Postextrasystolic T wave changes and angiographic coronary disease.

The significance of postextrasystolic T wave changes in beats following induced extrasystoles was assessed by angiography in 55 patients. These T wave changes were found in 81 per cent of coronary artery disease patients but also in 68 per cent of patients with normal coronary arteries (PNS). All patients with normal baseline electrocardiograms and normal coronary arteries showed postextrasystolic T wave changes. In electrocardiographic leads corresponding to the distribution of major coronary arteries, T wave changes occurred just as frequently when the artery was normal (54%) as when the artery was stenosed (55%). Left ventricular asynergy was not associated with an increased frequency of postextrasystolic T wave changes and in fact ejection fraction was greater end-diastolic pressure lower in patients with T wave changes. Thus, postextrasystolic T wave changes appear not to be useful in diagnosing or localising coronary artery disease.     

Postextrasystolic T wave changes in normal canine hearts

Premature ventricular beats were induced at variable coupling intervals and postextrasystolic T wave changes were observed following various postextrasystolic cycle lengths in 19 closed chest dogs with normal hearts. Following relatively longer postextrasystolic cycle lengths, reversal of the T wave polarity was seen in six dogs (31%), only T wave amplitude changes were seen in 6 dogs (31%), and no significant T wave changes were seen in seven dogs (38%). It was concluded that postextrasystolic T wave changes occur in normal hearts and have no useful diagnostic values.     

Postextrasystolic aortic pressure pulse response in coronary artery disease.

The response of the aortic systolic pressure after an extrasystole was evaluated in 100 consecutive patients with coronary artery disease. The patients were divided into four groups depending on the response of the first postextrasystolic beat. Group IA (45 patients), had lower systolic pressure, whereas group IB (40 patients), had a similar systolic pressure in the postextrasystolic beat, as compared to beats preceding the extrasystole. Group IIA (12 patients) and group IIB (3 patients), demonstrated an increased systolic pressure in the first postextrasystolic beat with subsequent beats in group IIB, also demonstrating pulsus alternans. Congestive heart failure and cardiomegaly were significantly more frequent in group II, as compared to group I patients. In group IIA and IIB, triple vessel disease was present in 83 and 100 per cent, respectively, as compared to 44 per cent in group I patients. Left ventricular end-diastolic pressure (mm. Hg) was 14 ± 6 and 12 ± 7 in group IA and IB respectively, as compared to 19 ± 9 (p < 0.025) in group IIA and 31 in group IIB. Comparing groups IA and IB with each other for cardiac output, stroke volume, end-diastolic volume and ejection fraction, revealed no significant difference. The cardiac output (L./min./M.²) was 2.2 ± 0.6 for group IIA, as compared (p < 0.01) to 2.8 ± 0.5 and 2.9 ± 0.5 in groups IA and IB. Stroke volume (ml./M.²) and ejection fraction were 30 ± 10 and 0.30 ± 0.08, respectively, for group IIA, which is signficantly less, as compared to group I patients. The end-diastolic volume (ml./M.²) in group IIA was 102 ± 28, which is significantly (p < 0.001) higher, as compared to group IA and IB. All patients in group IIB had an abnormal cardiac output, end-diastolic volume and ejection fraction. Thus, the differences in response between group I and group II patients to an extrasystole clearly define two distinct hemodynamic groups. The responses observed to an extrasystole are best explained by variable response of each group to postextrasystolic potentiation and aortic impedance.     

High-sensitivity troponin T level and angiographic severity of coronary artery disease

The association between circulating levels of cardiac troponins and angiographic severity of coronary artery disease (CAD) has not been studied. We investigated whether there is an association between the level of high-sensitivity troponin T (hs-TnT) and angiographic severity of CAD and whether this association is independent of conventional risk factors, N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and C-reactive protein (CRP). This case-control study included 904 patients with stable CAD (cases) and 412 patients with chest pain but without significant CAD on coronary angiogram (controls). Diagnosis of CAD was confirmed or excluded by coronary angiography. Cardiac TnT was measured with conventional and high-sensitivity assays in parallel using the same plasma sample. In patients with no CAD and in those with 1-, 2-, or 3-vessel disease, hs-TnT levels (median, twenty-fifth to seventy-fifth percentiles) were 0.005 μg/L (<0.003 to 0.009), 0.006 μg/L (0.003 to 0.011), 0.008 μg/L (0.004 to 0.013), and 0.010 μg/L (0.006 to 0.017), respectively (p <0.001). In multivariable analysis adjusting for cardiovascular risk factors and clinical variables including NT-pro-BNP and CRP, hs-TnT was an independent predictor of presence of CAD (adjusted odds ratio 1.30, 95% confidence interval 1.07 to 1.59, p = 0.009). In conclusion, in patients with stable and angiographically proved CAD, hs-TnT level is increased compared to subjects without CAD and correlates with angiographic atherosclerotic extent and burden. The association between increased levels of hs-TnT and presence of CAD was independent of traditional cardiovascular risk factors, NT-pro-BNP, and CRP.     

运动试验中R波及T波振幅变化对诊断冠心病的意义

目的 探讨平板运动试验(TET)过程中引起R波电压降低或T波增高的特征、临床意义及其与冠状动脉病变的关系.方法 通过对672例行TET检查患者的心电图进行分析,筛选出R波电压降低或T波增高患者,对其心电图特征进行分析并与冠状动脉造影检查进行对比观察.结果 22例患者在试验中出现R波电压降低,其中17例开始于运动中2～8 min,5例发生于运动结束后2～6 min;R波电压降低持续4～6 min;出现在V4～V6导联16例,Ⅱ、Ⅲ、aVF导联6例.11例在试验中出现T波增高,其中9例开始于运动中2～8 min,2例发生于运动结束后2～4 min;T波增高持续2～6 min;出现在V2～V4导联9例,Ⅱ、Ⅲ、aVF导联2例.33例患者冠状动脉造影显示均有管腔狭窄病变,其中左冠状动脉前降支病变20例,左冠状动脉回旋支病变4例,右冠状动脉病变4例,左冠状动脉前降支+右冠状动脉病变5例.结论 TET检查诱发R波电压降低或T波增高是判断冠状动脉狭窄病变较为可靠的指标.     

运动试验中R波及T波振幅变化对诊断冠心病的意义

目的探讨平板运动试验（TET）过程中引起R波电压降低或T波增高的特征、临床意义及其与冠状动脉病变的关系。方法通过对672例行TET检查患者的心电图进行分析,筛选出R波电压降低或T波增高患者,对其心电图特征进行分析并与冠状动脉造影检查进行对比观察。结果22例患者在试验中出现R波电压降低,其中17例开始于运动中2～8min,5例发生于运动结束后2～6min;R波电压降低持续4～6min;出现在V4～V6导联16例,Ⅱ、Ⅲ、aVF导联6例。11例在试验中出现T波增高,其中9例开始于运动中2～8min,2例发生于运动结束后2—4min;T波增高持续2～6min;出现在V2～V4导联9例,Ⅱ、Ⅲ、aVF导联2例。33例患者冠状动脉造影显示均有管腔狭窄病变,其中左冠状动脉前降支病变20例,左冠状动脉回旋支病变4例,右冠状动脉病变4例,左冠状动脉前降支＋右冠状动脉病变5例。结论TET检查诱发R波电压降低或T波增高是判断冠状动脉狭窄病变较为可靠的指标。     

Early T wave inversion after thrombolytic therapy predicts better coronary perfusion: Clinical and angiographic study

Objectives. This study was undertaken to test the hypothesis that early inversion of T waves after thrombolytic therapy for acute myocardial Infarction predicts patency of the infarct-related artery with high Thrombolysis in Myocardial Infarction (TIMI) perfusion flow and better in-hospital outcome.Background. Although numerous studies have demonstrated a strong association between early resolution of ST segment elevation after acute myocardial infarction and successful thrombolysis, little is known about early changes in T waves after thrombolytic therapy.Methods. Ninety-four consecutive patients with acute myocardial infarction treated with recombinant tissue-type plasminogen activator (rt-PA) were studied with admission and predischarge radionuclide ventriculography and with coronary angiography within 72 h of admission. Patient stratification was based on the presence or absence of early (within 24 h) T wave inversion.Results. Early T wave inversion was associated with a higher patency rate of the infarct-related artery (90% vs. 65%, p < 0.02) and less severe residual stenosis ([mean ± SD] 73 ± 27 vs. 83 ± 22, p = 0.06), and when only TIMI perfusion grade 3 was considered, the difference was even greater (77% vs. 41%, p < 0.001). Patients with early inversion of T waves had a lower peak creatine kinase value ([mean ± SD] 678 ± 480 vs. 1,076 ± 620, p < 0.01), and although a similar percent of patients with and without early T wave inversion had a normal ejection fraction (≥55%) on admission, a higher percent of patients with early inversion had a normal ejection fraction at hospital discharge (71% vs. 44%, p < 0.03). Early T wave inversion anticipated a more benign in-hospital clinical course with a lower incidence of adverse cardiac events (10% vs. 33%, p < 0.02).Conclusions. Early inversion of T waves in patients with acute myocardial infarction treated with thrombolytic therapy suggests patency of the infarct-related artery, better perfusion grade and left ventricular function and a more benign in-hospital course.     

倒置T波正常化与冠心病相关性的研究

目的探讨24小时内倒置T波出现正常化改变与冠心病相关性,为心肌缺血的诊断提供依据。方法回顾性分析140个病例,动态心电图检查76例有倒置T波正常化改变设为观察组,64例非倒置T波正常化改变设为对照组。分析比较两组患者的主要症状、主要诊断、部分患者冠状动脉造影检查结果。结果观察组：主要症状为胸闷、胸痛44例,临床诊断冠心病36例,其中冠状动脉造影25例,阳性24例。对照组：主要症状为心悸32例,临床诊断冠心病5例,其中冠状动脉造影检查5例,1例阳性（p〈0．05）。结论24小时动态心电图检查发现倒置T波正常化改变与冠心病显著相关,可以作为心肌缺血的一个诊断指标。     

Effort angina pectoris without electrocardiographic changes in coronary disease patients: correlations between scintigraphic and coronary angiographic findings

The absence of electrocardiographic changes during angina is an unusual occurrence. In 15 male patients with exercise-induced angina, the electrocardiogram failed to show the usual ischemic ST-T changes. The exercise thallium-201 myocardial imaging was employed as indicator of the ischemia and the results were correlated with coronary angiographic findings. The exercise thallium-201 myocardial imaging showed an exercise-induced reversible defect in 14 patients and a fixed defect in the remaining 1. Out of 15 patients, 13 had defects involving the infero-apical, posterior and postero-lateral segments. The coronary angiography, performed in all patients but 2, showed single-vessel coronary artery disease in 8 patients and double-vessel disease in 5. A significant circumflex or right coronary artery stenosis was found in all cases except 1; 2 patients had a coexistent left anterior descending coronary artery stenosis and 1 an isolated stenosis of this vessel. It is concluded that the myocardial scintigraphy is useful to assess the ischemic myocardial origin of chest pain in the absence of ST-T changes. The silence of the electrocardiogram might be due to the production of ischemia in not well explored areas, such as the inferior and posterior myocardial segments, and possibly to a smaller extension of ischemia.     

Ability of troponin T to predict angiographic coronary artery disease in patients with chronic kidney disease

Association between angiographic coronary artery disease and cardiac troponin T levels has been observed in patients with normal kidney function; however, this association remains unsettled in patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD). Over a 12-month period we retrospectively reviewed coronary angiograms (CAs) performed in 194 hospitalized patients with presumed acute myocardial injury. About 50% of the ESRD and 30% of the CKD patients had normal CAs. Troponin T levels significantly correlated with CAs in patients with normal kidney function (r = 0.4, p = 0.005) but not in ESRD and CKD patients (r = 0.2, p = NS, respectively).     

Identifying women with severe angiographic coronary disease

Abstract. Kreatsoulas C, Natarajan MK, Khatun R, Velianou JL, Anand SS (McMaster University; CARING Network, McMaster University; Population Health Research Institute, McMaster University and Hamilton Health Sciences; Interventional Cardiology, Hamilton Health Sciences; Eli Lilly Canada–May Cohen Chair in Women's Health, McMaster University; Michael G. DeGroote‐Heart and Stroke Foundation of Ontario Chair in Population Health Research, McMaster University; Population Genomics Program, McMaster University; McMaster University, Hamilton, ON, Canada). Identifying women with severe angiographic coronary disease. J Intern Med 2010; 268 :66–74. Objectives. To determine sex/gender differences in the distribution of risk factors according to age and identify factors associated with the presence of severe coronary artery disease (CAD). Design. We analysed 23 771 consecutive patients referred for coronary angiography from 2000 to 2006. Subjects. Patients did not have previously diagnosed CAD and were referred for first diagnostic angiography. Outcome measures. Patients were classified according to angiographic disease severity. Severe CAD was defined as left main stenosis ≥50%, three‐vessel disease with ≥70% stenosis or two‐vessel disease including proximal left anterior descending stenosis of ≥70%. Univariate and multivariate logistic regression was used to assess the association between risk factors and angina symptoms with severe CAD. Results. Women were less likely to have severe CAD (22.3% vs. 36.5%) compared with men. Women were also significantly older (69.8 ± 10.6 vs. 66.3 ± 10.7 years), had higher rates of diabetes (35.0% vs. 26.6%), hypertension (74.8% vs. 63.3%) and Canadian Cardiovascular Society (CCS) class IV angina symptoms (56.7% vs. 47.8%). Men were more likely to be smokers (56.9% vs. 37.9%). Factors independently associated with severe CAD included age (OR = 1.05; 95% CI 1.05–1.05, P < 0.01), male sex (OR = 2.43; CI 2.26–2.62, P < 0.01), diabetes (OR = 2.00; CI 1.86–2.18, P < 0.01), hyperlipidaemia (OR = 1.50; CI 1.39–1.61, P < 0.01), smoking (OR = 1.10; CI 1.03–1.18, P = 0.06) and CCS class IV symptoms (OR = 1.43; CI 1.34–1.53, P < 0.01). CCS Class IV angina was a stronger predictor of severe CAD amongst women compared with men (women OR = 1.82; CI 1.61–2.04 vs. men OR = 1.28; CI 1.18–1.39, P < 0.01). Conclusions. Women referred for first diagnostic angiography have lower rates of severe CAD compared with men across all ages. Whilst conventional risk factors, age, sex, diabetes, smoking and hyperlipidaemia are primary determinants of CAD amongst women and men, CCS Class IV angina is more likely to be associated with severe CAD in women than men.     

Inability of exercise-induced R wave changes to predict coronary artery disease

To determine the value of exercise-induced R wave changes in diagnosing coronary disease 200 patients undergoing coronary angiography were studied with 16 lead precordial exercise mapping. R wave amplitude was calculated before and immediately after exercise as the sum of R in all 16 leads, the sum of the R waves in the left plus the S waves in the right precordial leads, as well as the sum of the R waves only in those leads that manifested S-T segment depression. Coronary artery disease was found in 154 patients; S-T depression developed in 122 (sensitivity 79 percent); the sum of R increased or remained unchanged in 61 and decreased in 93 (sensitivity 40 percent). Forty-six patients did not have coronary artery disease; S-T depression developed in 5 (specificity 89 percent); the sum of R increased or was unchanged in 30 and decreased in 16 (specificity 35 percent). Similar results were obtained using the other criteria for calculating R wave amplitude. Exercise-induced S-T depression was identified in 5.1 ± 2.6 (mean ± standard deviation) of the 16 precordial leads and in 2.0 ± 1.1 of the chest leads of the standard electrocardiogram (p < 0.01). Thus, electrocardiographic alterations found in the standard chest leads represent only a small variable proportion of the total projection. When the whole precordial area was analyzed, R wave changes were so unpredictable that they could not be used in the diagnosis of coronary disease.     

Prediction of coronary artery disease using post exercise T wave change

In the evaluation of the exercise stress test, conventional electrocardiographic criteria using 1 or 2 mm ST segment depression below the isoelectric line yields many false positive results and is not so useful to predict the severity of coronary artery disease. In this study, we have attempted to predict the presence and the severity of coronary artery disease from the post exercise T wave change. Fifty-six patients who had positive treadmill exercise test results by conventional ST segment criteria and underwent selective coronary arteriography were studied. T wave change was defined as inversion or biphasic change in one or more of leads aVF, V4, V5, V6 during the recovery phase, and in the cases who showed T wave changes, T wave configuration were also analysed. Seventeen of 28 patients with and 11 of 28 patients without significant coronary artery disease showed post exercise T wave changes. This difference was not statistically significant. But in the cases who showed T wave changes, the maximum amplitude of the negative component of T wave was significantly greater in the true positive group than in the false positive group. And the development of deeply negative component (more than 1.5 mm) indicated the presence of multivessel coronary artery disease. In the cases who showed the negative component of T wave less than 1 mm, the characteristics of T wave configuration including the amplitude, height of positive component, and the depth from the isoelectric line were different between the 2 groups. These results suggest that careful observation of T wave during the recovery phase is useful to improve the diagnostic accuracy of the exercise electrocardiogram.     

巨大负性T波患者冠心病的预测影响因素

目的：探讨心电图巨大负性T波在冠心病诊断中的预测价值。方法：回顾性分析1998年1月至2001年12月64例心电图示巨大负性T波并在我院行冠状动脉造影检查的患者，对其心电图、超声心动图和临床资料进行统计分析。结果：心电图示无左心室肥厚或表现为对称性巨大负性T波则支持冠心病的诊断。巨大负性T波患者心电图缺乏左心室肥厚较对称性T波倒置对冠心病更有预测价值。结论：心电图巨大负性T波患者不伴左心室肥厚或对称性T波倒置是预测冠心病的重要因素。     

Aortic insufficiency and syphilitic coronary ostial disease. Pre- and postoperative angiographic aspects

The authors report the case of a 50 year old patient with severe aortic incompetence (stage IV on angiography) and syphilitic left coronary ostial disease confirmed by complementary investigations. Management comprised aortic valve replacement and saphenous vein aorto-coronary bypass. The postoperative angiographic appearances showed normal valve function and a permeable aorto-left anterior descending bypass graft. The outcome was also satisfactory from the clinical point of view.     

病态窦房结综合征与冠状动脉病变相关性的探讨

目的 探讨病变窦房结合综合征与冠状动脉病变的相关性,并观察冠状动脉病变介入治疗后患者的心脏变时功能变化。方法 对56例接受起搏器治疗的患者行选择性冠状动脉造影,对相应冠状动脉行经皮冠状动脉腔内成形术和冠状动脉内支架植入术治疗。结果 20例显示冠状动脉显著狭窄,但狭窄未累及窦房结动脉起源的冠状动脉或狭窄在窦房结动脉发生以远的血管段。其中12例14支血管接受经皮冠状动脉腔内成形术和冠状动脉内支架植入术治疗,6个月的随访造影无再狭窄,患者的心功能改善,临床缺血症状消失或明显减轻,但窦房结功能并未改善。结论 冠心病并非是病态窦房结综合征的主要病因;合并冠状动脉狭窄的病态窦房结综合征患者,经皮冠状动脉腔内成形术和冠状动脉内支架植入术治疗可以改善心肌缺血和心脏功能,但难以恢复窦房结的正常变时功能。