nor the ATP-dependent K(+) channel was modified by ligustrazine (300 microM). In conclusion, our results indicate that ligustrazine-mediated left anterior descending coronary artery relaxation is due to the activation of adenylate cyclase/protein kinase A cascade and the subsequent inhibition of nifedipine-sensitive, voltage-dependent L-type Ca(2+) channels. However, opening of K(+) channels seems to play no role in mediating the relaxation effect of ligustrazine.     

Mepindolol reduces myocardial necrosis in rats with coronary artery occlusion

Mepindolol is a newly developed beta-adrenergic blocking agent reported to counteract the chronotropic effect of catecholamines, with only little effect on contractility. This study was designed to assess whether or not mepindolol is effective in reducing infarct size. Accordingly, 16 rats, serving as controls, underwent coronary artery occlusion and did not receive any treatment; an additional 19 were treated with mepindolol (1 mg/kg s.c. t.i.d.) for 48 h. Finally, a third group (n = 18) underwent sham operation. Forty-eight hours later, infarct size was calculated from left ventricular creatine phosphokinase activity and found to average 52.4 +/- 7.8% (mean +/- SEM) of the left ventricle in control rats and 35.6 +/- 5.4% in treated rats (p less than 0.05). Left ventricular phospholipid content averaged 0.79 +/- 0.08 microgram P/mg protein in sham-operated rats and 0.61 +/- 0.04 microgram P/mg protein in control animals. In contrast, in mepindolol-treated rats, phospholipid concentration was 0.70 +/- 0.04 microgram P/mg protein (p less than 0.05), this suggesting a protective effect of the drug on ischemia-induced phospholipid degradation. The long-term effect of mepindolol on left ventricular hydroxyproline concentration was assessed 21 days post-coronary occlusion. Infarct size calculated by this method was 30.2 +/- 4.8% of left ventricle in 21 control animals and 18.2 +/- 4.2% in 28 treated rats (p less than 0.05), indicating that, as for the acute necrosis, the extent of scar development after coronary artery occlusion can be reduced by mepindolol.     

Stereospecific antiarrhythmic effects of naloxone against myocardial ischaemia and reperfusion in the dog.

1. The effects of both the (-)- and (+)-stereoisomers of naloxone in anaesthetized dogs with arrhythmias induced by acute coronary artery occlusion followed by reperfusion were investigated. 2. Following coronary artery occlusion and reperfusion, all dogs in the control group developed ischaemia- and reperfusion-induced cardiac arrhythmias, bradycardia and hypotension. 3. The opiate antagonist (-)-naloxone prevented the arrhythmias, bradycardia and hypotension due to myocardial ischaemia and reperfusion. 4. The (+)-stereoisomer of naloxone, which is inactive as an opiate antagonist, was without beneficial effects. 5. These results indicate a possible involvement of endogenous opioid peptides in the cardiac effects due to myocardial ischaemia and reperfusion, mediated by opiate receptors through opiate antagonism.     

Haemodynamic factors influencing myocardial ischaemia in a canine model of coronary artery stenosis: the effects of nitroglycerine.

At a critical degree of coronary stenosis (allowing a just adequate blood supply to the poststenotic area only at the expense of maximal hypoxic coronary vasodilatation), an additional loading of the heart induced marked local myocardial ischaemia, as indicated by appropriate biochemical, electrophysiological and haemodynamic changes. In this model myocardial oxygen demand was increased in three different ways: (i) increasing heart rate by atrial pacing; (ii) increasing afterload by aortic occlusion and (iii) increasing preload by blood infusion. These procedures were compared in their ability to produce local myocardial ischaemia and characterized by ST-segment elevation recorded from the endocardium and epicardium. Increasing afterload evoked the mildest degree of ischaemia since the resulting increase in coronary perfusion pressure and coronary flow almost met the augmented myocardial oxygen demand evoked by the elevated peripheral resistance and by the simultaneously increased preload. A rather more pronounced ischaemia was produced by increasing the preload. The most serious ischaemia of all was induced by atrial pacing. This reduced coronary flow and perfusion pressure and increased left ventricular end diastolic pressure (LVEDP). Nitroglycerine transiently reduced blood pressure and coronary blood flow and increased epicardial and endocardial ST-segment elevation; the changes had disappeared 10 min after terminating the infusion. However, at this time a prolonged protective action against pacing-induced ST-segment elevation was observed. This protection was also seen after intracoronary injections of nitroglycerine. This indicated that part of the beneficial effect of nitroglycerine in ischaemia is due to direct coronary and/or myocardial actions.     

The effect of tadalafil on the time to exercise-induced myocardial ischaemia in subjects with coronary artery disease

OBJECTIVE: To investigate the effect of tadalafil on the time to exercise-induced myocardial ischaemia in subjects with coronary artery disease (CAD). Background CAD and erectile dysfunction (ED) share similar risk factors. It is important to know the cardiovascular effects of tadalafil in patients with CAD during physical exertion that is comparable with sexual activity. METHODS: A randomized, placebo-controlled, double-blind, two-period, crossover study comparing the effects of tadalafil 10 mg and placebo on the time to exercise treadmill test (ETT)-induced myocardial ischaemia in subjects with stable CAD (n = 23; age range: 53-75 years, all exhibited ST-segment depression >1.5 mm at screening ETT at > 5METS). Haemodynamic responses to sublingual nitroglycerin (NTG) were assessed before and after ETT. RESULTS: Compared with placebo, tadalafil did not significantly affect the time to ETT-induced ischaemia (13 min/31 s vs. 13 min/36 s, respectively). Before exercise, NTG evoked decreases in sitting systolic blood pressure (SBP) that were significantly greater when subjects received tadalafil compared with placebo, and after exercise, more subjects experienced a decrease in SBP <85 mmHg in response to NTG after taking tadalafil vs. placebo. When subjects received tadalafil compared with placebo, SBP was lower at rest (-7 mmHg; -12,-2), during ETT (-10 mmHg; -16, -3), and after ETT (-13 mmHg; -19, -7). CONCLUSION: Tadalafil did not significantly alter the time to ETT-induced ischaemia compared with placebo in subjects with CAD. Tadalafil reduced resting and exercise SBP. Due to the potential for hypotension, the concomitant use of nitrates and tadalafil is contraindicated.     

An alpha-adrenergic coronary constriction during esophageal distention in the dog.

Previous work has shown an increase in sympathetic stimulation of the heart during chemical or mechanical irritation of visceral organs, but the involvement of the coronary circulation in such reflexes is not clear. In five preliminary experiments in anesthetized dogs, esophageal distention produced a sympathetic stimulation of the heart, as evidenced by an increase in heart rate, which was abolished by non-selective beta-adrenergic and muscarinic blockades. On the basis of these preliminary data, we further examined a sympathetic coronary constriction during acute esophageal distension in which any direct adrenergic coronary constriction was unmasked by muscarinic blockade with atropine (100 micrograms/kg, i.v.), and non-selective beta-adrenergic blockade with propranolol (1 mg/kg, i.v.). In seven dogs anesthetized with alpha-chloralose in an open-chest procedure, the esophagus was rapidly distended to a pressure of 36 +/- 2 mm Hg, which was not significantly different from the distending pressure used in the preliminary experiments. During esophageal distention, the mean circumflex blood flow decreased to 77 +/- 10% (SEM) of the predistention value. This decrease was statistically significant (p less than 0.05). There was no change in left ventricular pressure, mean arterial pressure dP/dtmax, or heart rate. Intracoronary administration of the nonselective alpha-adrenergic antagonist phentolamine completely abolished the reduction in mean circumflex coronary blood flow caused by esophageal distention in the presence of beta-adrenergic and muscarinic blockades. These results demonstrate a direct sympathetic coronary vasoconstriction elicited by esophageal distention. This vasoconstriction was due to activation of coronary alpha-adrenergic receptors.     

Ventricular arrhythmias parallel cardiac histamine efflux after coronary artery occlusion in the dog

Release of cardiac histamine by immunologic and pharmacologic stimuli is known to provoke ventricular arrhythmias. Augmented histamine efflux from ischemic myocardium has been proposed but remains controversial. The purpose of this study was to determine whether cardiac histamine efflux is precipitated by coronary artery occlusion and if so, whether histamine efflux is associated with the development of early ischemic ventricular arrhythmias. The left anterior descending coronary artery was occluded while recording a continuous electrocardiogram and coronary sinus blood was sampled frequently during the first 30 min of coronary artery occlusion in pentobarbital-anesthetized, open-chest dogs. Coronary sinus histamine concentration rose from a mean baseline of 0.06 +/- 0.10 ng/ml (+/- SD) before coronary artery occlusion to a mean peak of 0.61 +/- 0.40 ng/ml after coronary artery occlusion (p less than 0.0001; n = 14). The median peak coronary sinus histamine concentration was significantly greater in dogs that suffered ventricular fibrillation after coronary artery occlusion (n = 4) than in those that did not (n = 10) (0.86 ng/ml vs. 0.37 ng/ml; p = 0.05). The area under the coronary sinus histamine concentration-vs.-time curve ("total cardiac histamine efflux") correlated directly with the total number of ventricular premature contractions during the first 30 min after coronary artery occlusion (r = 0.81; p less than 0.005; n = 10), and with infarct size (r = 0.91; p less than 0.01; n = 6). Thus, during acute myocardial ischemia, the coronary sinus histamine concentration increases simultaneously with the development of early ischemic ventricular arrhythmias and in proportion to their severity.     

不同介入方法治疗冠脉前降支分叉病变的临床疗效评价

目的：评价不同介入方法治疗冠状动脉前降支分叉病变的近、中期疗效。方法：39例经冠脉造影证实左冠前降支分叉病变的患者，接受了主支植入支架，分支分别采用无钢丝保护、钢丝保护、对吻球囊扩张术、Crush技术或改良Crush技术，术后对患者进行临床随访，回顾性分析其结果。结果：39例患者共植入支架56枚，药物支架21枚，其中前降支药物支架15枚。分支与主支对吻球囊扩张11例，其中2例对吻球囊扩张失败；Crush技术或改良Crush技术5例，其中1例未完成对吻扩张。术毕主支血管无残余狭窄或残余狭窄〈10％，3例分支血管残余狭窄〉50％，手术成功率为92．3％（36／39），无严重急性并发症出现。住院期间无主要心脏不良事件（MACE）发生，随访期间MACE发生率为2．6％（1／39）。结论：根据冠脉分叉病变的病理分型采用不同的介入治疗方法是安全、可行的，并且近中期临床疗效较好。