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PubMed1977

Atypical progressive angina pectoris caused by a congenital coronary-pulmonary shunt and coronary atherosclerosis.

A 57-year-old man with atypical progressive angina caused by congenital coronary-pulmonary shunt and coronary atherosclerosis is described. The angina was rather consistently unresponsive to nitroglycerin. Following closure of the shunt and aortocoronary bypass surgery, the patient became asymptomatic and has remained free of angina 2 year postoperatively. Although the congenital anomaly is rare in adults, it may be considered in the differential diagnosis of atypical angina pectoris, particularly when there is either continuous murmur or systolic murmur over the lower parasternal area.

Angina Pectoris↗
PubMed1977

New approaches to resolving diagnostic problems in patients with angina pectoris.

Several new noninvasive techniques are now available to evaluate the patient with chest pain to determine if myocardial ischemia is present. Continuous ambulatory ECG monitoring can detect myocardial ischemia in some patients who have normal ECG responses to graded exercise tests. Defects in myocardial perfusion can be visualized by radionuclide imaging at rest and after exercise. Also, abnormal left ventricular wall motion due to myocardial ischemia can be detected by gated blood pool scanning at the same time. Other techniques can olso be valuable in evaluating wall motion. Standard M-mode echocardiography can detect anteroseptal and posteroinferior wall motion abnormalities with remarkable anatomic detail, and newer echo techniques are promising for delineating the motion of other parts of the left ventricle. Finally, abnormal contractile areas can be assessed by videotracking the fluoroscopic cardiac silhouette and by a new noninvasive technique, the displacement cardiograph, which does not involve radiation exposure. Although none of these tests are both highly sensitive and highly specific for myocardial ischemia, their combined application in a symptomatic patient may provide considerable useful information which will help to determine who should be subjected to the risk and expense of coronary arteriography.

Angina Pectoris↗
PubMed1977

Long-term results of the medical treatment of coronary artery disease.

The natural history of patients with ischemic heart disease varies widely depending upon the anatomic lesion and extent of left ventricular dysfunction. Several clinical variables may also be used to help determine the likelihood of long-term survival. Individuals with high-grade isolated disease of the left anterior descending coronary artery, without significant impairment of ventricular function, have little morbidity and mortality for the 2-year period after arteriography. At the other end of the spectrum, medically treated patients with stenosis of the left main coronary artery or three-vessel disease without such involvement have a reduced life expectancy compared with patients treated surgically. Global judgments on long-term results of the medical treatment of coronary artery disease are meaningless. Efforts should be made to delineate optimal treatment for various subgroups of patients under the broad rubric of ischemic heart disease.

Adult↗
PubMed1979

Echocardiographic and hemodynamic correlates in Prinzmetal angina pectoris: a case report.

In a patient suffering from Prinzmetal angina pectoris, ischemic attacks of the anterior left ventricular wall were associated with the following changes: fall in cardiac output; increased left ventricular diastolic pressure (LVDP) and volume; flattening of the septal motion; marked reduction of the mitral valve early diastolic amplitude and rate of opening; and marked reduction of the systolic closure velocity. It is suggested that LVDP rise depends, at least in part, on variations in left ventricular diastolic volume and segmental wall motion, and that disruption of the mitral valve motion derives from changes in LVDP and flow through the mitral orifice.

Angina Pectoris↗
PubMed1981

Prinzmetal's angina: atypical angiographic features of atypical angina pectoris.

Clinicians have puzzled over the coronary physiology associated with atypical angina pectoris for the past century. Recent recognition of coronary artery spasm, which has been so thoroughly documented with coronary angiography, has resolved many of these conceptual difficulties. However, several features of coronary artery spasm, both spontaneous and secondary to provocation with ergonovine maleate, remain poorly understood. This paper addresses the management problems associated with spontaneously occurring spasm in the setting of pre-existent atherosclerotic coronary artery disease, angiographically severe spasm unassociated with symptoms of angina pectoris or signs of myocardial ischemia, and the precipitation of angina pectoris by ergonovine maleate administration unaccompanied by demonstrable epicardial coronary artery spasm. The rationale, indications and therapeutic efficacy of a new class of agents known as slow channel inhibitors of calcium antagonists are discussed.

Acute Disease↗
PubMed1985

Diagnosis of vasospastic angina by analysis of heart rate response to exercise: effects of different levels of work load.

To examine alterations in control functions of the heart, which may account for the pathophysiologic conditions precipitating coronary arterial spasm, heart rate response to exercise in vasospastic angina was evaluated by using our previously developed method of frequency analysis. We also examined the effects of three different levels of work load on the heart rate response to treadmill exercise in 9 patients with vasospastic angina and 7 normal controls: stage 1 (2.5 Km/h, 10%), stage 3 (4.5 Km/h, 10%), and stage 5 (5.5 Km/h, 14%). The transfer function of heart rate control in vasospastic angina was characteristically different from that in normal controls: lower gain and more delayed phase angle of the system. Although this abnormality was observed in every test at 3 different levels of work load, the abnormality was more striking in tests at lower levels of work load: stage 1 or 3. The moderately light exercise test at stage 3 is most suitable as a test for detecting abnormal heart rate response to exercise in vasospastic angina because the exercise test at stage 1 had a poor S/N ratio.

Adult↗
PubMed1988

Prevention of vasospastic angina by alcohol ingestion: report of 2 cases.

The authors report 2 patients with vasospastic angina in whom alcohol ingestion was effective in preventing angina. Coronary angiography revealed no organic coronary stenosis but demonstrated coronary artery spasm during angina attacks. In 1 patient, alcohol ingestion every six hours completely suppressed frequent spontaneous angina. In the other patient, alcohol ingestion markedly prolonged the duration of the exercise on treadmill testing by preventing exercise-induced coronary spasm.

Alcoholic Beverages↗
PubMed1979

A retrospective evaluation of nifedipine therapy in Prinzmetal's angina.

A retrosepctive evaluation has been made of blood pressure, pulse rate, and number of anginal attacks per day in twenty-one patients diagnosed as Prinzmetal's Angina and treated with the investigational drug nifedipine. The effect of combining nifedipine with short- and long-acting nitrates or with propranolol was also evaluated. In consideration of the statisically significant reduction in the number of anginal attacks per day, p less than 0.001, together with the non-significant mean changes in blood pressure and pulse rate as well as the compatibility with the other drugs, it is concluded that nifedipine is a very useful drug, in a dose range of 30--120 mg per day, for the treatment of Prinzmetal's Angina. Recorded side-effects were of minimal severity and in no case caused nifedipine therapy to be discontinued.

Adult↗
PubMed2005

Need for documentation of guidelines for coronary artery spasm: an investigation by questionnaire in Japan.

BACKGROUND: Because there are no guidelines concerning coronary spasm in Japan, the present study examined the current status of the spasm provocation test. METHODS AND RESULTS: Questionnaires concerning the number of cases of coronary angiography, percutaneous coronary intervention, and invasive/non-invasive spasm provocation tests over 3 years (2001-2003) and the status of spasm provocation tests were sent to members of the Japanese Circulation Society in 120 cardiology hospitals in the Chugoku and Shikoku areas. Completed surveys were returned from 45 hospitals, giving a collection rate of 38%. As a spasm provocation agent, acetylcholine tests were performed in 29 hospitals, and ergonovine tests in 18 hospitals. Non-invasive spasm provocation tests were performed in only 9 hospitals (20%). In total, 5,267 patients underwent acetylcholine spasm provocation test (2,387 patients) or ergonovine spasm provocation test (2,880 patients) and vasospastic angina was diagnosed in 1,663 (2.4%) patients. Invasive spasm provocation tests were performed in 7.8% of patients with diagnostic catheterization and the spasm-positive rate was 31.6%. The difference among hospitals concerning the number of invasive spasm provocation tests was remarkable, and the angiographic spasm-positive standard and acetylcholine/ergonovine dose varied among the hospitals. CONCLUSIONS: Guidelines on coronary spasm in Japan are essential to overcome the current differences between institutions.

Angina Pectoris, Variant↗
PubMed1981

Noninvasive detection of coronary artery disease by myocardial imaging with thallium-201--the significance of pharmacologic interventions.

We obtained myocardial imaging with Tl during pharmacologic interventions. Dipyridamole-loading myocardial imaging was performed in 38 patients with CAD. The diagnostic accuracy of this method was 66%. The combination of dipyridamole-loading and exercise stress myocardial imaging increased the diagnostic sensitivity of CAD from 71% (exercise stress imaging only) to 87%. In addition, dipyridamole-loading myocardial imaging was useful for the diagnosis of CAD in patients who could not perform exercise stress test. Chest pain and ST-segment depression were induced less often during dipyridamole administration than exercise stress test. Animal experiments showed that dipyridamole caused abnormalities in myocardial blood flow and myocardial Tl uptake distal to the critical coronary stenosis. And dipyridamole increased myocardial blood flow by 142% and myocardial Tl concentration by 62% in the normally perfused myocardial segments. Ergonovine-loading myocardial imaging was performed in 8 patients with resting angina and without significant coronary stenosis. And in all of them, ergonovine induced cold-spots on myocardial imaging with or without chest pain and ST-segment shift. Ergonovine-loading myocardial imaging was useful for the diagnosis of angina induced by coronary artery spasm. The combination of initial and delayed resting myocardial imaging was useful to differentiate the underperfused but viable myocardium from the scar. And by comparing with radionuclide angiography obtained before and after NTG administration, NTG-loading myocardial imaging and ECG findings in 20 patients with CAD, we demonstrated that the transient defective myocardial segments were underperfused but viable.

Adult↗
PubMed1982

Assessment of left ventricular relaxation in the diseased heart in man.

To examine the exponential nature of the left ventricular pressure (LVP) fall during isovolumic relaxation (IRP) in 59 patients (normal (N), 6; angina pectoris (AP), 13; myocardial infarction (MI), 24; and congestive (CCM, 6) and hypertrophic (HCM, 10) cardiomyopathies), LVP and dP/dt were measured by a Millar's catheter-tipped transducer. In P vs time relation during IRP was reasonably fitted by a straight line (r greater than 0.97) in all cases. Time constant (msec) in CCM (56.9 +/- 10.7), HCM (44.8 +/- 12.4) and MI (43.8 +/-7.4 higher (p less than 0.05) than in N (30.3 +/- 5.5), and peak (-) dP/dt (mmHg/sec) was lower (841 +/- 171, 1152 +/- 397 and 1270 +/- 211, respectively; p less than 0.05) than in N (1885 +/- 150), suggesting impaired LV relaxation in these groups. However, (-) dP/dt upstroke pattern was exponential only in both N and 8 of the AP. The (-) dP/dt upstroke in the remaining groups lost its exponential nature, showing rather a down ward-convex curvature which was especially prominent in CCM. This indicates non-exponential fall of LVP during IRP. Thus, the present results suggest that impaired relaxation disturbs the exponential nature of LV relaxation.

Adult↗
PubMed1983

The usefulness of Holter monitoring in the evaluation of antiarrhythmic drug efficacy for tachycardia.

Using Holter monitoring tachycardia was found in 145 out of 2058 patients suffering from various underlying diseases. Three thousand seven hundred and forty monitorings were performed. The mean age of patients was 54.5 years with a range of 19 to 83 years. The observed tachycardia was classified into three types: tachycardia with short duration, tachycardia with long duration and tachycardia with complex form. The attacks of tachycardia were more frequently observed during periods of physical activity than during sleeping periods. The relationship of the number of tachycardia with short duration between 24-hour Holter monitorings was examined in order to establish day to day variability of the attacks. The 95% confidence interval about the resultant regression line was calculated and the percent reduction required for the evaluation of drug efficacy to avoid the chances of interference of spontaneous variation was found to be about 44.0, 55.0 and 82% when the total number of attacks during a 24-hour period were 50, 100 and 1,000, respectively. Holter monitoring showed higher positive results as compared to exercise testing for detection of tachycardia. Higher correlation coefficients between numbers of premature ventricular contractions (PVCs) and the plasma concentrations of procainamide or N-acetylprocainamide were observed in 3 or more successive PVCs than in individually occurring PVCs. Using repeated 24-hour Holter monitorings a significant reduction in the number of tachycardia was observed when the therapeutic concentration was reached after the combined or single administration of the drug. These results suggest that repeated Holter monitorings, exercise testing and determination of plasma level of the drug may be useful for the evaluation of antiarrhythmic drug efficacy for tachycardia.

Adult↗
PubMed1989

Clinical characteristics of sudden cardiac death in patients with vasospastic angina.

Of 383 patients with vasospastic angina who were followed for a period of 3.2 +/- 0.1 years, 9 (2%) died suddenly from cardiac causes. Calcium antagonists had been given to 98% of our patients. Only one patient who died suddenly had a fixed coronary stenosis of 75% or greater. Eight of the 9 patients showed ST segment elevation during anginal attack at rest, and 3 patients showed ST segment elevation at both anterior and inferior leads. Sudden death occurred in 6 of 41 patients (12.5%) who were documented to have multivessel coronary spasm, but in only 3 of 342 patients (1%) who had single vessel spasm (p less than 0.01). Serious arrhythmia occurred during anginal episode in 3 of 9 patients who died suddenly (53%) and in 52 of 374 who did not (14%). These results suggest that the frequency of sudden cardiac death was rather low in Japanese patients with vasospastic angina. The risk of sudden death was increased in patients with multivessel spasm and serious arrhythmia during anginal attacks but not these with fixed coronary stenosis.

Adult↗