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Selective coronary radiography was performed in 100 patients with chronic CHD. Three indices of total affection of the coronary arteries including that modified by the authors, were analyzed with regard to assessment of relationships between the main clinical characteristics and indicators of left ventricular functions. A higher sensitivity of Califf's index modified by the authors was noted.
Ten patients with proven single-vessel coronary artery disease and a positive exercise test for ischaemia were investigated to establish the importance and therapeutic implications of dynamic coronary stenosis in such patients. All patients interrupted their anti-anginal therapy and under took serial exercise testing in an attempt to identify variability in the ischaemic threshold. Ergonovine testing was performed in nine patients and all underwent 48 h of ambulatory ST segment monitoring while treatment was discontinued. Patients then entered a randomized double-blind study of atenolol and nifedipine; treadmill exercise testing and 48 h of ambulatory ST segment monitoring were performed at the end of each treatment phase. Six (60%) patients showed evidence of variability in coronary vasomotor tone four of whom developed significant ST segment changes during administration of ergonovine; a further two had greater than 30% variability in time to onset of ischaemia during serial treadmill exercise testing. Atenolol significantly increased the time to ischaemia on exercise testing, both in the group as a whole and in the subgroup with evidence of altered vasomotor tone when compared with no therapy, and led to a non-significant reduction in the frequency and duration of ischaemia during the patients' daily lives. Nifedipine, conversely, did not significantly increase time to ischaemia on exercise testing or reduce the frequency or duration of ambulatory ischaemia in either the whole group or the subgroup. With evidence of altered vasomotor tone when compared to no therapy however it was beneficial in terms of reduction in chest pain and requirement for glyceryl trinitrate during daily life.(ABSTRACT TRUNCATED AT 250 WORDS)
Short-term outcome and 10-year clinical outcome were reviewed in 114 consecutive patients after coronary artery bypass grafting (CABG) for single-vessel coronary artery disease (CAD). Gated equilibrium radionuclide cineangiography was performed soon after CABG in all cases, and revealed very good early graft patency rates. There was no perioperative mortality, and very low morbidity. During follow-up there were seven late deaths, two from cardiac disease and five from non-cardiac causes. Cumulative survival at 10 years was 93%. Cumulative freedom from additional cardiac invasive procedures was 96%, 93% and 80% at 1, 5, and 10 years, respectively, and cumulative freedom from angina was 93%, 80% and 73%. Conventional single-vessel CABG thus can be safely performed, with minimal postoperative morbidity and no mortality, providing good long-term relief of angina and circumventing need for additional invasive procedures.
Limitation of coronary perfusion of different degree induces inhomogeneous changes in resistance of vessels in the hypoperfusing zone: an adequate dilatory regulatory reaction may be followed by an increase in resistance of the coronary vessels. An active component of diastolic coronary resistance used to analyze vascular reactions, rate and character of changes in resistance under conditions of coronary perfusion as well as histological and electron-microscopic estimation of the vascular wall state testify to reversibility and active character of the observed changes in coronary resistance including its increase. This increase is pathogenetically significant as it may induce further development of the coronary perfusion disorder.
Coronary responses to adrenergic stimuli were determined in the intact beating heart before and after administration of practolol, 4-(2-hydroxy-3-isopropylaminoproproxy) acetanilide, which in low doses blocks myocardial but not vascular beta receptors. The left circumflex coronary artery of dogs was perfused with arterial blood at constant flow, and coronary perfusion pressure was measured. Before practolol, intracoronary injections of isoproterenol and norepinephrine and electrical stimulation of left cardiac sympathetic nerves caused reductions in perfusion pressure or vasodilatation associated with increases in left ventricular dp/dt, heart rate, and systolic pressure. After practolol, the coronary vasodilator response to isoproterenol was reduced by about 30% and occurred without significant changes in dp/dt, heart rate, and pressures. The addition of propranolol blocked completely the coronary responses to isoproterenol. Vascular responses to isoproterenol in the paw were not altered by practolol. Practolol antagonized the increases in dp/dt, heart rate, and systolic pressure and reversed coronary responses to norepinephrine and nerve stimulation from dilatation to constriction. The constriction, in turn, was reduced or reversed by phentolamine, an alpha receptor antagonist. Propranolol did not augment the constriction seen in response to norepinephrine and nerve stimulation after practolol. These results indicate that the coronary vasodilator action of norepinephrine and sympathetic nerve stimulation is indirect and caused by stimulation of myocardial beta receptors. The direct effect of these two stimuli on coronary vessels is minimal and is mediated through stimulation of alpha (vasoconstrictor) receptors. In contrast, the coronary vasodilator response to isoproterenol is both direct and indirect, resulting from stimulation of vascular and myocardial beta receptors; the direct vascular effect predominated in this study.
OBJECTIVE: To compare the clinical effects of rapamycin-eluting stent implantation and coronary artery bypass grafting (CABG) in treatment of the patients with multi-vessel coronary disease. METHODS: From January 2002 to December 2004, 262 patients with multi-vessel coronary disease underwent CABG, and 250 age, clinical characteristics, and characteristics of coronary disease-matched patients chose to receive rapamycin-eluting stent implantation. 6-9 months after the treatment angiography of the coronary artery was conducted. All the patients were followed up for 19 +/- 14 months. The clinical outcomes were compared. RESULTS: No intra-operative death occurred in the rapamycin-eluting stent implantation group with an operation success rate of 100%, significantly higher than that of the CABG group with 9 intra-operative deaths and an operation success rate of 96.6% (P < 0.01). Three perioperative deaths occurred in the rapamycin-eluting stent implantation with a perioperative death rate of 1.2%, not significantly different from that of the CABG group (1.9% with 5 perioperative deaths). The total death rate during hospitalization of the rapamycin-eluting stent implantation group was 1.2%, significantly lower than that of the CABG group (5.3%, P < 0.05). The rate of in-hospital major adverse cardiac event (MACE) of the rapamycin-eluting stent implantation group was 1.6%, significantly lower than that of the CABG group (5.3%, P < 0.05). There was no significant difference in MACE rate and angina pectoris recurrence during follow-up and event-free survival rate between these 2 groups. CONCLUSION: A better treatment for the patients with multi-vessel coronary disease, rapamycin-eluting stent implantation has the clinical effects comparable to those of the CABG.
BACKGROUND: Direct noninvasive visualization of the coronary vessel wall may enhance risk stratification by quantifying subclinical coronary atherosclerotic plaque burden. We sought to evaluate high-resolution black-blood 3D cardiovascular magnetic resonance (CMR) imaging for in vivo visualization of the proximal coronary artery vessel wall. METHODS AND RESULTS: Twelve adult subjects, including 6 clinically healthy subjects and 6 patients with nonsignificant coronary artery disease (10% to 50% x-ray angiographic diameter reduction) were studied with the use of a commercial 1.5 Tesla CMR scanner. Free-breathing 3D coronary vessel wall imaging was performed along the major axis of the right coronary artery with isotropic spatial resolution (1.0x1.0x1.0 mm(3)) with the use of a black-blood spiral image acquisition. The proximal vessel wall thickness and luminal diameter were objectively determined with an automated edge detection tool. The 3D CMR vessel wall scans allowed for visualization of the contiguous proximal right coronary artery in all subjects. Both mean vessel wall thickness (1.7+/-0.3 versus 1.0+/-0.2 mm) and wall area (25.4+/-6.9 versus 11.5+/-5.2 mm(2)) were significantly increased in the patients compared with the healthy subjects (both P<0.01). The lumen diameter (3.6+/-0.7 versus 3.4+/-0.5 mm, P=0.47) and lumen area (8.9+/-3.4 versus 7.9+/-3.5 mm(2), P=0.47) were similar in both groups. CONCLUSIONS: Free-breathing 3D black-blood coronary CMR with isotropic resolution identified an increased coronary vessel wall thickness with preservation of lumen size in patients with nonsignificant coronary artery disease, consistent with a "Glagov-type" outward arterial remodeling. This novel approach has the potential to quantify subclinical disease.
The 10-year results of randomized trials comparing percutaneous transluminal coronary angioplasty (PTCA) in patients with single-vessel coronary artery disease (CAD) with coronary artery bypass grafting (CABG) and medical treatment are not available yet. The aim of this evaluation was to compare our 10-year follow-up results after PTCA in patients with single-vessel CAD with the 10-year follow-up results after CABG and medical treatment in the Coronary Artery Surgery Study (CASS) trial. We evaluated the clinical outcome of 509 patients with single-vessel CAD 10 years after coronary angioplasty. The data were compared with the results of 214 patients with single-vessel CAD after CABG or medical treatment from the CASS trial. End points were defined as death and myocardial infarction. Statistical evaluation was performed by life-table analysis and 2-sided Fisher's exact test. The rate of survival was 86% 10 years after PTCA compared with 85% after CABG and 82% after medical treatment in patients from the CASS trial (p = NS). Survival free from myocardial infarction was 77% after coronary angioplasty, 70% after CABG, and 72% after medical treatment (p = NS). Thus, in patients with single-vessel CAD, infarct-free survival 10 years after coronary angioplasty compared favorably with the results after bypass surgery or medical treatment from the CASS trial.
OBJECTIVE: Description of the differences in complications within 30 days after percutaneous transluminal coronary angioplasty (PTCA) and coronary surgery (CABG) in patients suffering from multiple vessel coronary disease. DESIGN: Prospective, randomised. SETTING: 3 hospitals in the Netherlands. METHOD: Between 1988 and 1992, 183 Dutch patients took part in the European Coronary angioplasty versus bypass revascularisation investigation (CABRI) and were randomly treated with PTCA or CABG. Apart from the clinical result, all complications and cardiac events from time of randomisation until 30 days after the intervention were registered. RESULTS: The CABG group consisted of 88 patients with a total of 255 vascular obstructions, the PTCA group of 95 patients with 294 vascular lesions. In this short period of observation the clinical results of the two treatments were the same. The death rates were 1.1% and 2.1%, for CABG and PTCA respectively. The proportion of transmural, non-fatal myocardial infarctions was 2.3% in the CABG group versus 3.1% in the PTCA group. The proportion of reinterventions was higher in the PTCA group, 11.4% versus 1.1%. CONCLUSION: The differences in death rate and myocardial infarctions are not significant, in contrast to the difference in the numbers of reinterventions. These results appear to be in accordance with those of other randomised studies. Although long-term evaluation is needed, treatment of multiple vessel coronary disease by means of PTCA seems a reasonable alternative to coronary surgery.
There is uncertainty regarding the selection between coronary artery surgery and angioplasty in many patients with coronary artery disease, especially in those with 2-vessel disease. Whereas randomized trials will provide the best possible and most detailed data comparing therapy in these patients, clinical data bases may be used to provide a current perspective. The purpose of this study was to compare the long-term outcome of patients with 2-vessel coronary artery disease undergoing coronary surgery or angioplasty at Emory University hospitals in the years 1984 and 1985. Data on all patients with 2-vessel disease diagnosed at Emory University who underwent elective angioplasty or coronary surgery in the years 1984 and 1985 were compared. Categoric variables were analyzed by chi-square and continuous variables by unpaired t test. Survival was determined by the Kaplan-Meier method and differences in survival by the Mantel-Cox method. Determinants of survival were determined by Cox model analysis. There were 415 angioplasty patients and 454 surgical patients. Surgical patients were older and had more frequent systemic hypertension, diabetes mellitus, prior myocardial infarction, severe angina and congestive failure, and more significant narrowing in the left anterior descending coronary artery, totally occluded vessels and left ventricular dysfunction than did angioplasty patients. Complete revascularization was achieved more often in surgical patients. There was no difference in Q-wave myocardial infarction in the hospital. No angioplasty patient died compared with 1.1% of surgical patients (p = 0.03). Whereas 5-year survival was 93% in angioplasty patients and 89% in surgical patients (p = 0.11), there was no difference in risk-adjusted survival.(ABSTRACT TRUNCATED AT 250 WORDS)
To assess whether pharmacologic coronary vasodilation could provoke new left ventricular wall motion abnormalities in patients with single vessel coronary artery disease, systemic hemodynamics, coronary blood flow velocity and left ventricular wall motion were measured by two-dimensional echocardiography during administration of 10 mg of intracoronary papaverine in 14 patients before and again immediately after left coronary angioplasty (group 1). As a comparison with an intravenous method, left ventricular wall motion was analyzed after 0.56 mg/kg body weight of intravenous dipyridamole in a separate group of 13 patients with single vessel coronary disease (group 2). Heart rate-blood pressure product increased 3% to 6% in papaverine-treated patients and 14 +/- 11% (p = NS) in dipyridamole-treated patients. No angiographic collateral vessels were present in either group. Although intracoronary mean flow velocity measured in the 14 group 1 patients and in 5 normal control subjects during papaverine treatment increased from 125% to 400% of basal flow velocity, papaverine induced new left ventricular wall motion abnormalities in only 5 of the 14 patients before coronary angioplasty. In three of five patients, left ventricular wall motion abnormalities persisted after successful coronary angioplasty. Four of the 14 patients demonstrated augmentation of left ventricular wall motion with papaverine. After intravenous dipyridamole, only 3 of the 13 group 2 patients developed new left ventricular regional asynergy. These data suggest that selective (papaverine) and, most likely, global (dipyridamole) augmentation of coronary flow alone does not reliably identify potential ischemic left ventricular regions affected by critical single vessel coronary artery disease.
Our purpose was to compare patients with diffuse three-vessel coronary artery spasm and other types of coronary artery spasm without significant organic stenosis, and to elucidate clinical characteristics and risk factors. Patients were divided into two groups: group I consisted of 26 patients showing other types of coronary artery spasm; group II consisted of 5 patients with diffuse three-vessel coronary artery spasm. The mean age of patients in groups I and II was 52 and 50 years, respectively. The incidence of variant angina was higher in men than in women. The incidence of smoking was high in each group, but not significantly different. Exercise tests showed no significant differences between groups. All mean values of laboratory data, including lipoprotein (a) and low-density lipoprotein cholesterol in the two groups, were within normal ranges. There was no significant difference between groups. The incidence of spontaneous spam was much higher in patients with diffuse three-vessel coronary artery spasm (P < 0.01). Electrocardiographic (ECG) findings before the spasm were almost normal. All 5 patients with diffuse three-vessel coronary artery spasm demonstrated no important ST segment changes with episodes of angina during a coronary angiography on 12-lead ECG, compared to patients with other types of coronary artery spasm (P < 0.01). First, we conclude, diffuse three-vessel coronary artery spasm mostly occurs spontaneously. Second, we emphasize that diffuse three-vessel coronary artery spasm must be considered when 12-lead ECG shows no important ST segment changes with episodes of angina. Third, it is not easy to distinguish diffuse three-vessel coronary artery spasm from other types of coronary artery spasm on the basis of history, laboratory data, or electrocardiographic findings, including exercise tests.
To determine whether exercise testing can identify higher risk patients with 3-vessel coronary artery disease (CAD) whose survival might be prolonged by coronary artery bypass grafting (CABG), the results of CABG were compared with those of medical therapy in 1,249 nonrandomized patients with 3-vessel CAD from the Coronary Artery Surgery Study (CASS) registry who underwent exercise testing. Analysis of 28 variables by Cox's regression model for survival revealed an independent effect of the left ventricular (LV) score, the final exercise stage, and treatment received on survival. Seven-year survival rates between medical and surgical therapy were compared among subsets of patients according to the LV function and the results of exercise testing. Among patients with normal LV function, those with at least 1 mm of ischemic ST-segment depression or low exercise capacity had better 7-year survival if treated by surgical rather than medical therapy (p less than 0.05). Survival was not different between the medical and surgical groups in patients without ischemic ST depression or with good exercise capacity. Among patients with impaired LV function, surgery improved survival in most subsets of patients with the exception of patients with a preserved exercise capacity. These results support the use of exercise testing in the risk stratification of patients with 3-vessel CAD.
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The long-term outcome and the significance of residual ischemic myocardium, as assessed by predischarge exercise thallium scintigraphy and vessel patency, were studied in 97 patients with single vessel coronary artery disease by angiography 12 +/- 4 days after uncomplicated myocardial infarction. During a mean follow-up period of 39 +/- 17 months, no patients died, 6 (6%) had a recurrent nonfatal infarction and 25 (26%) experienced rapidly progressive angina requiring hospitalization. Although neither exercise-induced angina nor ST segment depression was predictive of a recurrent cardiac event, the mean number of infarct zone scan segments showing thallium redistribution (1.0 +/- 1.0 versus 0.5 +/- 0.8, p = 0.01) and the percent of patients with infarct zone redistribution (61 versus 39%, p = 0.05) were greater in those patients who experienced a late ischemic event. Kaplan-Meier analysis demonstrated a lower event-free survival rate in patients with redistribution (n = 45) than in those without redistribution (n = 52) (p = 0.019). Although no patient received immediate thrombolytic therapy, the infarct-related vessel was angiographically patent in 40 patients (41%). Vessel patency did not influence event-free survival, although a patent vessel, as compared with an occluded vessel, was associated with a greater prevalence of non-Q wave infarction (58 versus 21%, p less than 0.001), fewer persistent infarct zone thallium defects (1.2 +/- 1.1 versus 2.0 +/- 1.2, p = 0.001), more reversible infarct zone thallium defects (1.0 +/- 1.0 versus 0.5 +/- 0.9, p = 0.02) and a trend toward a higher left ventricular ejection fraction (53 +/- 10% versus 49 +/- 12%, p = 0.07). In summary, uncomplicated myocardial infarction in patients with single vessel coronary artery disease is associated with a very low incidence of subsequent death and reinfarction. The presence of infarct zone thallium redistribution, compared with its absence, is predictive of a higher cardiac event rate. These data should be considered when recommending prophylactic percutaneous transluminal angioplasty after uncomplicated myocardial infarction in asymptomatic patients with single vessel coronary disease. On the basis of these results, future randomized trials designed to evaluate the therapeutic efficacy of revascularization in asymptomatic postinfarction patients with single vessel disease should limit enrollment to those patients with residual ischemia located within the infarct zone.
Coronary artery disease is a major social problem. However, its epidemiology, pathophysiology, clinical course, diagnostic efficiency and therapeutic potential differ significantly with regard to gender and age. There are few comparative data available on morphological differences and immediate results of direct percutaneous interventions, aorto-coronary bypass grafting, complication rate, risk factors for developing complications after invasive procedures in CAD patients of both sexes and in various age groups. The aim of the study was to identify differences in the location and morphology of coronary plaque and left ventricular function in CAD patients with regard to gender and age. The study included consecutive patients with coronary artery disease diagnosed and treated in the Department of Hemodynamics and Angiocardiography Jagiellonian University Medical College from June 1997 to June 1998. Coronary angiography group, consisting of 1374 patients, 1004 men (73.1%) and 370 women (26.9%), of whom 1146 (83.4%), 890 men (77.7%) and 256 women (22.3%), were included in the final morphological and clinical analysis and in whom coronary angiography confirmed the presence of coronary plaque. The subgroups were further subdivided into two age groups: below and over 50 years of age. Clinical, angiographic and hemodynamic data were analysed retrospectively. Analysis revealed that among patients after invasive diagnosis because of suspected coronary artery disease atherosclerotic lesions in epicardial coronary vessels were significantly more frequently confirmed in men. In patients of both sexes the proportion of patients with angiographically confirmed lesions rises with age. In patients with angiographically documented coronary artery diseases the location and morphology of stenosis in epicardial coronary vessels differs between sexes in the corresponding age groups. Left ventricular function is better preserved in women.
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The effects of prostaglandins E1, E2, A1, F1 alpha, and F2 alpha on the coronary vascular resistance during intracoronary administration were studied in anaesthetized, open-chest dogs. PGE1 in doses of 0.1 - 3-10 mug/kg in single intracoronary administration produced a potent and comparatively long-lasting direct decrease of the resistance of the coronary vessels and a decrease in the systemic arterial pressure. The PGE2 and PGA1 actions on the coronary vessels were less potent. At variance with PGE1 and PGE2, the hypotensive effect of PGA1 is more expressed than its action on the resistivity of coronary vessels. PGE1 alpah and PGF2 alpha do not show any significant influence on the resistivity of the coronary vessels. The results of the investigations also permit to establish a correlation between the chemical structure and action of prostaglandins on the coronary vessels and to conclude that one of the most important functional groups that determines the prostaglandin action on the coronary vessels most decisively is the keto-group at C-9 of cyclopentane ring. As coronary dilatator agents in anaesthetized dogs, the activity of the prostaglandins ranged in the order E1 greater than E2 greater than A1 greater than F1 alpha greater than F2 alpha.