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Coronary artery disease remains rare (6% of all cardiovascular disease) in black Africa despite its progression in recent years. Infarcts in black Africans have similar characteristics to those seen in Western countries in patients aged under 40, notably regarding the frequency of infarcts as the first manifestation of the disease, the small number of stenoses and the incidence (18%) of patients with normal coronary arteriography (spasm? thrombosis?). Risk factors are the same as in Western countries, but the hemoglobin S or C trait could be a predisposing factor. The long-term outcome of infarcts is severe because of notable myocardial sequelae of imprecise origin: delayed hospitalisation and absence of thrombolysis? absence of angioplasty? socio-economic problems and lack of health education.
BACKGROUND: Currently recognized risk factors for coronary artery disease have been identified primarily from investigations of white populations. In this investigation, we estimated mortality rates for coronary disease and for any cause and identified risk factors for death from coronary disease among whites and blacks. METHODS: Data collected over a 30-year period in the Charleston Heart Study were used to estimate mortality rates and quantify associations with risk factors assessed at the base-line examination in 1960 and 1961 of 653 white men, 333 black men, 741 white women, and 454 black women. RESULTS: There were no significant racial differences in the rate ratios for death from coronary disease; however, women had significantly lower death rates than men. Over the 30-year period, the mortality rates for coronary disease per 1000 person-years were 5.2 for white men (95 percent confidence interval, 4.1 to 6.3), 4.6 for black men (3.0 to 6.2), 2.1 for white women (1.6 to 2.6), and 3.2 for black women (2.3 to 4.0). Significant, or nearly significant, predictors of mortality due to coronary disease were systolic blood pressure in all four groups; serum cholesterol level among white men, white women, and black women; and smoking among white men, white women, and black men. Although the difference was not statistically significant, the risk of death from coronary disease was consistently increased among diabetics in all four groups. A higher level of education was predictive of lower rates of death due to coronary disease among white men and black women. For all causes of death taken together, the rates for blacks were higher than the rates for whites. The presence of hypertension, a history of smoking, and a history of diabetes were significant or nearly significant predictors of mortality from any cause in all four groups. CONCLUSIONS: Although the rates of death from coronary disease were somewhat lower among black men than white men and higher among black women than white women, the black:white mortality rate ratios were not statistically significant, and the major risk factors for mortality from coronary disease were similar in blacks and whites in the 30-year follow-up of the Charleston Heart Study.
A 66-year-old-man with carotid stenosis complicated by coronary disease is reported. He suffered from mild motor weakness on the right side and speech disturbance. Radiological examination revealed 90% stenosis at the cervical portion of the left internal carotid artery, and two-vessel coronary disease. In order to prevent intraoperative cardiac stroke, initial percutaneous coronary angioplasty (PTCA), was performed and the subsequent carotid endarterectomy (CEA) was performed successfully. Preoperative symptoms gradually improved and he was discharged as ambulatory. Because atherosclerosis is always systemic, patients with carotid artery disease should be examined for coronary disease. We recommend greater use of coronary angiography and, when a lesion is found, the use of PTCA, which is a safer method in terms of preventing intraoperative cardiac stroke of CEA than any other method.
Coronary occlusive disease following cardiac transplantation is monitored using serial angiography, and graded on a 3 point scale according to the amount of narrowing observed in major vessels. Disease progression is modelled as a continuous time Markov process. The Gibbs sampler is used to estimate the marginal posterior distributions of the transition rates between grades of disease and from each grade to death.
This report describes a method of using Bayes Theorem for determining the post-test likelihood for coronary disease from the exercise test. The pre-test likelihood is determined from the age, sex, and type of chest pain. Discriminant analysis of the amount of S-T depression, maximum pressure rate product and sex of the patient is then used to determine the sensitivity and specificity of the patient's exercise test for coronary artery disease. The post-test likelihood for coronary artery disease can then be calculated using Bayes Theorem. The discriminant function was estimated from a training set of 174 patients. This was then applied to 113 new patients who had both exercise tests and coronary arteriograms. In this new set, 47 patients had a post-test likelihood of 90% or greater for coronary disease. Only one of these patients had normal coronary arteriograms, a predictive accuracy of 98%. Of the 25 patients with a post-test likelihood of 10% or less for coronary disease, four had multivessel disease and four had single vessel disease. The predictive accuracy for the absence of coronary disease was 68%. The predictive accuracy for the exclusion of multivessel disease was 84%. Eight of 10 patients with left main disease had a post-test likelihood for coronary disease of greater than 90%.
To assess the likelihood of procedural success in patients with multivessel coronary disease undergoing percutaneous coronary angioplasty, 350 consecutive patients (1,100 stenoses) from four clinical sites were evaluated. Eighteen variables characterizing the severity and morphology of each stenosis and 18 patient-related variables were assessed at a core angiographic laboratory and at the clinical sites. Most patients had Canadian Cardiovascular Society class III or IV angina (72%) and two-vessel coronary disease (78%). Left ventricular function was generally well preserved (mean ejection fraction, 58 +/- 12%; range, 18-85%) and 1.9 +/- 1.0 stenoses per patient had attempted percutaneous coronary angioplasty. Procedural success (less than or equal to 50% final diameter stenosis in one or more stenoses and no major ischemic complications) was achieved in 290 patients (82.8%), and an additional nine patients (2.6%) had a reduction in diameter stenosis by 20% or more with a final diameter stenosis 51-60% and were without major complications. Major ischemic complications (death, myocardial infarction, or emergency bypass surgery) occurred in 30 patients (8.6%). In-hospital mortality was 1.1%. Stepwise regression analysis determined that a modified American College of Cardiology/American Heart Association Task Force (ACC/AHA) classification of the primary target stenosis (with type B prospectively divided into type B1 [one type B characteristic] and type B2 [greater than or equal to two type B characteristics]) and the presence of diabetes mellitus were the only variables independently predictive of procedural outcome (target stenosis modified ACC/AHA score; p less than 0.001 for both success and complications; diabetes mellitus: p = 0.003 for success and p = 0.016 for complications). Analysis of success and complications on a per stenosis dilated basis showed, for type A stenoses, a 92% success and a 2% complication rate; for type B1 stenoses, an 84% success and a 4% complication rate; for type B2 stenoses, a 76% success and a 10% complication rate; and for type C stenoses, a 61% success and a 21% complication rate. The subdivision into types B1 and B2 provided significantly more information in this clinically important intermediate risk group than did the standard ACC/AHA scheme. The stenosis characteristics of chronic total occlusion, high grade (80-99% diameter) stenosis, stenosis bend of more than 60 degrees, and excessive tortuosity were particularly predictive of adverse procedural outcome. This improved scheme may improve clinical decision making and provide a framework on which to base meaningful subgroup analysis in randomized trials assessing the efficacy of percutaneous coronary angioplasty.
CONTEXT: Coronary atherosclerosis in acromegaly was not extensively investigated in the literature until now. At autopsy, it was demonstrated in about 20% of patients with long-lasting disease, and myocardial infarction was reported as cause of death in a quarter of acromegalics. OBJECTIVE: The objective of the study was to evaluate coronary atherosclerosis in a cohort of acromegalics with controlled or uncontrolled disease. DESIGN: Coronary risk was evaluated by the Framingham algorithm, according to the Framingham score (FS). Patients were stratified into low (<6%), intermediate (6-20%), and high (>20%) midterm risk. Coronary calcium deposits were detected by multidetector computed tomography and measured by the Agatston algorithm. Coronary artery calcium [Agatston score (AS)] was quantified at the level of left main artery, left anterior descendent artery, left circumflex artery, right coronary artery, and posterior descendent artery. Total AS values in healthy persons are less than 50 (aged < 60 yr) and less than 300 (age > or = 60 yr). PATIENTS: Thirty-nine patients (12 males and 27 females, aged 53.0 +/- 2.1 yr) were evaluated. In each patient, the mean of at least four determinations of serum IGF-I, assayed during the last 2 yr before study, was normalized for the age-matched normal range, and the result was presented as sd value (IGF-I sd). On the basis of serum IGF-I sd, acromegaly was considered controlled (< or =1.9 sd; n = 24) or uncontrolled (> or = 2.0 sd; n = 15). RESULTS: The FS was intermediate in 12 and high in two acromegalics. Overall, the FS was not correlated with serum GH values and IGF-I sd. Mean FS was not significantly different between patients with controlled and uncontrolled acromegaly. Total AS was increased in nine patients, most frequently in left anterior descendent, left circumflex, and left main arteries. In these nine patients, mean AS was similar in individuals with controlled and those with uncontrolled acromegaly, and the rate of 17% patients with controlled disease having increased AS was not statistically different from the rate of 33% uncontrolled acromegalics. Total AS was increased in six of 12 males and in three of 27 females (chi(2) 7.1, P < 0.01). Overall, total AS correlated with FS (r(2) = 0.4, P < 0.0002) but not age, body mass index, disease duration, indexed left ventricular mass, serum cholesterol, triglycerides, GH, or IGF-I levels. Increased AS was more frequently observed in acromegalics with diabetes mellitus (chi(2) = 5.2, P < 0.05) or hypertension (chi(2) = 9.8, P < 0.002) but not in smokers (chi(2) = 1.34, P = NS). Seven of nine patients with coronary calcium deposits had a FS greater than 6%. In six of 13 patients with FS greater than 6%, multidetector computed tomography did not demonstrate coronary calcifications. CONCLUSIONS: In our study, the integrated evaluation of FS and AS showed that 41% of acromegalics are at risk for coronary atherosclerosis and that coronary calcifications were evident in about half of them despite the fact that myocardial infarction was not more frequent in acromegalic patients than the general population. Moreover, the control of acromegaly did not influence significantly the extent of coronary atherosclerosis.
Single-vessel coronary disease has been considered so far a benign condition, for which the medical therapy may represent the optimal treatment. In order to assess the effectiveness of this approach, we studied 323 patients who had come to our attention for ischemic heart disease and resulted affected by single-vessel coronary artery disease. From our data it appears that single-vessel coronary artery disease is frequently associated with myocardial infarction and post-infarction aneurysm. Coronary angiography indicated that left anterior descending coronary artery is the most frequently affected vessel, and that its involvement is often associated with lethal outcome. Forty-two out of the 323 patients underwent coronary artery bypass surgery; the remaining patients were medically treated. Surgical patients showed a better improvement respect to the medical group, while survival was not statistically different. An unexpected result was the relatively high risk in circumflex artery lesion. These data may justify a broader utilization of invasive therapy in recent onset angina, in light of the excellent results recently obtained with percutaneous transluminal coronary angioplasty.
The authors studied 31 cases of coronary artery disease with normal or minimally diseases coronary arteries in black Africans, 29.8% of 104 coronary patients undergoing coronary angiography in this series. These 31 cases comprised 16 cases of infarction, 10 cases of angina, 3 ventricular aneurysms and 2 cases of silent ischemia in diabetic patients. Twenty-five patients were men (80.6%). There were 6 women (19.3%) two of whom presented in the post-partum period. The average age of these patients was 45 years (males: 47.7 years; females: 41.8 years). The following risk factors were noted: smoking (60%), hypertension (25.8%), obesity (29%), diabetes (12.9%), serum cholesterol (average 2.15 g/l), serum triglycerides (average 1.25 g/l). The risk index per patient was 1.29. In comparison with coronary patients with angiographic coronary lesions (n = 73), the patients with normal angiography were significantly younger, comprised more females and had fewer risk factors (especially hypertension and diabetes), though this was not statistically significant. The prevalence of inaugural infarction was 81.2% in the cases of infarction with normal coronary arteries. These infarcts may be complicated by ventricular aneurysm formation. Spontaneous spasm was observed in 3 out of 31 patients (9.6%) at coronary angiography. A provocative test was performed in only 2 cases and 1 was positive. This deserves further study and may have therapeutic implications. The authors emphasise the high incidence of hemoglobin S or C traits (57.1%). These heterozygotic hemoglobinopathies could be a risk factor in these coronary patients with normal coronary angiography.
AIMS: To assess hypertension control in patients with stable coronary disease in France. DESIGN: A cross sectional study was conducted in a representative sample of 794 cardiologists. PARTICIPANTS: The first 6 patients with coronary disease received at practitioner's office were included. MAIN OUTCOME MEASURES: Cardiovascular risk factors, antihypertensive drugs, cardiovascular history were reported. BP was measured. Patients considered as hypertensive by his cardiologist and receiving antihypertensive drugs were considered as hypertensive. Controlled hypertension was defined as a blood pressure < 140/90 mmHg. Uncontrolled hypertension was defined as blood pressure > or = 140/90 mmHg. Among the uncontrolled hypertensives we distinguished patients with isolated systolic hypertension: diastolic blood pressure < 90 mmHg and systolic blood pressure > or = 140 mmHg. RESULTS: All variables were available in 6,349 patients who form the basis of this report. 3,161 patients were hypertensive. Of them, 1,846 (58.4%) were uncontrolled hypertensives, whom 1,280 (69.3%) were uncontrolled on the basis of systolic blood pressure alone. CONCLUSION: This study conducted in a representative sample of French cardiologists indicates that there is a considerable potential to further reduce cardiovascular morbidity in patients in secondary prevention.
Despite the proven benefits of many cardiac procedures, some are used less frequently for African Americans than for white patients with known or suspected coronary disease. This study explored differences between ethnic groups that may affect patient recall of physician recommendations of cardiac procedures. Also examined were patients' responses when asked about adhering to those recommendations. The data examined were collected from interviews with 1,333 African American and white hospital inpatients with known coronary disease admitted to the Birmingham-Black Health Seeking for Coronary Heart Disease Project (1989-1990) in Alabama. Respondents were asked to recall previous health care encounters, physician recommendations of cardiac procedures, and adherence to those recommendations. Compared with whites, fewer African American patients recalled physicians recommending some cardiac procedures. If procedure recommendations were recalled, no ethnic differences were found in patient recall of adhering to those recommendations. Predictors of recall of the recommended procedures were identified by multivariate logistic regression. Patients' knowledge of having coronary disease was the common factor that predicted their recall of all cardiac procedures. Other predictor variables included some cardiac risk factors and symptoms, socioeconomic status, and ethnicity. Although health care practice is influenced by many factors, it is important to examine variables that may lead to a reduction in ethnic disparities in coronary disease morbidity and mortality.
Previous studies have shown that the interleukin-2-induced propagation of lymphocytes from endomyocardial biopsy specimens, an indicator of cellular rejection, is associated with the development of graft coronary disease in heart transplant patients. To further investigate the concept of cell-mediated immune responses in graft coronary disease, we have applied the methodologies of interleukin-2-induced propagation of lymphocytes from arterial tissues. In a group of 23 patients, which included 6 heart, 6 kidney, and 11 liver transplant recipients, we observed that arterial lymphocyte growth was significantly associated with obliterative vasculopathy (p less than 0.03). T-cell phenotyping analysis of coronary artery-derived lymphocyte cultures from three heart transplant patients with graft coronary disease showed significant numbers of CD4, CD8 double-negative T cells and T-cell receptor-gamma delta cells, especially when the cultures were established with relatively high doses of 400 U/ml of interleukin-2. These data suggest that the subset of CD4-CD8-, T cell receptor-gamma delta+ T cells may play a role in the pathogenesis and progression of graft coronary disease.
PURPOSE: To assess the effects of physician specialty on the knowledge, management, and outcomes of patients with coronary disease or heart failure. MATERIALS AND METHODS: We performed a systematic search of MEDLINE from 1980 to 1997, as well as bibliographic references to articles about the effects of physician specialty on the knowledge, treatment, and outcomes of patients with coronary disease or heart failure in the United States. RESULTS: Twenty-four articles met our criteria for inclusion (including eight that involved knowledge or self-reported practices, 14 that described actual practice patterns, and six that measured clinical outcomes). Cardiologists were more knowledgeable than generalist physicians about the optimal evaluation and management of coronary disease but not about the use of angiotensin-converting enzyme (ACE) inhibitors for heart failure. Patients with unstable angina or myocardial infarction were more likely to receive proven medical therapies, and possibly had improved outcomes, if they were treated by cardiologists. The use of lipid-lowering drugs after myocardial infarction was also more common among patients of cardiologists. ACE inhibitor use for heart failure was probably greater, and short-term readmission rates were lower, with cardiology care. CONCLUSIONS: Patients with coronary disease or heart failure in the United States who are treated by cardiologists appear more likely to receive evidence-based care and probably have better outcomes. Investigation of collaborative models of care and innovative efforts to improve the use of proven therapies by physicians are needed.
BACKGROUND: A family history of premature coronary artery disease (CAD) in a first-degree relative is an independent risk factor for coronary disease. Both genetic and environmental influences are likely to be responsible and may interact, but their relative importance is unclear. METHODS AND RESULTS: We studied endothelial function in 50 first-degree relatives (31 men, 19 women; mean age, 25+/-8 years) of patients (men < or = 45 years, women < or = 55 years) with proven CAD. All subjects were well, lifelong nonsmokers, not diabetic, and not hypertensive and took no medications. Using high-resolution external vascular ultrasound, we measured brachial artery diameter at rest and in response to reactive hyperemia (with increased flow causing an endothelium-dependent vasodilatation) and to sublingual glyceryltrinitrate (GTN, an endothelium-independent dilator). Vascular responses were compared with those of 50 healthy control subjects matched for age and sex. Flow-mediated dilatation (FMD) was impaired in the family history group (4.9+/-4.6% versus 8.3+/-3.5% in control subjects, P<.005). In contrast, GTN caused dilatation in all subjects (family history, 17.1+/-8.8%; control subjects, 19.0+/-6.3%; P=NS), suggesting that reduced FMD was due to endothelial dysfunction. When the family history subjects were subdivided, those found to have a serum cholesterol > 4.2 mmol/L (group A, n=10) had mildly impaired FMD compared with control subjects (5.5+/-5.1% versus 8.3+/-3.5%). In others whose affected relative had coronary risk factors (group B, n=24), FMD was also only slightly reduced (6.2+/-4.8% versus 8.3+/-3.5%). In contrast, subjects with no risk factors and whose affected relative had a normal cardiovascular risk factor profile (group C, n=16) had markedly impaired FMD (2.9+/-3.7% versus 8.3+/-3.5%). Although ANOVA of the three family history subgroups did not reach statistical significance (F=2.55, P=.09), pairwise analysis showed that FMD in group C was significantly impaired compared with group B (P=.026). CONCLUSIONS: Healthy young adults with a family history of premature coronary disease may have impaired endothelium-dependent dilatation, even in the absence of other cardiovascular risk factors. Those subjects, who were free of risk factors and whose affected first-degree relative was free of risk factors, had the most impaired endothelial function, suggesting a genetic influence on early arterial physiology that may be relevant to later clinical disease.
Percutaneous transluminal coronary angioplasty (PTCA) has an important therapeutic role in the treatment of coronary artery disease. The purpose of this study was to investigate the role of 201Tl scintigraphy in symptomatic patients with multi-vessel coronary artery disease undergoing angioplasty who had previously undergone coronary graft operations. 201Tl imaging was carried out in 12 patients prior to PTCA, 6 weeks and 6 months to 1 year post-PTCA. Prior to PTCA, 201Tl imaging correctly identified the site of the dominant lesion in all patients in correlation with the catheter results. Six weeks post-PTCA, seven cases who had angiographically successful angioplasty showed persistent defects on 201Tl imaging. In five of these cases, follow-up catheter showed that re-stenosis had occurred. Six months to 1 year post-PTCA, 201Tl imaging was found to have good correlation (11 out of 12 patients) with the catheter results. The results suggest that 201Tl imaging is useful in the management of patients with multi-vessel disease undergoing angioplasty.
Cardiologists have traditionally focused on coronary narrowing as seen on angiography and have orientated treatment towards bypassing these lesions or widening them with angioplasty. In patients with stable coronary artery disease, percutaneous coronary interventions reliably relieve angina and myocardial ischemia, but do not prevent myocardial infarction or reduce mortality. Cholesterol lowering therapy has been shown, in several large, randomized trials reported over the past decade, to reduce mortality and coronary events, including the need for revascularization in a broad spectrum of patients. Mechanical and metabolic treatments for coronary disease should be used synergistically.
A borderline left main narrowing was discovered during coronary angiography in a young asymptomatic man with positive stress test. IVUS demonstrated minimal diameter of 2.9 mm and the cross-sectional area was 11.5 mm(2). CTs were performed, and an eccentric calcific plaque was imaged at the ostium of the left main. Based on all three image modalities after discussing the different therapeutic options with the patient he was referred for bypass surgery.