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PubMed2005

Rheumatoid arthritis is an independent risk factor for multi-vessel coronary artery disease: a case control study.

The risk for cardiovascular (CV) disease is increased in rheumatoid arthritis (RA) but data on the burden of coronary atherosclerosis in patients with RA are lacking. We conducted a retrospective case-control study of Olmsted County (MN, USA) residents with RA and new-onset coronary artery disease (CAD) (n = 75) in comparison with age-and sex-matched controls with newly diagnosed CAD (n = 128). Angiographic scores of the first coronary angiogram and data on CV risk factors and CV events on follow-up were obtained by chart abstraction. Patients with RA were more likely to have multi-vessel coronary involvement at first coronary angiogram compared with controls (P = 0.002). Risk factors for CAD including diabetes, hypertension, hyperlipidemia, and smoking history were not significantly different in the two cohorts. RA remained a significant risk factor for multi-vessel disease after adjustment for age, sex and history of hyperlipidemia. The overall rate of CV events was similar in RA patients and controls; however, there was a trend for increased CV death in patients with RA. In a nested cohort of patients with RA and CAD (n = 27), we measured levels of pro-inflammatory CD4+CD28null T cells by flow cytometry. These T cells have been previously implicated in the pathogenesis of CAD and RA. Indeed, CD4+CD28null T cells were significantly higher in patients with CAD and co-existent RA than in controls with stable angina (P = 0.001) and reached levels found in patients with acute coronary syndromes. Patients with RA are at increased risk for multi-vessel CAD, although the risk of CV events was not increased in our study population. Expansion of CD4+CD28null T cells in these patients may contribute to the progression of atherosclerosis.

Angina Pectoris↗
PubMed1989

Effect of exercise protocol and lead selection on the accuracy of heart rate-adjusted indices of ST-segment depression for detection of three-vessel coronary artery disease.

To assess the effect of exercise protocol and number of monitoring leads on the ability of the ST/HR slope and delta ST/HR index to identify three-vessel coronary artery disease, the exercise ECGs of 50 patients who had coronary arteriography were reviewed. Test performance of the ST/HR slope using the Cornell exercise protocol with 13 leads was compared with performance obtained from the standard 12 leads and from sets of only 3 leads, as well as with test outcome using Bruce protocol equivalent stages with multiple-lead sets. ST/HR slopes could be calculated in 100% of patients using data from the Cornell protocol, but in only 80% of patients using the Bruce protocol with 13 leads (chi 2 = 8.1, p less than 0.005) and 54% of patients using the Bruce protocol with 3 leads (chi 2 = 21.0, p less than 0.001). With the Cornell protocol and 13 leads, an ST/HR slope partition of 6.0 microV/bpm identified three-vessel disease with a sensitivity of 96%, specificity of 58%, and overall test accuracy of 76%. At matched specificity, the Bruce protocol 13-lead ST/HR slope partition of 5.0 microV/bpm had a sensitivity of only 48% and overall test accuracy of 53% for three-vessel disease in those patients with calculable test outcomes (each p less than 0.01). Receiver operating characteristic curve analysis confirmed the superior performance of data acquired with the Cornell protocol and demonstrated no significant loss of Cornell ST/HR slope performance calculated from fewer monitored leads. Performance of the delta ST/HR index was similar with 3 leads and with 13 leads.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary Disease↗
PubMed1991

201Tl scintigraphy in the assessment of patients with multi-vessel coronary disease undergoing angioplasty who have previously had a coronary bypass graft operation.

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.

Aged↗
PubMed2002

Plasma level of homocysteine is inversely-associated with the development of collateral circulation in patients with single-vessel coronary artery disease.

Homocysteine induces endothelial injury and inhibits endothelial cell proliferation, which is a key role in angiogenesis. The purpose of this study was to investigate whether the plasma level of homocysteine is associated with the development of collaterals in patients with single-vessel coronary artery disease (CAD). Among a series of 105 male patients with angiographic estimation, 49 with single-vessel CAD were intensively investigated. Development of collaterals was classified by Rentrop's method. Univariate and multivariate analyses revealed that hyperhomocysteinemia negatively affected the development of collaterals (p=0.0015 and 0.0011, odds ratio 0.69, 95% confidence interval 0.52-0.90), whereas the duration of angina and percent stenosis evaluated by quantitative coronary angiography had a positive affect. Moreover, the level of homocysteine in the group with poorly developed collaterals (n=7, Rentrop class 0 and 1) was significantly higher than that in the group with well-developed collaterals (n=12, Rentrop class 2 and 3) of the patients with single-vessel disease showing total occlusion (p=0.034). This study clearly demonstrates that the plasma level of homocysteine is independently and inversely associated with the development of collateral circulation in CAD patients. Homocysteine might be a new undesirable aspect of ischemic heart disease through its inhibition of collateral development.

Adult↗
PubMed1989

Relation between exertional ischemia and prognosis in mildly symptomatic patients with single or double vessel coronary artery disease and left ventricular dysfunction at rest.

The randomized multicenter trials indicate that survival in patients with coronary artery disease and left ventricular dysfunction is enhanced by surgical therapy compared with medical therapy. This beneficial effect of coronary bypass surgery was demonstrated in patients with either three vessel or left main coronary artery disease, but not in those with one or two vessel disease. To determine whether subgroups of mildly symptomatic patients with one or two vessel coronary artery disease and left ventricular dysfunction have an increased risk of death or cardiac events during medical therapy, 53 consecutive patients with angiographically defined one or two vessel disease and impaired left ventricular function (ejection fraction 20% to 40%) were studied by exercise electrocardiography (ECG) and rest and exercise radionuclide angiography. All but two patients had previous myocardial infarction, and all were asymptomatic or only mildly symptomatic during medical therapy. By univariate life table analysis, mortality during medical therapy was associated significantly with the ST segment response to exercise (p less than 0.05) and with both the exercise ejection fraction (p less than 0.05) and the magnitude of change in ejection fraction with exercise (p less than 0.005). In patients with an exercise ejection fraction greater than 30%, the probability of survival at 6 years was 97 +/- 3% (+/- SE) compared with a survival rate of 62 +/- 14% in the remaining subjects (p less than 0.005). Similarly, 6 year survival was 100% in patients whose ejection fraction increased from the value at rest but was only 74 +/- 10% in the remaining patients (p less than 0.005). Exercise capacity was not associated with survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2005

[Combined approach to the treatment of severe aortic stenosis and to three coronary vessel diseases in patients with brain meningioma and severe stenosis of internal carotid artery].

The authors present a case report of a 76-year-old man with a simultaneous finding of severe aortic stenosis, three coronary vessel diseases, severe stenosis of internal carotid artery and brain meningioma. The patient was scheduled for carotid endarterectomy 2 months prior the aortic valve replacement and coronary artery bypass grafting. Brain meningioma was removed 3 months after the cardiac procedure. The authors present a successful interdisciplinary co-operation in the treatment strategy.

Aged↗
PubMed2003

Acute two-vessel coronary closure in a patient with Down's syndrome.

Myocardial infarctions are rare in patients with Down's syndrome. This paper reports an unusually aggressive presentation of two-vessel simultaneous coronary occlusion during an intended percutaneous intervention. Since survival in patients with Down's syndrome is improving, encounters with late (and perhaps unusual) sequelae of coronary artery disease are expected to increase.

Adult↗
PubMed2000

Accuracy of dobutamine technetium 99m sestamibi SPECT imaging for the diagnosis of single-vessel coronary artery disease: comparison with echocardiography.

BACKGROUND: Recent experimental studies have shown that technetium 99m methoxyisobutyl isonitrile (MIBI) underestimates flow heterogeneity induced by dobutamine and that this might have an impact on the sensitivity of dobutamine MIBI in patients with single-vessel coronary artery disease (CAD). This study compares the accuracy of dobutamine MIBI single-photon emission computed tomography (SPECT) and simultaneous echocardiography in the diagnosis of single-vessel CAD. METHODS AND RESULTS: Ninety-one patients (age 57 +/- 12 years) with single-vessel CAD or without significant CAD were studied with dobutamine (up to 40 microg/kg per minute)-atropine (up to 1 mg) stress echocardiography (DSE) and simultaneous MIBI SPECT imaging. CAD was predicted on the basis of myocardial ischemia (transient wall motion abnormalities by DSE and reversible perfusion defects by MIBI). Ischemia was detected by MIBI in 30 of the 54 patients with and in 10 of the 37 patients without significant single-vessel CAD (sensitivity 56%, confidence interval [CI] 45 to 66; specificity 73%, CI 64 to 82; accuracy 63%, CI 53 to 73). Ischemia was detected by DSE in 30 patients with and in 6 patients without significant CAD (sensitivity of DSE 56%, CI 45 to 66; specificity 84%, CI 76 to 91; accuracy 67%, CI 57 to 77, P = not significant vs MIBI). For both imaging methods, sensitivity was significantly higher in patients with left anterior descending than in patients with left circumflex or right coronary artery stenosis (75% vs 40%, P <.05). The addition of echocardiography to MIBI did not improve the diagnostic accuracy (68% CI 59 to 78, P = not significant vs DSE or MIBI alone). CONCLUSIONS: DSE and MIBI SPECT imaging have similar moderate sensitivity for the diagnosis of single-vessel CAD. Sensitivity of each of these techniques is higher in patients with left anterior descending than in patients with left circumflex or right coronary artery stenosis. There is no improvement of diagnostic accuracy by use of the combination of both techniques.

Aged↗
PubMed1986

[Functional state of the heart in patients with hypertension and varying degrees of atherosclerosis of the coronary vessels].

Twenty-five patients with stable arterial hypertension associated with the painful syndrome in the heart region were examined. In addition to the general clinical examination, all the patients were subjected to echocardiography, bicycle ergometry, and coronaroangiography. According to the character of alterations in the coronary arteries the patients were distributed into 3 groups. The first group comprised the patients with angiographically intact coronary arteries, the second the patients with initial atherosclerosis of the coronary arteries. The third group included the patients with disseminated atherosclerosis of the coronary arteries. In accordance with the bicycle ergometry data, the coronary insufficiency associated with essential hypertension was primarily related to the disseminated atherosclerosis of the coronary arteries. However, in cases of marked hypertrophy of the left ventricle the patients could develop relative coronary insufficiency. The pump and total contractile function of the myocardium remained satisfactory in all the examinees. In the third group patients, however, there were alterations in the local contractility as shown by the ventriculography findings. The diastolic function of the myocardium of the left ventricle was disordered in all the patients examined, while alterations in that function correlated with an increase in the mass of the left ventricle myocardium whatever the degree of changes in the coronary vessels.

Adult↗
PubMed1976

Periaortic denervation in reconstructive surgery of coronary vessels.

Stimulation of sympathetic nervous conductive pathways and ganglia innervating the heart leads to a sudden increase in the cardiac performance and to a qualitative change in the phasic blood flow within the coronary vascular bed. This so-called malignant increase in the blood flow is accompanied by relative coronary insufficiency and increased mechanical stress imposed upon the coronary arteries. A denervation operation according to Arnulf does not prevent the propagation of excitation from the right stellate ganglion to the heart. A complete denervation is obtained by additional cutting of the right-side postganglional fibres. Then in a dog no changes occur in the coronary arterial blood flow measured at rest during the operation. In reconstructive surgery of coronary vessels in man, after denervation the peroperative blood flow in the aortocoronary bypass to the anterior interventicular branch increases. After a surgical denervation operation, the prevention of propagation of sudden neurogenic stimuli via the cervical sympathetic segment to the heart ventricles is the most striking result. Such a "protection" of the heart might retard the development rate of coronary insufficiency accompanying the ischaemic heart disease.

Animals↗
PubMed1985

Vectorcardiograms in dilated cardiomyopathy and triple vessel coronary artery disease: a comparative study by ventricular gradient.

An analysis using vectorcardiography and left ventriculography was made on forty patients, 17 of whom had dilated cardiomyopathy (DCM), 14 with triple vessel coronary artery disease (CAD) and 9 control subjects. QRS deflection area vector (Aqrs) was directed the most posteriorly in the DCM group and the second most posteriorly in the CAD group. Ventricular gradients (G) were smaller in the DCM and CAD groups than in the control group and directed more posteriorly in the DCM group than in the CAD and control groups. G/Aqrs was the smallest in the DCM group and the second smallest in the CAD group. Aqrs-At Angle was the widest in the DCM group and the second widest in the CAD group. Left ventricular ejection fraction (EF) showed high correlations with the azimuth of Aqrs (r = 0.659), with the magnitude of G (r = 0.720), with G/Aqrs (r = 0.785) and with Aqrs-At Angle (r = -0.855). From this evidence, we conclude that the magnitude of G, G/Aqrs and Aqrs-At Angle have a definable relationship with the impairment of left ventricular function and the Aqrs-At Angle is an especially useful parameter to detect the grade of myocardial damage in both the DCM and CAD groups.

Adult↗
PubMed2005

Myocardial perfusion after angioplasty in patients suspected of having single-vessel coronary artery disease: improvement detected at rest-stress first-pass perfusion MR imaging--initial experience.

PURPOSE: To prospectively assess myocardial perfusion before and after successful intervention in patients suspected of having single-vessel coronary artery disease by using a steady-state free precession (SSFP) perfusion magnetic resonance (MR) imaging sequence. MATERIALS AND METHODS: Local ethics committee approval and informed consent were obtained. Rest-stress perfusion MR imaging studies were performed in 18 patients with coronary artery disease (12 men, six women; mean age, 58.6 years +/- 13.6 [standard deviation]; range, 30-79 years) at 1.5 T with a multisection saturation-recovery SSFP sequence and 0.025 mmol gadopentetate dimeglumine per kilogram of body weight. MR studies were performed before (n = 18), several days after (n = 18), and 8 months after (n = 10) coronary intervention. Nine patients underwent percutaneous transluminal coronary angioplasty (PTCA) alone, and nine patients underwent PTCA with stent placement. Myocardial perfusion reserve index (MPRI) was calculated by dividing results of myocardial perfusion at maximal vasodilation by results at rest. The standard for myocardial perfusion was technetium 99m tetrofosmin single photon emission computed tomography. Statistical significance was tested with univariate variance analysis and Student t tests. RESULTS: In the area of the stenosed vessel, MPRI was 1.04 +/- 0.24 before treatment and 2.18 +/- 0.57 several days afterward (P < .001). In remote areas, MPRI was 2.42 +/- 0.44. In the stent group, MPRI increased by 156%, from 0.99 +/- 0.20 before stent placement to 2.53 +/- 0.53 after (P < .001). Similarly, in the PTCA only group, MPRI increased by 72%, from 1.08 +/- 0.27 before PTCA to 1.87 +/- 0.39 after (P < .001). At follow-up in patients without recurring chest pain, MPRI was 2.14 +/- 0.37 in the area of the treated artery and 2.29 +/- 0.47 in remote areas (P = .06). CONCLUSION: The MPRI, derived from rest-stress examinations, can provide information on success of interventional procedures in stenosed coronary arteries.

Adult↗
PubMed2001

A simple method for heart stabilization during off-pump multi-vessel coronary artery bypass grafting: surgical technique and short term results.

Minimally invasive cardiac surgery regroups several technical options including small incision, video-assisted surgery and beating heart surgery but mechanical stabilization for off-pump multi-vessel coronary artery bypass grafting (CABG), remains a problem. We developed a simple method of stabilization with a fenestrated polytetrafluroethylene patch. Four sutures were passed deeply into the myocardium surrounding the anastomotic site. The sutures were then passed through the patch. Gentle traction on tied sutures, allowed immobilization and exposure in the selected area. This method which was carried in 95 patients, provides good stabilization for performing off-pump multi-vessel CABG in all cardiac territories.

Aged↗
PubMed1993

Exercise-induced silent myocardial ischemia in single vessel coronary artery disease associated with Q wave infarction. Assessment by thallium 201 single-photon emission computed tomography.

PURPOSE: To examine the relationship between the symptom of ischemia and the amount of abnormally perfused myocardium, coronary arteriography and exercise and redistribution thallium 201 single-photon emission computed tomography (SPECT) were analyzed. MATERIALS AND METHODS: The study group consisted of 153 patients with single-vessel coronary artery disease; 53 patients had no pathologic Q waves (group 1) and 100 patients had pathologic Q waves consistent with the area supplied by the diseased vessel (group 2). Twenty normal subjects were used as control subjects. The apical, mid, and basal left ventricular levels of the short-axis view and apical portion of the long-axis view were divided into 20 segments, and segmental images were scored blindly on a 0 (normal) to 4 (severely reduced uptake) scale. The redistribution score was defined as the thallium 201 defect score of exercise subtracted from that of the redistribution image and was used as a measure of the amount of ischemic myocardium. RESULTS: The redistribution score in 20 control subjects was 0.20 +/- 2.06, and the upper limit of normal redistribution score was defined as mean + 2 x SD (4.32). In group 1, 40 of 53 patients had a redistribution score above the normal range. In group 2, 34 of 100 patients had a redistribution score above the normal range. Of 40 patients in group 1, angina during exercise was observed in 22 patients (55 percent). Twenty-two patients who had angina had a redistribution score of 15.2 +/- 6.7, while those who did not have angina had a score of 13.7 +/- 5.2 (p = NS). Of 34 patients in group 2, angina was observed in 10 patients (29 percent) during exercise. Ten patients with angina had a redistribution score of 10.1 +/- 4.4, and those without angina had a score of 9.9 +/- 3.4 (p = NS). CONCLUSION: Thus, the incidence of silent ischemia without the Q wave infarct zone was found to be higher than that within the ischemic zone without Q wave. Patients with silent and symptomatic ischemia during exercise have similar amounts of ischemic myocardium demonstrated by tomographic thallium 201 imaging; this was found in patients who had Q wave infarction and in those who did not.

Angina Pectoris↗