Chest pain as a predictor of coronary artery disease in patients with obstructive aortic valve disease

To clarify the association between chest pain and significant coronary artery disease in patients who have aortic valve disease, 76 consecutive candidates for aortic valve replacement were evaluated prospectively with use of a historical questionnaire and coronary arteriography. Of the 76 patients, 19 (25 percent) had no chest pain, 21 (28 percent) had chest pain that was not-typical of angina pectoris and 36 (47 percent) had chest pain typical of angina pectoris. In 18 of 19 patients the absence of chest pain correlated with the absence of coronary artery disease. The single patient without chest pain who had coronary artery disease had evidence of an inferior myocardial infarction in the electrocardiogram. Thus, absence of chest pain and the absence of electrocardiographic evidence of infarction predicted the absence of coronary disease in all cases.

The presence of chest pain did not predict the presence of coronary artery disease, but the more typical the pain of angina pectoris the more likely were patients to have significant coronary artery disease. Of the 21 patients with atypical chest pain, 6 (29 percent) had coronary artery disease, but of the 36 patients with typical angina pectoris 23 (64 percent) had significant coronary artery disease. In addition, when patients with chest pain not typical of angina pectoris also had coronary artery disease, the diseased vessels usually supplied smaller areas of the left ventricle than when the pain was typical of angina pectoris. In 21 of 23 patients (91 percent) with typical angina pectoris and significant coronary artery disease, lesions were present in the left coronary artery. There was no systolic pressure gradient across the aortic valve that excluded the presence of coronary artery disease, although all patients with a calculated aortic valve area of less than 0.4 cm² were free of coronary artery disease. Patients with severe left ventricular dysfunction were more likely to have normal coronary arteries.     

Incidence of coronary artery disease in patients with valvular heart disease.

The case notes, cardiac catheterisation data, and coronary arteriograms of 239 patients investigated for valvular heart disease during a five year period were reviewed. Angina present in 13 of 95 patients with isolated mitral valve disease, 43 of 90 patients with isolated aortic valve disease, and 18 of 54 patients with combined mitral and aortic valve disease. Significant coronary artery disease was present in 85 per cent of patients with mitral valve disease and angina, but in only 33 per cent of patients with aortic valve disease and angina. Patients with no chest pain still had a high incidence of coronary artery disease, significant coronary obstruction being present in 22 per cent with mitral valve disease, 22 per cent with aortic valve disease, and 11 per cent with combine mitral and aortic valve disease. Several possible clinical markers of coronary artery disease were examined but none was found to be of practical help. There was, however, a significant inverse relation between severity of coronary artery disease and severity of valve disease in patients with aortic valve disease. Asymptomatic coronary artery disease is not uncommon in patients with valvular heart disease and if it is policy to perform coronary artery bypass grafting in such patients, routine coronary arteriography must be part of the preoperative investigation.     

Relation of angina to coronary artery disease in mitral and in aortic valve disease

Of 129 patients with either mitral or aortic valve disease angina was present in 55 (42%). It was more frequent in aortic (60%) than in mitral valve disease (33%). The standard 12-lead electrocardiogram was not helpful in distinguishing underlying occlusive coronary artery disease. Coronary arteriography demonstrated coronary artery disease in 26 patients (20%), only 2 of whom had no angina. The incidence of coronary artery disease was almost identical in both the mitral and aortic groups (22% and 17%, respectively), but the percentage of those with demonstrable coronary artery disease accompanying angina was much higher in the mitral group (67% as against 29%). Angina in mitral valve disorders is thus much more likely to be the result of disease of the coronary arteries. Coronary arteriography is mandatory in all patients in both groups who have angina. Otherwise it seems unnecessary as coronary artery disease was found in only 2 patients who did not have angina.     

Relation of angina to coronary artery disease in mitral and in aortic valve disease.

Of 129 patients with either mitral or aortic valve disease angina was present in 55 (42%). It was more frequent in aortic (60%) than in mitral valve disease (33%). The standard 12-lead electrocardiogram was not helpful in distinguishing underlying occlusive coronary artery disease. Coronary arteriography demonstrated coronary artery disease in 26 patients (20%), only 2 of whom had no angina. The incidence of coronary artery disease was almost identical in both the mitral and aortic groups (22% and 17%, respectively), but the percentage of those with demonstrable coronary artery disease accompanying angina was much higher in the mitral group (67% as against 29%). Angina in mitral valve disorders is thus much more likely to be the result of disease of the coronary arteries. Coronary arteriography is mandatory in all patients in both groups who have angina. Otherwise it seems unnecessary as coronary artery disease was found in only 2 patients who did not have angina.     

Coronary lesions due to aortic valve disease. I -- Occurrence and clinical prognosis]

A multicentre retrospective study of 467 cases of operated aortic valve disease was undertaken to define the indications of coronary arteriography in the pre-operative work-up. Significant coronary artery disease was present in 15% of all cases or, more precisely, in 17% of cases with angina and in 8% when investigation was only routine. Coronary artery disease was more frequent in males, in patients with clinical or electrical evidence of previous myocardial infarction, in patients with ST-T wave changes, and when angina was severe (more than one attack per day). None of these factors was specific. It is therefore difficult to limit coronary arteriography to these patients or there would be a risk of missing significant lesions in a small number of cases. It is important to give the surgeon all the necessary information before aortic valve replacement and so coronary arteriography should be widely practiced in this context. However exceptions may be made for young patients and also those in congestive cardiac failure in whom coronary arteriography represents an unnecessary risk before surgery.     

Angina pectoris and coronary artery disease in patients with severe aortic valvular disease

We studied the clinical, hemodynamic, and angiographic findings of 90 consecutive patients with significant symptomatic aortic valve disease, 40 years of age or older, to evaluate the prevalence of angina pectoris in relation to coronary artery disease and the effect upon cardiac function.The prevalence of chest pain was 66% (typical angina, 39%; atypical chest pain, 27%), and the prevalence of coronary artery disease was 39%. The prevalence of coronary artery disease in patients with typical angina was 77%, in contrast to 25% in patients with atypical chest pain $\text{(}\text{P}\text{= 0.001)}$. Only two of the 35 patients (6%) with coronary artery disease were free of chest pain. Although the incidence of coronary artery disease in patients with aortic stenosis was slightly higher than in patients with aortic regurgitation or aortic stenosis-aortic regurgitation, it was not statistically significant.Patients with aortic regurgitation and coronary artery disease had significantly lower ejection fraction than patients with aortic stenosis and coronary artery disease. There were no significant differences between ejection fraction in patients without coronary artery disease in the different groups. Patients with aortic stenosis and coronary artery disease tend to have lower mean pressure gradients than those without coronary artery disease. Patients with coronary artery disease in aortic regurgitation and aortic stenosis-aortic regurgitation tend to have higher left ventricular end-diastolic pressure.This study indicates that although patients with aortic valve disease and typical angina are most likely to have associated coronary artery disease, it is not possible to predict this disorder with accuracy by means of clinical or hemodynamic findings.Since the presence or absence of coronary artery disease in patients undergoing aortic valve replacement has prognostic and therapeutic significance, we recommend that coronary arteriography be performed in all patients with significant aortic valve disease undergoing cardiac catheterization when they present with any form of chest pain, or in patients over the age of 40 years even if no chest pain is present. Coronary arteriography would also rule out anomalous aortic origin of the coronary arteries.     

Prevalence of coronary artery disease in patients with isolated aortic valve stenosis.

The prevalence of significant coronary artery disease (reduction in luminal diameter by more than 50%) among 88 consecutive patients with aortic stenosis requiring aortic valve replacement at Hammersmith Hospital was examined. Twenty two (34%) patients had significant coronary disease. Nineteen of 42 (45%) patients with typical angina had coronary disease; three of 20 (15%) patients with atypical chest pain had coronary disease, while none of 26 patients free of chest pain had significant coronary disease. Risk factors for coronary disease were equally distributed among patients with and without significant luminal obstruction. Because of the small, but definite, hazard of coronary arteriography and in the interest of cost containment it is suggested that patients with aortic stenosis who are free of chest pain do not require routine coronary arteriography. This applies particularly to patients requiring urgent aortic valve replacement.     

Indications for coronary angiography in patients with acquired heart valve diseases with reference to risk factors

The aims of the study were to examine the frequency of coronary artery disease (CAD) in patients with acquired valvular heart disease and to investigate the parameters by which significant coronary artery stenosis can be identified without invasive measures in these patients. For this reason 266 consecutive patients with acquired valvular heart disease (aortic, mitral or combined lesions) were examined retrospectively. In 24 patients (9%) a significant (50% or more reduction of the diameter) coronary artery stenosis was found. The prevalence of CAD increased with age: only one patient younger than 50 years, but 23 patients (13%) older than 50 years revealed significant CAD (19% men, 7% women). Increased levels of cholesterol and/or triglycerides were found more frequently in patients with CAD (33% and 29%, respectively) than in those without (6% and 12%, respectively). No differences were found in patients with aortic and mitral valve disease. Patients with typical chest pain revealed CAD in 30% of cases, whereas only 5% of the patients without angina pectoris (or 4% with atypical chest pain) showed a significant coronary artery stenosis. A high percentage (62%) of patients with typical chest pain and mitral valve disease revealed CAD. None of the 77 female patients without typical angina pectoris had significant coronary artery stenosis, whereas 11% of the male patients showed significant CAD even without typical symptoms. In 51 patients without typical angina pectoris and with no risk factors, no CAD was observed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Detection of coronary disease before valve surgery. Contribution of myocardial scintigraphy with dipyridamole

The detection of coronary disease before valve surgery remains difficult in the absence of coronary arteriography. The contribution of myocardial scintigraphy with dipyridamole (MS-DP) was studied in 34 consecutive patients with valve disease (11 mitral and 23 aortic) with a mean age of 63 +/- 11 years having undergone coronary arteriography before valve surgery. Coronary arteriography was performed because of angina (21 cases) or age (women greater than 50, men greater than 40). Positive criteria of coronary disease were the presence of at least one frank and clearly visible fault of myocardial perfusion (MS-DP positive) and at least one stenosis of greater than 70 per cent by coronary arteriography. Coronary disease existed in 13 patients (38 per cent). Ten patients (29 per cent) had a positive MS-DP. The sensitivity and specificity of MS-DP in detecting coronary disease were 69 per cent and 95 per cent respectively. Its positive predictive value was 90 per cent. MS-DP was negative in all asymptomatic patients (19 per cent of them having coronary disease) and in 11 symptomatic patients (18 per cent of them having coronary disease). The low positive predictive value of angina (52 per cent) increased to 90 per cent when combined with a positive MS-DP. Because of relatively low sensitivity, basing indications for coronary arteriography before valve surgery on the results of MS-DP cannot be advised.     

Prevalence of Coronary Artery Disease in Patients with Valvular Heart Disease

ABSTRACT. To evaluate the usefulness of preoperative coronary angiography in patients undergoing preoperative investigation because of valvular heart disease, we performed coronary angiography in a consecutive series of 329 patients. The prevalence of significant coronary artery disease was 32%. Asymptomatic coronary artery disease was present in 13%. Angina pectoris proved to be a poor predictor of coronary artery disease in aortic valve disease. In mitral valve disease, however, the specificity was high. A cost-benefit calculation was carried out in order to assess what advantage routine coronary angiography might have. According to this, coronary angiography should be performed in all patients suffering from valvular heart disease with angina pectoris, whereas it can be omitted in younger patients without angina. A cut-off point of 60 years seems appropriate for aortic valve disease and 65 years for mitral valve disease.     

Prevalence of coronary disease in patients with aortic stenosis]

We analyzed a consecutive series of 188 patients, older than 44 years, with significant aortic stenosis, who underwent coronary arteriography (73 women and 115 men). There were 38 patients (20.2%) with coronary artery disease ( or = 50% reduction in the luminal diameter). Sixty-eight patients had typical angina pectoris, 52 atypical angina, and 68 did not have chest pain. We found to have coronary disease in 29.4%, 23.1% and 8.8% respectively. Sensitivity of typical angina to detect coronary disease was 52.6%, with an specificity of 68%, and a negative predictive value of 85%. Inclusion of atypical angina improved the sensitivity to 84.2%, and the negative predictive value to 91.2%, but lessened the specificity to 41.4%. Six patients among the 38 with coronary disease (15.7%), did not have chest pain, and 3 of them were younger than 60 years. We conclude that absence of angina is not enough to exclude coronary artery disease in patients 50 years old with aortic stenosis being considered for aortic valve replacement.     

Coronary Arteriography in Isolated Aortic and Mitral Valve Disease

Abstract: Coronary arteriography in isolated aortic and mitral valve disease. A. Saltups. Aust. N.Z. J. Med., 1982, 12 , pp. 494–497.
Coronary arteriographic findings in 200 patients with isolated aortic and mitral valve disease were reviewed to examine the relationship between obstructive (>50% diameter stenosis) coronary artery disease (CAD) and angina pectoris (AP).
Of 100 patients with aortic valve disease, 30 had CAD of whom 20 gave a history of AP. Thirty-two of 52 patients (61%) with AP did not have CAD and 10 of 48 (21%) had CAD without AP. CAD was evenly distributed among patients with aortic stenosis, incompetence and mixed aortic valve disease.
CAD was found in 23 of 100 patients with mitral valve disease. Sixteen of 32 patients with mitral incompetence had CAD of whom four had AP. Seven of 68 patients with mitral stenosis or mixed mitral valve disease had CAD. AP was noted by four of these seven patients but by none of the 61 with normal coronary arteriograms (p <0.0001). Asymptomatic CAD was more common among patients with mitral incompetence (12/28 vs 3/64 P<0.005).
AP was an unreliable marker for CAD in aortic valve disease or mitral incompetence. Conversely, CAD was uncommon without AP in mitral stenosis or mixed mitral valve disease.
Coronary arteriography seems indicated in the pre-operative assessment of patients aged40 years with aortic valve disease or mitral incompetence. Its value is limited in patients with mitral stenosis or mixed mitral valve disease without AP.     

Prevalence of coronary artery disease in patients with rheumatic heart disease in the current era

BACKGROUND: This study was undertaken to determine the prevalence of coronary artery disease in patients with rheumatic heart disease undergoing valve surgery. METHODS AND RESULTS: Consecutive patients with rheumatic heart disease (n=376) who were above the age of 40 years, and scheduled for valve surgery underwent diagnostic coronary angiogram to delineate coronary arteries. The patients were divided into three groups based on valve involvement (mitral valve, aortic valve, and combined aortic and mitral valve). Significant coronary artery disease was considered to be present if one or more coronaries showed 50% or more luminal stenosis. There were 287 (76.3%) males and 89 (23.7%) females. The mean age of the study population was 51.2+/-8.2 years. Eighty-nine (23.8%) patients had typical chest pain, 116 (30.6%) patients had atypical chest pain and 171 (45.5%) patients had no chest pain. Hypertension was noted in 88 (23.4%) patients, 65 (17.3%) patients had diabetes, 98 (26.1%) patients were smoker, and 66 (17.6%) patients had dyslipidemia, and 15 (4.0%) patients gave past history of myocardial infarction. Of the total 376 patients, 46 (12.2%) patients were found to have significant coronary artery disease. In patients with mitral vale disease the prevalence was 13.5% (13/96), while it was 15.3% (19/124) in patients with aortic valve disease and 9% (14/156) in those with combined mitral and aortic valve disease. CONCLUSIONS: Our results suggest that the overall prevalence of coronary artery disease in a group of patients with rheumatic heart disease undergoing valve surgery in the current era is 12.2%. This prevalence is much lower than the figures reported earlier in the Western literature.     

Rapid development of coronary arterial stenosis following valve replacement: an unusual cause of myocardial ischemia

A 56-year-old woman had unstable angina pectoris 3 months after aortic and mitral valve replacement for rheumatic heart disease. Repeat coronary arteriography revealed critical proximal left anterior descending and circumflex artery stenoses in previously normal coronary arteries. This case emphasizes the need for thorough evaluation of postoperative valvular patients, despite normal preoperative coronary arteriograms.     

Prevalence of significant coronary heart disease in valvular heart disease in Indian patients

Records of 326 patients were analysed to determine the prevalence of coronary heart disease (CHD) in patients with valvular heart disease (VHD) and to identify the group in whom coronary arteriography is essential. Significant CHD (60% or more luminal narrowing) was found in 7 per cent of cases, and its prevalence was 3 per cent in mitral, 10 per cent in aortic, and 6 per cent in combined mitral and aortic valve disease. Angina was present in 14 per cent of patients with mitral, 39 per cent with aortic, and 21 per cent with combined mitral and aortic valve disease. Seventy-three per cent of patients with CHD had angina whereas only 19 per cent with angina had CHD. The prevalence of CHD was higher in patients above 50 years (13%) and in males (98%) as compared to those below 50 years (3%) and females (none). We conclude that the prevalence of CHD is low in our patients with VHD. Routine coronary arteriography is recommended only in males over the age of 50 years.     

Coronary atherosclerosis in patients with acquired valvular disease

BACKGROUND: Coronary atherosclerosis often coexists with acquired valvular disorders. There is growing evidence in literature that these two conditions may have common aetiology. AIM: To assess the incidence of coronary atherosclerosis in patients with acquired valvular disorders and to compare clinical parameters as well as the prevalence of risk factors between patients with aortic and mitral valve diseases. METHODS: The study group consisted of 155 patients (101 males, 54 females, mean age 58.2+/-9.7 years) with acquired valvular disorder who between 2000 and 2002 underwent invasive cardiac evaluation in our department prior to planned cardiac surgery. Aortic stenosis was detected in 74 patients, aortic insufficiency -- in 26, mitral stenosis -- in 33, and mitral regurgitation -- in 14 subjects. All patients underwent clinical evaluation, echocardiography, coronary angiography and laboratory tests. RESULTS: Patients with aortic stenosis had similar prevalence of coronary atherosclerosis to patients with aortic insufficiency, and patients with mitral stenosis -- to patients with mitral regurgitation. When the two groups -- patients with aortic valve disease and patients with mitral valve disease were compared, significant coronary lesions were more often detected in patients with aortic valve disease (36% vs 12.8%, p<0.05). Also, patients with aortic valve disorder were older, predominantly of male gender, had more often angina but less often heart failure, and had higher total cholesterol level than patients with mitral valve disease. CONCLUSIONS: Significant coronary lesions are more frequently encountered in patients with aortic valve disorder than in those with mitral valve disease. A high prevalence of atherosclerotic risk factors in patients with aortic valve disease may suggest that this condition has similar aetiology to that of coronary artery disease.     

冠状动脉旁路移植术同期行瓣膜手术临床分析

目的总结在冠状动脉旁路移植术同期行心脏瓣膜手术的临床经验。方法30例患者在冠状动脉旁路移植术同期进行瓣膜手术,年龄40-76（62．9±10．4）岁。其中缺血性瓣膜病变22例,风湿性瓣膜病变8例。术前冠状动脉造影诊断26例,术中发现冠脉严重病变4例。全组共移植血管133支（平均4．43支）。同期行主动脉瓣置换术3例、二尖瓣置换术12例、二尖瓣成形术8例、双瓣膜手术7例。结果术后住院死亡1例（3．3％）,死于严重低心排血量。术后心功能Ⅰ级22例、Ⅱ级7例,均较术前明显改善。结论同期行冠状动脉旁路移植术和瓣膜手术安全、有效。冠心病与心脏瓣膜病同时存在明显加重了心肌损害,完善纠治瓣膜病变、充分心肌再血管化和严格的术中心肌保护是手术成功的关键。     

Significance of angina pectoris in aortic valve stenosis.

Of 60 patients aged 45 to 66 years with aortic valve stenosis, 28 (47 per cent) had angina pectoris. Significant coronary arterial obstruction was shown by selective coronary cineangiography in 14 of them. Systolic pressure gradients across the aortic valve were lower in patients with angina than in those without. In those with angina, systolic gradients were higher in those with normal coronary arteriograms than in those with demonstrable coronary arterial disease. Aortic valve replacement relieved the angina in all patients who had normal coronary arteriograms. When valve replacement was combined with coronary bypass grafting in those with coronary arterial disease, surgical mortality was higher and symptomatic relief less predictable. Incapacitating angina in patients with aortic stenosis was nearly always associated with significant coronary disease. In those with less severe angina it was impossible to predict the state of the coronary arteries. Two patients, who did not have angina and who did not undergo coronary arteriography, died after aortic valve replacement and were found at necropsy to have unsuspected severe coronary disease. We, therefore, suggest that coronary arteriography should be carried out in all patients over the age of 40 years in whom surgery is being considered for aortic stenosis.     

Should a Regurgitant Mitral Valve Be Replaced Simultaneously with a Stenotic Aortic Valve?

Mitral valve regurgitation frequently accompanies aortic valve stenosis. It has been suggested that mitral regurgitation improves after aortic valve replacement alone and that the mitral valve need not be replaced simultaneously Furthermore, mitral regurgitation associated with coronary artery disease, particularly in patients with poor left ventricular function, shows immediate improvement after coronary artery bypass grafting. We studied 60 consecutive patients with aortic stenosis and mitral regurgitation to determine the degree of improvement in mitral regurgitation after aortic valve replacement alone versus aortic valve replacement combined with coronary artery bypass grafting. Thirty-six of the patients had normal coronary arteries (Group 1); the other 24 had symptomatic coronary artery disease requiring bypass surgery (Group 2). Echocardiography was performed preoperatively, 1 week postoperatively, and at follow-up. In Group 1, left ventricular ejection fraction did not improve early or at 2.5 months postoperatively, but mitral regurgitation improved gradually during follow-up. In Group 2, mitral regurgitation showed improvement 1 week postoperatively (p < 0.001), and left ventricular ejection fraction was improved at 2.5 months. We conclude that patients with aortic valve stenosis and mild-to-severe mitral regurgitation, without echocardiographic signs of chordal or papillary muscle rupture and without coronary artery disease, should undergo aortic valve replacement alone. The mitral regurgitation will remain the same or improve. For patients with coexisting coronary artery disease, simultaneous aortic valve replacement and coronary artery bypass grafting are imperative; however, the mitral valve again requires no intervention, since mitral regurgitation improves significantly after the other 2 procedures.     

Significance of angina pectoris in aortic valve stenosis.

Of 60 patients aged 45 to 66 years with aortic valve stenosis, 28 (47 per cent) had angina pectoris. Significant coronary arterial obstruction was shown by selective coronary cineangiography in 14 of them. Systolic pressure gradients across the aortic valve were lower in patients with angina than in those without. In those with angina, systolic gradients were higher in those with normal coronary arteriograms than in those with demonstrable coronary arterial disease. Aortic valve replacement relieved the angina in all patients who had normal coronary arteriograms. When valve replacement was combined with coronary bypass grafting in those with coronary arterial disease, surgical mortality was higher and symptomatic relief less predictable. Incapacitating angina in patients with aortic stenosis was nearly always associated with significant coronary disease. In those with less severe angina it was impossible to predict the state of the coronary arteries. Two patients, who did not have angina and who did not undergo coronary arteriography, died after aortic valve replacement and were found at necropsy to have unsuspected severe coronary disease. We, therefore, suggest that coronary arteriography should be carried out in all patients over the age of 40 years in whom surgery is being considered for aortic stenosis.