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PubMed1992

Fluoroscopic coronary artery calcification and associated coronary disease in asymptomatic young men.

Little is known about the diagnostic significance of coronary artery calcification detected fluoroscopically in apparently healthy young men. This study compared the presence of fluoroscopically detected coronary artery calcification with angiographic coronary artery disease in asymptomatic male military aircrew undergoing noninvasive cardiac screening tests and coronary arteriography for occupational indications. Of 1,466 men screened with coronary fluoroscopy, 613 underwent coronary arteriography because of one or more abnormal noninvasive test results. The mean age (+/- SD) of all subjects screened was 40.2 +/- 5 years (range 26 to 65). Significant coronary artery disease (greater than or equal to 50% diameter stenosis) was found in 104 of the 613 subjects with arteriograms (16.9% disease prevalence). Overall sensitivity and specificity for coronary artery calcification detection of significant disease, based only on those subjects undergoing arteriography, were 66.3% and 77.6%, respectively. For measurable disease (mild plus significant), sensitivity was 60.6% and specificity 85.9%. Positive and negative predictive values were 37.7% and 91.9%, respectively, for significant disease. For measurable disease, positive and negative predictive values were 68.9% and 80.9%, respectively. In these asymptomatic young men, a fluoroscopic examination negative for coronary artery calcification indicated a low risk of significant coronary artery disease, whereas a positive test result (calcification present) substantially increased the likelihood of angiographically significant coronary artery disease.

Adult↗
PubMed1995

[Identification of multivessel coronary disease using myocardial Thallium-201 and dipyridamole scintigraphy in acute myocardial infarction in the thrombolytic era].

Recently some Authors observed a low sensitivity of submaximal exercise thallium-201 myocardial scintigraphy for predicting multivessel coronary disease in patients with recent acute myocardial infarction (AMI) treated with thrombolytic therapy. The aim of our study was to evaluate the accuracy of dipyridamole thallium-201 single photon emission computerized tomography (DIP-SPECT) for predicting the location and the extent of coronary artery disease in patients with recent uncomplicated AMI and to compare the results obtained in patients treated with thrombolytic therapy (Group T) to those obtained in patients treated with non-thrombolytic therapy (Group NT). We examined 61 consecutive patients with recent uncomplicated AMI by predischarge DIP-SPECT as well as by coronary angiography. In the Group T the total number of reversible perfusion defects per patient was 2.6 +/- 1.9 of which 2.1 +/- 1.6 at infarct site and 0.5 +/- 0.7 in other coronary territories; similarly, in the Group NT the total number of reversible perfusion defects per patient was 2.5 +/- 1.6 (NS compared to Group T) of which 1.9 +/- 1.2 (NS compared to Group T) at infarct site and 0.5 +/- 0.8 (NS compared to Group T) in other coronary territories. In Group T, DIP-SPECT demonstrated a sensitivity of 84% with specificity of 60% for predicting critical (> or = 70%) stenoses at infarct site as well as a sensitivity of 54% with specificity of 54% in the other coronary territories (data are expressed in number of patients per cent). The sensitivity and specificity observed in Group NT did not differ significantly from those of Group T.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary Angiography↗
PubMed1987

Effect of prior myocardial infarction and extent and location of coronary disease on accuracy of exercise echocardiography.

Exercise echocardiography is an emerging technique for the evaluation of patients with suspected coronary artery disease. In this study, rest and immediate postexercise echocardiograms were performed in 123 patients who were stratified on the basis of prior myocardial infarction and the number and location of coronary artery stenoses at cardiac catheterization. The location of wall motion abnormalities on rest and postexercise studies was correlated with the location of coronary artery stenoses. The sensitivity of exercise echocardiography for detecting coronary artery disease in patients with multivessel disease was 97% in those with and 86% in those without prior infarction. The corresponding sensitivity for patients with single vessel disease was 100% and 72%, respectively. Multivessel disease was present in 59 patients, but specifically identified as such in only 32 (54%). Normal rest and exercise echocardiograms were seen in 12 patients with coronary artery disease, 8 of whom had single vessel disease. It is concluded that the subjective analysis of the exercise echocardiogram accurately identifies the majority of patients with coronary artery disease. Its sensitivity is greatest in those with multivessel coronary disease. It is limited in those with single vessel coronary disease and in accurately identifying the subset of patients with multivessel disease.

Angiography↗
PubMed2003

Evaluation of outcome and cost-effectiveness using an FDG PET-guided approach to management of patients with coronary disease and severe left ventricular dysfunction (PARR-2): rationale, design, and methods.

Patients with severe ventricular dysfunction and coronary disease have high morbidity and mortality. They may benefit from revascularization but have significant perioperative morbidity and mortality. Positron emission tomography (PET) imaging with F-18-fluorodeoxyglucose (FDG) can detect viable myocardium that may recover from revascularization in such patients. It is unclear whether use of FDG PET in this population improves outcome or is cost-effective. The principal aim of this study is to determine whether FDG PET-guided therapy improves clinical outcome compared to standard care. Secondary objectives are to determine whether FDG PET-guided therapy improves left ventricular (LV) function, improves quality of life, and provides a cost benefit versus standard care. Included in this multicenter randomized controlled trial are patients with coronary artery disease and severe LV dysfunction who are referred for revascularization, heart failure, or cardiac transplantation or in whom FDG PET is potentially useful. Consenting subjects will be randomized to therapy directed by FDG PET or standard care. The primary outcome is the composite cardiovascular endpoint of cardiac death, myocardial infarction, transplantation, or rehospitalization for unstable angina or heart failure. Secondary outcomes include health-related quality of life, costs, mortality, cardiovascular events, and LV function. Assuming two-sided alpha=0.05, power=80%, a sample size of 206 patients per group is required to detect a 15% absolute difference in the primary outcome between PET-directed therapy compared to standard care. Analyses will be conducted on an intention-to-treat basis. To our knowledge, this is the first large trial to evaluate whether FDG PET-directed therapy is effective and provides a cost benefit in patients with severe LV dysfunction. If so, thousands of such patients can be risk-stratified to select who is likely to benefit from revascularization.

Cost-Benefit Analysis↗
PubMed1994

Cyclosporin A and transplant coronary disease after heart transplantation: facts and fiction.

From published data in the currently available literature on animal experiments, it can be concluded that CyA may be involved in the development of hypertension and renal dysfunction. These side effects are probably related to a disturbed vasomotor tone and a pathologic reaction to physiologic vasoconstrictive and vasodilative agents following administration of high doses of CyA. These effects are dose related and reversible and were undetected at clinically applied levels of immunosuppression. It therefore appears to be unlikely that this pathologic response is operative in precipitating or promoting TCD, which is supported by findings of in vivo and in vitro studies on human coronary arteries as well as by comparison of immunosuppressive protocols comparing series with and without application of CyA. Chronic graft dysfunction, as depicted by late mortality in heart and isolated lung transplant recipients and by loss of kidney allograft survival, yields an annual rate of between 4 and 6% per year. It is only in heart transplantation that TCD has been tried to be associated with CyA application. If CyA-related damage were to occur in coronary arteries independent from immunologic factors, the incidence of coronary disease should be similar in heart, lung, liver, and kidney transplants. This is not the case. Although continuous investigation on the side effects of immunosuppressive agents is definitely necessary, we should concentrate our research activities on potential prophylactic and therapeutic measures to overcome the single most important risk factor of long-term surviving patients after solid organ transplantation: chronic rejection.

Animals↗
PubMedDate not supplied

Stress perfusion/metabolism imaging: a pilot study for a potential new approach to the diagnosis of coronary disease in women.

BACKGROUND: The diagnosis of coronary artery disease (CAD) in women continues to be a challenge. F-18 deoxyglucose (FDG) positron emission tomography (PET) has been used for detection of myocardial ischemia at rest. Little has been reported about FDG stress imaging. The aim of this pilot study was to assess stress FDG PET imaging for defining CAD in a group of women referred for chest pain. METHODS: Stress FDG imaging was performed in 19 women (mean age 59 +/- 10 years). All had abnormal stress testing before entering the study. FDG and 2-methoxy-2-methylpropyl isonitrile were injected at peak stress (treadmill n = 8, dipyridamole n = 11) followed by PET and single photon emission computed tomography image acquisitions. Myocardial ischemia was defined by regions that demonstrated both a defect on perfusion imaging and increased FDG uptake relative to uptake in normal perfusion zones. Defect/normal zone FDG ratios were also determined. Coronary angiography was performed on all patients. RESULTS: Average, or mean, body mass index was high at 29.2 +/- 5 kg/m2. Nine of 19 patients had significant CAD. Eight of 9 with CAD had FDG-defined ischemia. Nine of the 10 without CAD had negative FDG images (sensitivity 89%, specificity 90%). The average defect/normal zone FDG ratio was greater in patients with CAD than in those without (2.4 +/- 1.9 vs 0.9 +/- 0.4, P < .05). CONCLUSIONS: Regional FDG uptake in areas of perfusion defects with stress increased in this group with CAD. These pilot data suggest that stress FDG PET may be diagnostically helpful in obese female patients. This novel approach may complement current methods of CAD detection in women and warrants further study.

Aged↗
PubMed1984

[Prognostic value of the late potentials of ventricular activation in coronary disease].

Identification of subsets of patients with coronary artery disease (CAD) who are prone to ventricular tachycardia or fibrillation (VT/VF) and to sudden arrhythmic death still represents one of the major problems in clinical cardiology today. Ninety-two patients with CAD were included in this prospective study, which was designed to assess the prognostic significance of ventricular late potentials (VLP) detected non-invasively using high-gain electrocardiography and signal averaging. The results clearly demonstrate that the presence of VLP increases the risk of VT/VF and the risk of sudden arrhythmic death in CAD patients. Because of its high sensitivity and non-invasiveness, high-gain electrocardiography should be included among the various electrophysiological investigations used to assess prognosis in CAD patients.

Adult↗
PubMed1994

Intravascular ultrasound versus angiography for measurement of luminal diameters in normal and diseased coronary arteries.

Quantitation of coronary luminal diameter with a 20 MHz mechanically rotating intravascular ultrasound (IVUS) catheter was compared with orthogonal-view cineangiography by use of a semiautomated edge-detection algorithm in 48 patients undergoing coronary angioplasty. Quantitative comparison of 196 matched segments was attempted, but in only 174 (88.8%) was a direct comparison of the two techniques possible. In angiographically normal coronary arteries (46 segments) the correlation between the values obtained by quantitative coronary angiography (QCA) and those achieved by IVUS was excellent (r = 0.92, p < 0.0001). For mild stenoses (80 segments) the correlation coefficient was only fair (r = 0.467, p < 0.001). After percutaneous transluminal coronary angioplasty the correlation coefficient between IVUS and QCA data (48 segments) was very weak (r = 0.282, p < 0.05). In conclusion, coronary IVUS is feasible and safe and even for a limited range of coronary arterial narrowing, significant correlations between IVUS and QCA measurements of minimal lumen diameter were found. They were excellent in normal coronary arteries, moderate in mildly diseased arteries, and weak after balloon angioplasty.

Angioplasty, Balloon, Coronary↗
PubMed1975

[Evaluation of load tolerance in patients with coronary disease].

12 patients with the diagnosis of coronary heart disease and angina pectoris underwent evaluation of heart rate as an indicator of tolerance of a given work load. A floating catheter in a pulmonary artery and a peripheral arterial catheter permitted measurement of blood pressures. Oxygen uptake per minute (VO2) was measured by Douglas bags and oxygen content of arterial and mixed-venous blood was determined at rest and during each minute of submaximal and symptom-limited maximal exercise on a treadmill. In the minute of exercise, in which 60-80% (mean 71.3%) of maximal heart rate (HF max) were attained, VO2 averaged 60.3% VO2 max, cardiac output (Q) 72.5% Q max and mean pulmonary arterial pressure (PAP) 26.6 mm Hg. With one exception, Q leveled off or dropped in the last minutes of exercise beyond 85% HF max. Heart rate (HF), oxygen difference between arterial and mixed venous blood (DavO2) and PAP reached their highest values in the last minute. It is suggested that heart rates up to 70% HF max, as individually determined in a symptom-limited maximal exercise test, are the tolerable limit during occupational activities. 85% HF max should not be exceeded during exercise training. Left ventricular function may be impaired beyond that limit because of acute coronary or myocardial insufficiency, and the regulation of cardiac output becomes uneconomical.

Coronary Disease↗
PubMed2005

Update on using coronary calcium screening by computed tomography to measure risk for coronary heart disease.

Coronary artery disease (CAD) is the number one killer of adults in the United States, claiming one-half million deaths annually. Early detection and prevention strategies clearly remain a top priority for health care providers in order to reduce the high mortality rate of heart disease. As an unequivocal reflection of arteriosclerosis, coronary arterial calcium (CAC) may provide a means to qualitatively assess the overall disease severity and likewise serve as a means to assess risk for CHD. It is known that patients with heavy calcium burdens have more advanced CAD, a concomitantly a higher likelihood of coronary stenoses, and a concomitant higher risk for acute cardiac events. Computed tomography has been shown to be an accurate, non-invasive method to quantify coronary calcification burden in patients. Evidence shows that calcium measurements by CT correlate well with histological plaque analyses, and that CAC measurements accurately reflect disease severity and can be useful to assess individual risk for CHD. The purpose of this article is to summarize the currently available evidence that has attempted to validate CAC screening as a screening exam and risk predictor for coronary heart disease.

Calcinosis↗
PubMed1975

Variations in right and left coronary blood flow in man with and without occlusive coronary disease.

The relation of angiographically recognized coronary occlusion to regional myocardial blood flow has not been studied adequately in spite of its clinical significance. This is particularly important, as revascularization procedures, based on angiographic studies, are being performed with increasing frequency. To compare the severity of reduction in flow to the severity of coronary occlusion, regional myocardial blood flow (85-Kr washout) was measured in 34 patients. Selective coronary anteriograms were obtained using the Sones technique, and occlusions were graded as a percentage of luminal diameter. Of 26 right coronary arteries for which satisfactory arteriograms and coronary blood flow measurements were obtained, 16 were normal and 10 had significant stenosis (greater than 50%). Dominant right coronary arteries appeared to have high flows (67 plus or minus 6 ml min-minus1 per 100 g muscle) and a greater incidence of occlusion (10 of 20) than nondominant arteries, which had less flow (41 plus or minus 2 ml min-minus1 per 100 g muscle) and a lower incidence of occlusion (1 of 8). Coronary blood flow in 16 normal left coronary arteries was 84 plus or minus 5 ml min-minus1 per 100 g muscle and in 15 with 50 per cent or greater occlusion, 68 plus or minus 3 ml min-minus1 per 100 g muscle. Though coronary blood flow appeared reduced when lesions of both the right and left coronary arteries were present, a critical reduction was seen only when occlusion was greater than 90 per cent.

Adult↗
PubMed2004

Less affluent area of residence and lesser-insured status predict an increased risk of death or myocardial infarction after angiographic diagnosis of coronary disease.

PURPOSE: Low socioeconomic status (SES) predicts coronary artery disease (CAD) onset, but its value among patients with CAD is uncertain. Geographic measures (e.g., residential neighborhood) may predict risk, but this requires further evaluation. METHODS: A cohort of 3410 patients with significant, angiographically-defined CAD (> or =1 lesion of > or =70% stenosis) joined a registry during the period between 1993 and 2000 and was followed for 6.7 years (median 3.7 years). A geographic SES measure-residential economic status (RES)-and insurance type were examined for association with mortality or myocardial infarction (MI). RESULTS: In Cox regression adjusting for 17 covariates, lower RES quartile was associated with increased death/MI (p-trend<0.001), death (p-trend=0.001), and MI (p-trend=0.07). First RES quartile (vs. fourth) predicted death/MI (hazard ratio [HR]=1.32, 95% confidence interval [CI]=1.07-1.62, p=0.01) and death (HR=1.46, CI=1.12-1.91, p=0.006), but not MI (HR=1.18, p=0.31). Compared with private insurance, self-pay (HR=1.88, p=0.053), charity care (HR=1.71, p<0.001), and Medicaid (HR=1.43, p=0.24), but not Medicare (HR=0.95, p=0.68), were associated with death/MI. CONCLUSIONS: Both geographic (RES) and economic (insurance) measures of SES independently predicted risk of death/MI in a large population with angiographically-defined CAD. This suggests that SES remains a significant predictor of health outcomes after CAD has developed, and that geographic measures of SES deserve further evaluation.

Adult↗
PubMed2001

[Evaluation of a new stress echocardiography technique combining exercise and dobutamine in the detection of coronary disease].

Dobutamine stress echocardiography (DSE) and exercise stress echocardiography (ESE) are widely used for diagnosis of coronary artery disease. Each of these methods has limitations: secondary effects of Dobutamine, poor imaging quality, difficulty in attaining the maximal heart rate. The authors evaluated a test associating pedalling exercise at a constant low load (30-60 watts) with Dobutamine infusion (10-20-30-40 j/Kg/min +/- Atropine) (DES + E) in 42 patients referred for suspected coronary artery disease. All patients underwent coronary angiography on Day 1. There was significant coronary disease (> 50% stenosis) in 19 of the 42 patients. Sensitivity, specificity, negative predictive value, positive predictive value and overall diagnosis value were respectively 84, 87, 84, 87 and 86%. In the first 20 patients, the DES + E was compared directly with DES: There was only one undesirable side effect (hypertension) with DES + E compared with 5 with DES alone. The target heart rate was attained with lower doses of Dobutamine with DES + E (32.35 vs 39.42 j/Kg/min, p = 0.05). DES + E therefore seems to be a promising technique which is better tolerated than DES alone with very satisfactory diagnostic performances. However, these results require further confirmation in larger numbers of patients.

Cardiotonic Agents↗
PubMed1995

Occult and frequent transmission of atherosclerotic coronary disease with cardiac transplantation. Insights from intravascular ultrasound.

BACKGROUND: Transplant coronary artery disease is a major cause of morbidity and mortality after cardiac transplantation. However, limited data exist regarding the potential contribution of coronary atherosclerosis in the donor heart to cardiac-allograft vasculopathy. METHODS AND RESULTS: We performed quantitative coronary angiography and intravascular ultrasound imaging in 50 of 62 consecutive heart-transplant recipients (40 men, 10 women, mean age, 53 +/- 9 years) 4.6 +/- 2.6 weeks after transplantation. The donor population consisted of 30 men and 20 women (mean age, 32 +/- 12 years). Ultrasound imaging visualized all three coronary arteries in 22 patients, two coronary arteries in 23, and one coronary artery in 5. Ultrasound imaging detected coronary atherosclerosis (intimal thickness > or = 0.5 mm) in 28 patients (56%). However, the angiography was abnormal in only 13 patients (26%). The sensitivity and specificity of coronary angiography were 43% and 95%, respectively. With ultrasound, the average atherosclerotic plaque thickness was 1.3 +/- 0.6 mm and the cross-sectional area narrowing was 34 +/- 16%. Atherosclerotic involvement frequently was focal (85%), eccentric (mean eccentricity index, 87 +/- 8), and near arterial bifurcations. Donors of the transplant recipients with coronary atherosclerosis were older than those without atherosclerosis (37 +/- 12 versus 25 +/- 10 years, P = .001). Maximal intimal thickness correlated with donor age (r = .54, P = .0001). Multivariate analysis demonstrated that donor age (P = .0001), male sex of donor (P = .0006), and recipient age (P = .03) were independent predictors of atherosclerosis. CONCLUSIONS: Coronary atherosclerosis is frequently but inadvertently transmitted by means of cardiac transplantation from the donor to the recipient. Long-term outcomes of donor-transmitted coronary artery disease will require further evaluation.

Adult↗
PubMed1997

[Imaging methods in diagnosis of coronary heart disease].

Coronary heart disease is the leading cause of death and disability worldwide. Coronary angiography makes it possible to visualize coronary artery stenosis and can be used for angioplasty and stent implantation; however, it does not allow the assessment of changes in myocardial microcirculation. The severity of an angiographically evaluated coronary stenosis does not always correspond to the extent of myocardial ischemia. Noninvasive techniques are needed to re-examine our reliance on coronary angiography and to explore the clinical value of the physiological assessment of coronary artery stenoses. Such noninvasive techniques might become important tools in the future following an overall evaluation of coronary morphology, myocardial function and perfusion ascertained by all available methods.

Coronary Circulation↗
PubMed1989

[The relation of electric myocardial instability to the intensity of coronary disease--correlation of the data of programmed electrostimulation of the ventricles, selective coronarography and contrast ventriculography].

Altogether 104 persons with coronary disease were examined in order to determine the correlation between the presence of electric myocardial instability (EMI) identified with the aid of programmed electrostimulation of the ventricles (PESV) and the gravity of injuries to the coronary vessels and to the contractile myocardium of the left ventricle (LV). In accordance with the number of the stimulation-induced recurrent contractions (RC), the patients were distributed into 4 groups. The patients of the second group (4 to 9 RC), of the third group (with unstable tachycardia) and of the fourth group (with stable tachycardia) were considered as having EMI. A marked relationship was discovered between EMI identified with the aid of stimulation and the condition of the contractile myocardium of the LV according to the ventriculography readings (the frequency of recording akinetic and dyskinetic myocardial segments, the magnitude of the end-diastolic pressure). Coronary circulation failure (the degree of stenotic injury to the coronary arteries, the number of impaired vessels) did not determine EMI according to the PESV data.

Adult↗
PubMed1979

[Estimation of coronary disease mortality and morbidity in France from epidemiological data].

The incidence of coronary heart diseases in France is estimated from three sources of information. Mortality statistics underestimate the number of deaths from coronary heart diseases. An evaluation of this number is proposed, but with a rather important lack of precision; for example, between 10 and 20% of male mortality between age 45 and 64. These French coronary death rates are inferior to those of numerous other European or Anglo-Saxon countries, but are comparable with those of some mediterranean countries. The incidence of coronary heart diseases measured in the Paris Prospective Study is inferior by half to that of the Framingham Study and is also inferior to those of several male populations from the 7 Countries Study, in the same age limits. Three French registers give similar results about the incidence of acute myocardial infarction. This incidence is equal to the lower limit of those measured in 21 foreign registers. These concording data suggest that the incidence of coronary heart diseases is relatively moderate in France. Etiological hypotheses are planned and the interest in a surveillance of French sanitary data is reminded.

Adult↗