Coronary Anatomy In Patients Research Articles

Role of Coronary CT Angiography in the Evaluation of Acute Chest Pain and Suspected or Confirmed Acute Coronary Syndrome

Advances in CT technology have resulted in improved imaging of the coronary anatomy in patients with stable coronary artery disease, using coronary CT angiography (CCTA). Recent data suggest that CCTA may play a role in higher risk patients, such as those evaluated in the emergency room with acute chest pain. Data thus far support the use of CCTA in low-risk patients with acute chest pain. Recent literature suggests that CCTA may play a role in the risk stratification of selected intermediate-risk patients. In this review, the authors discuss the emerging role of CCTA in higher risk patients, such as those with suspected or confirmed acute coronary syndrome (ACS). The excellent accuracy of CCTA in detecting obstructive coronary artery disease in patients with ACS is detailed, along with a highlighting of the safety of using CCTA in this setting. The authors also discuss the role for CCTA atheromatous plaque characterization, which is being increasingly recognized as an important predictor of clinical outcomes.

Abnormal coronary anatomy in patients with atrial switch: a predictor of serious cardiac adverse event?

Abstract Introduction Sudden death and heart failure are severe long-term complications after atrial switch for D-transposition of the great arteries (D-TGA). Mechanisms and factors of long-term complications are poorly known. Right ventricle ischemia may be involved in these complications. Since coronary malformations are present in about 30% of D-TGA, we aimed to look for an association between these complications and the presence of coronary anomalies. Methods The study is an observational international study in two tertiary centers. Adults with history of atrial switch and severe rhythmic or hemodynamic complications, history of heart transplantation or cardiovascular death were included. Patients under 18 years old and/or with corrected transposition of great arteries were excluded. A χ2 test was used to compare the proportion of coronary anomalies in this cohort to the one from population of D-TGA reported in previous studies. Results Forty-two patients were included: 11 women (26.2%) and mean age at the time of the study was 43.3±6.4 years. Eight patients (19.0%) died at a mean age 41.3±9.0 years. No ablation for ventricular tachycardia was reported while 15 (35.7%) patients underwent ablation for a SVT (supraventricular tachycardia). Thirty three patients (78.6%) suffered from heart failure and/or severe right ventricle dysfunction and 4 patients (9.5%) were transplanted at a mean age of 29.3±8.3 years. Ten (23.8%) patients suffered from both arrhythmic events and heart failure. Twelve patients (28,6%) had abnormal coronary anatomy. The χ2 test showed no significant difference of coronary anatomy between our population and a pooled population of 647 D-TGA from previous studies (28.7%, p=0.9804). By multivariate analysis, severe pulmonary hypertension and severe tricuspid regurgitation were significantly associated with cardiovascular death and/or heart transplantation (respectively: p=0.0323, OR= 2.5, and p=0.0494, OR= 4.0). SVT ablation tended to be associated to survival (p=0.0928 with OR= 2.2). Conclusions No difference of coronary anomalies ratio in complicated Mustard or Senning patients was seen in comparison with the coronary anomalies ratio of all D-TGA. These results plead against a role of abnormal coronary anatomy in right ventricle dysfunction. Ischemia may be more related with the alteration of micro vascularization and a mismatch between oxygen needs and supply. Funding Acknowledgement Type of funding source: None

Abnormal Coronary Anatomy in Patients with Transposition of the Great Arteries and Atrial Switch: A Predictor of Serious Cardiac Adverse Events?

Sudden cardiac death and heart failure are well known long-term complications after atrial switch for D-transposition of the great arteries (D-TGA). Right systemic ventricular dysfunction is common and myocardial ischemia has been implicated as a putative mechanism for sudden death, with coronary anomalies prevalent in 30% of cases. We sought to assess an association between adverse events and coronary anomalies in patients with D-TGA and atrial switch surgery. An observational study was conducted in 3 tertiary centers (Montreal Heart Institute, Canada, Nationwide Children’s hospital, Chicago, USA and Hopital cardiologique Louis Pradel de Lyon, France). Adults with D-TGA and atrial switch surgery qualified for inclusion if they had a major adverse cardiovascular event (MACE), i.e., ventricular arrhythmia, sudden cardiac death, heart failure, cardiac transplantation, or cardiovascular death. The prevalence of coronary anomalies was compared to historical controls. Forty-five patients were included. Twenty-one (46.7%) patients experienced a ventricular arrhythmia and 35 (77.8%) suffered from symptomatic heart failure and/or severe right ventricular dysfunction. Twelve patients (26.7%) had congenitally abnormal coronary arteries. There was no difference in the prevalence of coronary anomalies between the cohort with a MACE and a pooled population of 647 historical controls with D-TGA (28.7%, p = 0.89). In conclusion, the prevalence of congenital coronary anomalies is not higher in patients with D-TGA and atrial switch surgery who had adverse cardiovascular events. It could be hypothesized that ischemic complications in this patient population are more likely to be related to a supply-demand mismatch of the distal microvasculature rather than proximal coronary anomalies.

Preoperative echocardiographic determination of the coronary anatomy in patients with transposition of the great arteries - helping or confusing the surgeon?

In this single center observational study we aimed to determine the accuracy of echocardiography in diagnosing the coronary artery anatomy in neonates with d-transposition of the great arteries before arterial switch operation and to evaluate the impact of an incorrect echocardiographic diagnosis on the intra- and postoperative course after surgery. Therefore, 131 neonates with (simple) d-transposition of the great arteries, diagnosed from 2004 to 2017, were analyzed. Coronary artery patterns described in preoperative echocardiography were compared to intraoperative findings and accuracy was evaluated concerning impact on the intra- and postoperative course. Intraoperatively, usual coronary artery anatomy (1LCx2R) was described in 90 patients (69%) and coronary artery variants in 41 patients (31%, 1L2RCx n = 18, others n = 23). Overall, echocardiographic diagnosis was correct in 69% (n = 90). When classifying in usual coronary artery anatomy vs. coronary artery variant, echocardiographic diagnosis was correct in 77.1% (92% in usual coronary artery versus 20% in coronary artery variants). While univariate analysis showed significantly longer duration of surgery (261 vs. 276 min, p = 0.042) and extracorporeal circulation time (165 vs. 178 min, p = 0.026) in patients with an incorrect preoperative echocardiographic diagnosis, multivariate analysis showed no influence of an incorrect diagnosis or of coronary artery pattern on the intraoperative course. The postoperative course was not significantly different in both groups. In conclusion, accuracy of echocardiographic diagnosis of coronary artery anatomy is high in usual coronary pattern (92%) but low in coronary artery variants (20%). A wrong echocardiographic diagnosis is not associated with an unfavorable intra- and postoperative course after arterial switch operation.

The role of GRACE score in the prediction of high-risk coronary anatomy in patients with non-ST elevation acute coronary syndrome.

In patients with non-ST elevation acute coronary syndrome (NSTE-ACS), identification of the patients with high-risk coronary anatomy (HRCA) who are most likely to require coronary artery bypass grafting (CABG) is crucial. The SYNTAX score (SXscore) is an angiographic grading tool designed to determine the complexity of coronary artery disease. It appears that CABG offers significantly better outcomes in patients with SXscore ≥ 33, which shows severe HRCA. We sought to assess the accuracy of the GRACE score in predicting HRCA in terms of SXscore in patients with NSTE-ACS. Patients admitted to our coronary unit with a diagnosis of NSTE-ACS and undergoing coronary angiography during hospitalisation were recruited to this study. Patients were categorised into two groups based on SXscore: HRCA (SXscore ≥ 33) and low-risk coronary anatomy (LRCA, SXscore < 33). The cut-off level of GRACE score for HRCA was established by receiver operator characteristic (ROC) analysis. We studied 207 consecutive patients (mean age: 59 ± 11 years, 27.5% female). The GRACE score was 139 ± 34 in the HRCA group and 114 ± 33 in the LRCA group (p = 0.001). There was a significant positive correlation between SXscore and GRACE score (r = 0.338, p < 0.001). The area under ROC curve for GRACE score was 0.71 (95% CI 0.60-0.81, p = 0.001). A GRACE score of 123 was identified as the optimal cut-off to predict HRCA with a sensitivity of 71% and a specificity of 60%. In multivariate regression analysis, GRACE score ≥ 123 was the only variable that identified HRCA (OR 2.8, 95% CI 1.18-6.6, p = 0.019).Conclusions: Our study demonstrates that, in the setting of NSTE-ACS, patients with HRCA, who are most likely to require CABG, have higher GRACE scores at presentation. However, the ability of GRACE score to predict HRCA was modest.

Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study

Objectives To determine if coronary computed tomographic angiography enhances prediction of perioperative risk in patients before non-cardiac surgery and to assess the preoperative coronary anatomy in patients who experience a...

OP-079 The Role of GRACE Score in Prediction of High Risk Coronary Anatomy in Patients with Non-ST Elevation Acute Coronary Syndrome

Background: In patients with non-ST elevation acute coronary syndrome (NSTE-ACS), identification of the patients with high-risk coronary anatomy (HRCA) who are most likely to require coronary artery bypass grafting (CABG) is crucial. The SYNTAX score (SXscore) is an angiographic grading tool designed to determine the complexity of coronary artery disease. It appears that CABG offers significantly better outcomes in patients with SXscore ≥ 33, which shows severe HRCA. Aim: We sought to assess the accuracy of the GRACE score in predicting HRCA in terms of SXscore in patients with NSTE-ACS. Methods: Patients admitted to our coronary unit with a diagnosis of NSTE-ACS and undergoing coronary angiography during hospitalisation were recruited to this study. Patients were categorised into two groups based on SXscore: HRCA (SXscore ≥ 33) and low-risk coronary anatomy (LRCA, SXscore < 33). The cut-off level of GRACE score for HRCA was established by receiver operator characteristic (ROC) analysis. Results: We studied 207 consecutive patients (mean age: 59 ± 11 years, 27.5% female). The GRACE score was 139 ± 34 in the HRCA group and 114 ± 33 in the LRCA group (p = 0.001). There was a significant positive correlation between SXscore and GRACE score (r = 0.338, p < 0.001). The area under ROC curve for GRACE score was 0.71 (95% CI 0.60–0.81, p = 0.001). A GRACE score of 123 was identified as the optimal cut-off to predict HRCA with a sensitivity of 71% and a specificity of 60%. In multivariate regression analysis, GRACE score ≥ 123 was the only variable that identified HRCA (OR 2.8, 95% CI 1.18–6.6, p = 0.019). Conclusions: Our study demonstrates that, in the setting of NSTE-ACS, patients with HRCA, who are most likely to require CABG, have higher GRACE scores at presentation. However, the ability of GRACE score to predict HRCA was modest.

DOES GRACE SCORE INCREMENT PROGNOSTIC ASSESSMENT AFTER ANGIOGRAPHY IN ACUTE CORONARY SYNDROMES?

Rational: The GRACE Score assessed at admission predicts mortality in patients with non-ST elevation acute coronary syndromes (ACS). However, once coronary anatomy is assessed, it is not known whether this score increments prognostic assessment. Objective: To test the hypothesis that the GRACE Score adds prognostic value to coronary anatomy in patients with ACS. Methods: Prospective cohort, including patients with ACS who underwent coronary angiography while admitted to the hospital. Anatomical extension of coronary disease was characterized by the Duke Jeopardy score (DJS) and the number diseased artery (NDA). The primary end-point was the composite of death, non-fatal MI or refractory unstable angina. Results: 112 patients enrolled, aged 70 ± 12, 14% incidence of cardiovascular events. C-statistics for GRACE was 0.68 (95%CI=0.53-0.84), for DJS was 0.78 (95%CI=0.67-0.9) and for NAD was 0.74 (95%CI=0.61-0.88). Logistic regression analysis demonstrated independent predictive value of GRACE in relation to anatomical information. However, when this Score was added to DJS or NDA, no improving in c-statistic was observed: DJS-GRACE had a c-statistics of 0.78 (95%CI=0.64–0.92) and NAD-GRACE of 0.76 (95%CI=0.60–0.92). Conclusion: The GRACE score does not add prognostic value to angiographic data in patients with ACS.

Coronary computed tomography as an alternative to invasive coronary angiography in the evaluation of patients referred for valvular disease surgery

Background: Coronary angiography is routinely performed in most patients referred for valvular or thoracic aortic disease surgery. Coronary computed tomography (CT) angiography is currently the only alternative to invasive angiography in the evaluation of coronary anatomy. Aim: An assessment of the usefulness of dual-source CT for the evaluation of coronary anatomy in patients before planned cardiac valvular surgery. Methods: 98 consecutive patients with a haemodynamically significant valvular heart disease and guideline based indications for coronary angiography to exclude CAD before planned valvular surgery were included. Exclusion criteria were: cardiac arrhythmia (atrial fibrillation, frequent ventricular and supraventricular premature beats), estimated glomerular filtration rate 1000. In the remaining patients, complete CT evaluation was performed with the administration of a contrast agent. Conventional invasive coronary angiography was subsequently performed in patients with at least one > 50% stenosis, artifacts due to calcifications, or motion artifacts. Results: In 79 (80.6%) patients, CT angiography excluded the presence of a significant coronary artery stenosis without the need for invasive angiography. Conventional coronary angiography was required in 19 (19.4%) patients, including 13 (13.3%) patients with a > 50% stenosis in CT angiography, 2 (2%) patients with calcification artifacts, 1 (1%) patient with motion artifacts, 2 (2%) patients with CACS > 1000 in whom CT angiography was nor performed, and 1 (1%) patient with allergic symptoms during administration of a test dose of the contrast agent. Ultimately, significant CAD was diagnosed in 9 (9.2%) patients in whom coronary artery bypass surgery was also performed. In addition, cardiac CT angiography revealed vascular anomalies in 5 (5.1%) patients. In 14 patients, CT angiography was also used for previously planned evaluation of a coexisting aortic aneurysm. Conclusions: Coronary CT angiography may be useful to exclude significant CAD in patients referred for valvular disease surgery. It also allows concomitant evaluation of other cardiac structures, large vessels including the thoracic aorta, and calcifications within the aorta, aortic valve and mitral apparatus.

208 Relationship between erectile dysfunction and coronary anatomy in patients with ischemic heart disease debut

208 Relationship between erectile dysfunction and coronary anatomy in patients with ischemic heart disease debut

Coronary anatomy characteristics in patients with isolated right bundle branch block versus subjects with normal surface electrocardiogram

Introduction and objectiveIsolated right bundle branch block is a common finding in the general population. It may be associated with variations in detailed coronary anatomy characteristics. The aim of this study was to investigate the coronary anatomy in patients with isolated right bundle branch block and to compare that with normal individuals. MethodIn this case–control study we investigated the coronary anatomy by reviewing angiographic films in two groups of normal coronary artery patients: patients with right bundle branch block (RBBB) (n = 92) and those with normal electrocardiograms (n = 184). ResultsThere was no significant difference between the two groups in terms of diminutive left anterior descending artery, dominancy, number of obtuse marginal artery, diagonal, acute marginal artery, the position of the first septal versus diagonal branch, presence of ramus artery, and size of left main artery. The number of septal branches was higher in the case group (p-value <0.001). Origination of the atrioventricular node artery from the right circulatory system was more common in both groups but cases showed more tendency to follow this pattern (p-value = 0.021). The frequency of the normal conus branch was higher in the cases versus controls (p-value = 0.009). ConclusionsCoronary anatomy characteristics are somewhat different in subjects with RBBB compared to normal individuals.

Thoracic aortic atheroma severity predicts high-risk coronary anatomy in patients undergoing transesophageal echocardiography.

IntroductionWe hypothesized a relationship between severity of thoracic aortic atheroma (AA) and prevalence of high-risk coronary anatomy (HRCA).Material and methodsWe investigated AA diagnosed by transesophageal echocardiography and HRCA diagnosed by coronary angiography in 187 patients. HRCA was defined as ≥ 50% stenosis of the left main coronary artery or significant 3-vessel coronary artery disease (≥ 70% narrowing).ResultsHRCA was present in 45 of 187 patients (24%). AA severity was grade I in 55 patients (29%), grade II in 71 patients (38%), grade III in 52 patients (28%), grade IV in 5 patients (3%), and grade V in 4 patients (2%). The area under receiver operating characteristic curve for AA grade predicting HRCA was 0.83 (p = 0.0001). The cut-off points of AA to predict HRCA was > II grade. The sensitivity and specificity of AA > grade II to predict HRCA were 76% and 81%, respectively. After adjustment for 10 variables with significant differences by univariate regression, AA > grade II was related to HRCA by multivariate regression (odds ratio = 7.5, p< 0.0001). During 41-month follow-up, 15 of 61 patients (25%) with AA >grade II and 10 of 126 patients (8%) with AA grade ≤ 2 died (p= 0.004). Survival by Kaplan-Meier plot in patients with AA > grade II was significantly decreased compared to patients with AA ≤ grade II (p= 0.002).ConclusionsAA > grade II is associated with a 7.5 times increase in HRCA and with a significant reduction in all-cause mortality.

Effectiveness of Myocardial Perfusion Scintigraphy to Predict Coronary Anatomy in Patients with Non-ST Elevation Acute Coronary Syndrome

The risk stratification of conservatively managed patients presenting with non-ST elevation (NSTE) acute coronary syndromes (ACS) is frequently accomplished by the use of myocardial perfusion scintigraphy (MPS) in clinical practice. However, whether one can predict the extent of coronary artery disease (CAD) on angiography by MPS in this setting is unknown. In this study, the correspondence of findings on MPS to those on coronary angiography was retrospectively analyzed in 55 patients presenting with NSTE ACS. Patients' mean age was 64 years, 55% were men, and 87% had positive troponins. Of these patients, 42% of patients with perfusion defects involving the anterior wall presented with significant extensive CAD on coronary angiography, consisting of left main disease, 3-vessel disease, or 2-vessel disease involving the left anterior descending coronary artery. In patients with perfusion defects limited to 1 territory, 50% also had extensive CAD. A "negative" result on MPS was associated with extensive CAD in 37% of patients and the absence of significant lesions in only 8%. In conclusion, these findings suggest that MPS alone may be of limited clinical utility in distinguishing troponin-positive NSTE ACS patients with extensive CAD from those with more limited disease and should prompt further investigation of the use of MPS for this indication.

Multislice Computed Tomography Coronary Angiography: Risk Stratification of Patients in the Perioperative Period

Multislice computed tomography coronary angiography is emerging as a reliable non-invasive method for the assessment of coronary artery disease, coronary anatomy and cardiac function. Improvements in computed tomography technology hold the promise of replacing the standard invasive procedure of conventional coronary angiography in selected patient groups. The ability of a six-second scan to identify flow-limiting coronary artery stenoses as well as characterising coronary atheromatous plaque components provides valuable information that can assist in refining perioperative cardiovascular risk. Multislice computed tomography's high negative predictive value and high specificity for stenoses allows it to effectively rule out coronary artery disease in patients with cardiac risk factors who have non-diagnostic or equivocal non-invasive cardiac stress tests. Other uses include evaluating patients who are symptomatic following percutaneous coronary intervention, evaluating coronary artery bypass grafts and coronary stent patency, detecting coronary stenosis prior to valve surgery and assessing coronary anatomy in patients with technically difficult arterial access. Avoiding the small but definite risks of conventional coronary angiography makes cardiac computed tomography an appealing alternative. An overview of multislice computed tomography is presented with particular attention placed on its role in the risk stratification of selected patients in the perioperative period. A risk stratification algorithm is suggested.

Impact of Renal Insufficiency on Angiographic, Procedural, and In-Hospital Outcomes Following Percutaneous Coronary Intervention

Patients with chronic renal insufficiency (RI) have higher in-hospital mortality and major adverse cardiac event (MACE) rates after percutaneous coronary intervention (PCI). The mechanisms of this adverse course are not well understood. It was hypothesized that this worse outcome may be caused by inadequate PCI results secondary to more complex coronary anatomy in patients with RI. Baseline, procedural, and outcome variables of all PCI cases at the University Health Network are entered prospectively in the PCI Registry. All PCI cases between April 1, 2000, and October 31, 2005, excluding patients in shock, who had preprocedural creatinine clearance (CrCl) measured were included in this study (n = 10,821 of 11,023 patients). Moderate RI (CrCl <60 ml/min) was evaluated as an independent predictor of procedural outcomes, death, and MACE (defined as death, myocardial infarction, abrupt closure, or coronary artery bypass grafting). Moderate RI (CrCl <60 ml/min) independently predicted the procedural outcomes of worse residual stenosis >20% (p = 0.03), number of undeliverable stents (p = 0.003), and smallest stent diameter (p <0.001). Worst residual stenosis >20% and any undeliverable stent were significantly associated with in-hospital MACEs (odds ratio [OR] 3.97, 95% confidence interval [CI] 3.0 to 5.3, p <0.001 and OR 1.89, 95% CI 1.2 to 2.9, p = 0.002) and mortality (OR 3.82, 95% CI 2.2 to 6.7, p <0.001 and OR 3.0, 95% CI 1.6 to 5.9, p = 0.002). These risks were independent of all other measured variables. In conclusion, moderate to severe RI was a strong predictor of worse procedural results during PCI, which, in turn, were independent predictors of in-hospital MACE and mortality and independent contributors to the higher risk of in-hospital adverse events observed after PCI in patients with RI.

Computed tomographic coronary angiographic assessment of high-risk coronary anatomy in patients with suspected coronary artery disease and intermediate pretest probability

It is unclear if computed tomographic coronary angiography (CTA), an evolving technique for the evaluation of coronary artery disease (CAD), can identify patients with high-risk coronary anatomy. Among patients referred for invasive angiography at Hamilton Health Sciences (Hamilton, Ontario, Canada), those with an intermediate pretest probability (25%-60% likelihood of a significant stenosis) were prospectively identified using a multivariate risk score and were studied on a 64-detector Toshiba Aquilion scanner (Toshiba Medical Systems, Tokyo, Japan) before invasive angiography. Patients with high-risk anatomy (left main, 3-vessel CAD, or 2-vessel CAD involving the proximal left anterior descending artery) or at least 1 significant stenosis were identified on CTA and invasive angiography, and the results of these modalities were compared on a per patient basis. Eighty patients were enrolled in the study (mean age 56 +/- 9 years, male-female ratio 43:37). Nondiagnostic scan results were obtained in 5 patients (6%). By CTA, 13 patients had high-risk anatomy and 31 patients had at least 1 significant stenosis. For the per patient detection of high-risk anatomy, CTA had 100% sensitivity (95% CI 69%-100%), 95% specificity (95% CI 86%-95%), a positive likelihood ratio of 18.0 (95% CI 6.4-50.3), and a negative likelihood ratio of 0.05 (95% CI 0-0.072). Revascularization was performed in 100% of patients with high-risk anatomy on CTA, 83% with at least 1 significant stenosis on CTA, and 0% without a significant stenosis on CTA. In appropriately selected patients, CTA is a highly sensitive and specific technique for the detection of high-risk anatomy and maybe a valuable method for noninvasive risk stratification.

Abstract 2875: Long-Term Outcomes Following Vascular Surgery in Patients With Multivessel Coronary Artery Disease: Analysis of Randomized and Excluded Patients from the Coronary Artery Revascularization Prophylaxis (CARP) Trial

Background: The Coronary Artery Revascularization Prophylaxis (CARP) Trial was a multicenter randomized study that showed no long-term survival benefit with revascularization prior to elective vascular surgery in patients with stable coronary artery disease (CAD). To determine whether subsets with high-risk anatomy benefited from preoperative revascularization, survival was determined in randomized and registry patients who underwent coronary angiography within 6 months of vascular surgery. Methods: Over a 4-year enrollment period, 4,876 patients were screened prior to vascular surgery and 1,048 (21.5%) had preoperative coronary angiography for either multiple cardiac risks or an abnormal preoperative stress test. The cohort included 462 randomized and 586 excluded patients and the probability of survival was determined at 2.5 years following vascular surgery. Results: Of 1,048 patients with preoperative coronary angiography, non-obstructive disease (&lt; 70%) was present in 192 (18.3%) and 1 vessel disease (VD) was present in 244 (23.3%), with a combined survival of 0.84. Previous bypass surgery (CABG) was present in 225 (21.5%), with a survival of 0.78. High risk coronary anatomy in patients without prior CABG included 2-VD in 204 (19.5%), 3-VD in 130 (12.4%) and an unprotected left main stenosis &gt; 50% in 48 (4.6%) patients. Their long-term survival according to the preoperative revascularization status is shown in the Table . Conclusions: The results demonstrate that an unprotected left main stenosis was present in 4.6% of high-risk patients presenting for vascular surgery and was the only anatomical subset that demonstrated a survival benefit with preoperative revascularization prior to vascular surgery. These data may warrant additional strategies to identify patients with unprotected left main disease either prior to or immediately following vascular surgery. Long-Term Probability of Survival at 2.5 Years Following Vascular Surgery

A standardized definition of ischemic cardiomyopathy for use in clinical research

ObjectivesWe sought to evaluate the association between the extent of coronary artery disease (CAD) and survival in patients with symptomatic heart failure (HF) and to create the most prognostically powerful clinical definition of ischemic cardiomyopathy. BackgroundAn ischemic etiology of HF is known to be a predictor of adverse outcome; however, there is no uniform definition for ischemic cardiomyopathy. MethodsWe assessed the clinical history and coronary anatomy of patients with symptomatic HF and ejection fraction ≤40% undergoing diagnostic coronary angiography between 1986 and 1999 (n = 1,921). Five classification schemes were tested to identify the most prognostically powerful method for defining the extent of CAD and to develop the best definition of ischemic cardiomyopathy for prognostic purposes. ResultsA more extensive CAD was independently associated with shorter survival. When the various classification schemes were compared, a modified number-of-diseased-vessels classification, in which patients with single-vessel disease and no prior history of revascularization or myocardial infarction (MI) were classified as nonischemic, provided the most prognostic power. A definition of ischemic cardiomyopathy that incorporated this definition had more prognostic power than the traditional definition. ConclusionsAngiographically diagnosed ischemic HF is associated with shorter survival than nonischemic HF. A more extensive CAD is independently associated with shorter survival, and patients with single-vessel disease and no history of MI or revascularization should be classified as nonischemic for prognostic purposes. Standardization of the definition of ischemic cardiomyopathy will be useful in the conduct and interpretation of clinical research in HF.

Acute coronary syndromes: unstable angina and non-Q-wave myocardial infarction.

Ischemic heart disease includes a wide spectrum of conditions, ranging from silent ischemia and exertion-induced angina, through unstable angina, to acute MI. Unstable angina occupies the center of this spectrum, causing disability and risk greater than that of chronic stable angina but less than that of acute MI1 (Fig 1⇓). Although non–Q-wave MI for many years was considered prognostically similar to unstable angina, recent longitudinal studies indicate that it is similar to Q-wave infarction2 3 (Fig 2⇓). Figure 1. Cumulative 6-month mortality from ischemic heart disease. Diagnosis on admission to hospital (n=21 761; 1985 to 1992). From Duke Cardiovascular Database. Reproduced with permission from Reference 1. Figure 2. Top, Cumulative 1-year combined death or MI among patients with Q-wave and non–Q-wave MI treated with fibrinolysis. Reproduced with permission from Reference 2. Bottom, Risk of subsequent cardiac events in stable convalescing patients after first non–Q-wave and Q-wave MI. Reproduced with permission from Reference 3. The concept of unstable angina has emerged from observations of frequent symptoms preceding acute MI, followed by prospective documentation that unstable symptoms frequently culminated in acute MI. The syndrome was rapidly accepted as a well-defined clinical entity as specific clinical manifestations, pathophysiological mechanisms, laboratory findings, and treatment became better characterized. Unstable angina is currently one of the leading causes of hospital admission for CAD, and non–Q-wave MI accounts for >30% of admissions for acute MI.1 4 Yet, the diagnosis of unstable angina remains clinical, based on symptom recognition. The physician caring for patients with unstable angina is in a privileged position of recognizing rapidly evolving CAD and being able to intervene to prevent irreversible left ventricular damage and progression of CAD. Unstable angina is classically described as a heterogeneous disease, referring to a wide spectrum of clinical manifestations from stable angina to MI, of disease …

Nonatherosclerotic coronary artery disease: more than just stenosis.

Coronary angiography is most commonly performed to evaluate atherosclerotic coronary artery stenosis. However, it is important to be aware of the spectrum of coronary anomalies, including congenital and acquired nonatherosclerotic conditions. Potentially fatal congenital coronary anomalies may manifest at any age. If not recognized, such anomalies may prevent complete assessment of coronary anatomy in patients evaluated for atherosclerotic disease. Detection of coronary anomalies associated with congenital conditions, such as transposition of the great arteries, a single ventricle, or tetralogy of Fallot, is important prior to surgery to prevent complications and allow appropriate bypass during surgery. Acquired nonatherosclerotic coronary disease may occur as a primary abnormality or as part of a multisystem disorder and may mimic atherosclerotic disease. Although most nonstenosing coronary anomalies are uncommon or rare, they are individually important and many are treatable. Knowledge of variant coronary anatomy and the appearances of nonatherosclerotic coronary anomalies is essential for good patient care.