Extension Of Coronary Disease Research Articles

RESIDUAL CARDIOVASCULAR RISK AND SEVERITY OF CORONARY DISEASE

Abstract Background The presence of residual risk in patients with a history of atherosclerotic cardiovascular disease (ASCVD) is a cause of additional cardiovascular events. The aim of this study is to correlate residual cardiovascular risk with the severity of coronary disease. Methods We enrolled 52 patients hospitalized with a diagnosis of acute coronary syndrome from September to October 2023 at the Clinical and Rehabilitation Cardiology of the San Filippo Neri Hospital. All patients were treated with percutaneous and/or surgical coronary revascularization and had a history of ASCVD. Thirty of these patients had a single–vessel coronary disease and 22 had a multivessel coronary disease. We analyzed the main cardiovascular risk factors and the received therapies in both groups. Results Triglyceride levels were significantly higher in the group with a multivessel coronary disease (132.94 ± 65.41 mg/dl vs 94.06 ± 37.63 mg/dl; p=0.01) as well as the levels of glycated hemoglobin (50.91 ± 15.23 mmol/mol vs 42.92 ± 6.65 mmol/mol; p=0.01) and high–sensitivity C–reactive protein (hs–CRP, 1.25 ± 1.48 mg/dl vs 0.65 ± 0.46 mg/dl; p=0.04). We found no significant differences between the two groups for the other main cardiovascular risk factors and the therapies. Conclusions Our data show that higher levels of triglycerides, glycated hemoglobin and hs–CRP, an inflammatory biomarker, are associated with a more extensive coronary disease. This finding suggests that a better metabolic control, in terms of glycated hemoglobin and triglyceride levels, and inflammation could contribute to the reduction of coronary disease extension.

Association of Multiple Genetic Variants with the Extension and Severity of Coronary Artery Disease.

BackgroundMetabolic syndrome (MS) is a condition that, when associated with ischemic heart disease and cardiovascular events, can be influenced by genetic variants and determine more severe coronary atherosclerosis.ObjectivesTo examine the contribution of genetic polymorphisms to the extension and severity of coronary disease in subjects with MS and recent acute coronary syndrome (ACS).MethodsPatients (n = 116, 68% males) aged 56 (9) years, with criteria for MS, were prospectively enrolled to the study during the hospitalization period after an ACS. Clinical and laboratory parameters, high-sensitivity C-reactive protein, thiobarbituric acid reactive substances, adiponectin, endothelial function, and the Gensini score were assessed. Polymorphisms of paraoxonase-1 (PON-1), methylenotetrahydrofolate reductase (MTHFR), endothelial nitric oxide synthase (ENOS), angiotensin-converting enzyme (ACE), angiotensin II type 1 receptor (AT1R), apolipoprotein C3 (APOC3), lipoprotein lipase (LPL) were analysed by polymerase chain reaction (PCR) technique, followed by the identification of restriction fragment length polymorphisms (RFLP, and a genetic score was calculated. Parametric and non-parametric tests were used, as appropriate. Significance was set at p < 0.05.ResultsPolymorphisms of PON-1, MTHFR and ENOS were not in the Hardy-Weinberg equilibrium. The DD genotype of LPL was associated with higher severity and greater extension of coronary lesions. Genetic score tended to be higher in patients with Gensini score < P50 (13.7 ± 1.5 vs. 13.0 ± 1.6, p = 0.066), with an inverse correlation between genetic and Gensini scores (R = -0.194, p = 0.078).ConclusionsThe LPL polymorphism contributed to the severity of coronary disease in patients with MS and recent ACS. Combined polymorphisms were associated with the extension of coronary disease, and the lower the genetic score the more severe the disease.

TCT-293 Quantifying Total Atherosclerotic Burden Non-Invasively Through Coronary Computed Tomography Angiography: A Comparison With Multivessel Intravascular Ultrasound Data

Introduction: The extension of atherosclerotic disease is one the most powerful predictors of cardiovascular outcomes. Accurate methods that quantify coronary disease extension may be useful in assessing prognosis, guiding treatment and evaluating disease progression. While intravascular ultrasound (IVUS) is the gold-standard method to quantify atherosclerosis, coronary computed tomography angiography (CCTA) is a promising non-invasive alternative. Hypothesis: We compared previously proposed and novel CCTA scores to multivessel IVUS parameters in order to explore the best way to non-invasively assess the global extent of coronary atherosclerotic disease. Methods: Patients with high risk coronary disease referred for percutaneous coronary intervention were prospectively enrolled. For all cases, CCTA and multivessel IVUS imaging were obtained. Calcium score and 4 previously reported CCTA scores were calculated and compared to average IVUS derived percent atheroma volume (PAV). A novel score was created through comparison with IVUS. Spearman’s correlation coefficients were used to correlate score data with IVUS PAV. Receiver-operating characteristics (ROC) curves were created to establish the ability of each score to predict a PAV above the median. Results: 62 patients with a mean age of 59.7 ± 9.2 years were enrolled. 67.7% were males, 41.9% diabetics and 75.8% had multivessel coronary disease. In average, 3.8 ± 0.7 vessels, comprising 123.8 ± 31.3 mm in length, were imaged with IVUS per patient. All evaluated scoring systems, with the exception of the CONFIRM score, correlated significantly with IVUS derived percent atheroma volume. A novel “soft plaque” CCTA score, that excludes segments with purely calcified plaques, showed the strongest correlation with IVUS PAV (ρ=0.73, p Conclusion: A soft plaque score that takes into account the number of segments with significant non-calcified or mixed plaques correlates strongly - and better than previously described scores - with multivessel IVUS percent atheroma volume. This is possibly the most sensible way to quantify total coronary atherosclerotic burden non-invasively through CCTA.

Impact of Hypertension History on Short and Long-Term Prognosis in Patients with Acute Myocardial Infarction Treated with Percutaneous Angioplasty: Comparison Between STEMI and NSTEMI

Previous studies analyzing the impact of hypertension (HTN) on myocardial infarction (MI) outcome reached conflicting results and scarce data are available in patients treated with percutaneous coronary intervention (PCI). In this study the prognostic impact of HTN history in ST-elevation MI (STEMI) and Non-STEMI (NSTEMI) patients treated with PCI was analyzed. We compared characteristics of 1,031 STEMI and 437 NSTEMI patients, in relation to the presence of HTN. Median follow-up duration was 40.2months. HTN was significantly higher in NSTEMI vs. STEMI patients (p<0.001). NSTEMI patients were older, with higher values of left ventricular ejection fraction (LVEF) and more frequently with previous myocardial revascularization than STEMI patients either among hypertensives and non-hypertensives. At univariate analysis HTN resulted associated with long-term mortality in STEMI but not in NSTEMI patients. At multivariate analysis HTN was not associated with either in-hospital and long-term mortality in both NSTEMI and STEMI group. In conclusion, in the PCI era HTN does not influence MI patients prognosis; other factors, such as age, admission LVEF, coronary disease extension, previous MI and creatinine levels are independently associated with MI patients outcome even though this should not discourage from a strict control of HTN after the acute event.

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.

Acurácia dos escores GRACE e TIMI na predição da gravidade angiográfica da síndrome coronariana aguda

The accuracy of the GRACE and TIMI scores in predicting coronary disease extension in patients with non-ST-elevation acute coronary syndromes (ACS) has not been established. To assess the hypothesis that the GRACE and TIMI risk scores satisfactorily predict coronary disease extension in patients withnon-ST-elevation ACS undergoing coronary angiography. Individuals meeting the objective criteria for ACS and undergoing coronary angiography during hospitalization were consecutively assessed. Angiographic coronary disease was described as follows: quantification of coronary disease extension by using Gensini score; presence of any coronary artery obstruction (> 70% or > 50% when affecting left main coronary artery); and presence of severe disease (three-vessel disease or affecting the left main coronary artery). Of 112 patients assessed, a positive correlation of the Gensini score was observed with the GRACE (p = 0.017) and TIMI (p = 0.02) scores, but that association was weak (r = 0.23 and r = 0.27; respectively). The GRACE score could predict neither obstructive coronary disease (area under the ROC curve = 0.57; 95% CI = 0.46 - 0.69), nor severe coronary disease (ROC = 0.59; 95% CI = 0.48 - 0.70). The TIMI score proved to be a modest predictor of coronary disease (ROC = 0.65; 95% CI = 0.55 - 0.76) and of severe coronary disease (ROC = 0.66; 95% CI = 0.56 - 0.76). (1) There is a positive association between the values of the TIMI or GRACE scores and the extension of coronary artery disease in patients with ACS; (2) however, the degree of that association is not sufficient to make those scores accurate predictors of coronary angiography results.

Coronary Disease Extension Determines Mobilization of Endothelial Progenitor Cells and Cytokines After a First Myocardial Infarction With ST Elevation

Introduction and objectives Multivessel coronary disease is still a postinfarction prognostic marker despite new forms of reperfusion, such as primary angioplasty. The aim of this study was to determine the time sequence of various sets of endothelial progenitor cells and angiogenic cytokines (vascular endothelial growth factor, hepatocyte growth factor) according to the degree of extension of the postinfarction coronary disease. Methods We studied the release kinetics in 32 patients admitted for a first myocardial infarction with ST elevation, grouped according to whether they had single or multivessel disease, and 26 controls. Results The patients had a higher number of endothelial progenitor cells and angiogenic cytokines than the controls at all 3 measurements (admission, day 3, and day 7) of the following subsets: CD34, CD34+CD133+, CD34+KDR+, and CD34+CD133+KDR+CD45+(weak); this latter was higher on day 7. The levels of these cell subsets were all higher in the patients with single-vessel disease and at all 3 measurements. The vascular endothelial growth factor levels were raised during the first week and the hepatocyte growth factor showed an early peak on admission for infarction. No significant differences were seen in the cytokines according to coronary disease extension. Conclusions Although the release kinetics of different subsets of endothelial progenitor cells in patients with a first acute myocardial infarction with ST elevation was similar in those with single vessel disease to those with multivessel disease, the number of circulating endothelial progenitor cells was greater in the patients with single vessel disease. The vascular endothelial growth factor levels were raised during the first postinfarction week and the hepatocyte growth factor were higher on admission.

La extensión de la enfermedad coronaria determina la movilización de las células progenitoras endoteliales y las citocinas tras un primer infarto de miocardio con elevación del ST

Introduction and objectives Multivessel coronary disease is still a postinfarction prognostic marker despite new forms of reperfusion, such as primary angioplasty. The aim of this study was to determine the time sequence of various sets of endothelial progenitor cells and angiogenic cytokines (vascular endothelial growth factor, hepatocyte growth factor) according to the degree of extension of the postinfarction coronary disease. Methods We studied the release kinetics in 32 patients admitted for a first myocardial infarction with ST elevation, grouped according to whether they had single or multivessel disease, and 26 controls. Results The patients had a higher number of endothelial progenitor cells and angiogenic cytokines than the controls at all 3 measurements (admission, day 3, and day 7) of the following subsets: CD34, CD34+CD133+, CD34+KDR+, and CD34+CD133+KDR+CD45+(weak); this latter was higher on day 7. The levels of these cell subsets were all higher in the patients with single-vessel disease and at all 3 measurements. The vascular endothelial growth factor levels were raised during the first week and the hepatocyte growth factor showed an early peak on admission for infarction. No significant differences were seen in the cytokines according to coronary disease extension. Conclusions Although the release kinetics of different subsets of endothelial progenitor cells in patients with a first acute myocardial infarction with ST elevation was similar in those with single vessel disease to those with multivessel disease, the number of circulating endothelial progenitor cells was greater in the patients with single vessel disease. The vascular endothelial growth factor levels were raised during the first postinfarction week and the hepatocyte growth factor were higher on admission. Full English text available from: www.revespcardiol.org

B-type natriuretic peptide as an independent predictor of coronary disease extension in non-ST elevation coronary syndromes with preserved systolic function

B-type natriuretic peptide (BNP) has been employed as a risk marker in patients with coronary artery disease (CAD) with ST elevation and non-ST elevation. It is not yet established if early BNP measurements provide additional information to troponin and electrocardiographic analysis in patients without ventricular enlargement and systolic dysfunction. This study compared BNP levels in patients with stable angina (SA) and acute coronary syndromes with non-ST elevation in relation to angiographic lesions (NSTEMI-ACS). Moreover, the diagnostic utility of BNP was determined using the receiver operating characteristic curve. 280 patients with CAD without ST elevation and preserved systolic function were studied. BNP samples were measured in all recruited patients within 24 hours of hospitalization. BNP values increased progressively with the severity of diagnosis: SA (n = 85; 50.4 ± 50 pg/ml) NSTEMI-ACS (n = 195; 283 ± 269 pg/ml; p < 0.0001). The analysis of BNP in relation to the number of involved vessels demonstrated significantly increased levels in patients with multivessel disease compared to patients with 1- or 2-vessel disease (p < 0.001 and p < 0.003). Values of BNP >80 pg/ml were shown to be able to predict CAD severity and coronary vessel involvement (AUC = 0.80; p = 0.0001) with a sensitivity of 78% and a specificity of 72%. In multivariate analysis, BNP levels >80 pg/ml, CAD history, and ST deviation >2 mm were confirmed as independent predictors of CAD severity. Circulating BNP levels appear elevated in NSTEMI-ACS, without left ventricular systolic dysfunction. A BNP cut-off value of 80 pg/ml is a good predictor of CAD extension.

B-type natriuretic peptide levels predict extent and severity of coronary disease in non-ST elevation coronary syndromes and normal left ventricular systolic function

BackgroundB-type natriuretic peptide (BNP) has been used recently as a biological marker in patients with coronary artery disease (CAD) with ST-elevation, as well as without ST-elevation. BNP is able to predict systolic dysfunction, adding new prognostic information to existing traditional markers. However is not known if there is a relation between the quantity of BNP levels and the severity of coronary artery disease. MethodsThis study compared B-type natriuretic peptide (BNP) levels in patients with stable angina (SA) and acute coronary syndromes (ACS) without ST-elevation in relation to angiographic lesions using TIMI and Gensini Scores. We studied 282 patients with CAD without ST elevation and preserved systolic function. BNP samples were measured in all recruited patients within 24hours of hospitalization. ResultsBNP values were progressively increased in relation to the severity of diagnosis: SA (52.6±49.4pg/mL ) UA (243.3±212pg/mL) NSTE-ACS (421.7±334pg/mL) (p<0.0001 and p<0.007 respectively). No statistically significant difference was observed between patients with SA and controls (21.2±6.8pg/mL). The analysis of BNP levels in relation to the number of involved vessels demonstrated significantly increased levels in patients with multivessel disease compared to patients with 1 or 2 vessel disease (1–86.2±46.3pg/mL; 2–127±297pg/mL; 3–295±318pg/mL; 4–297±347pg/mL p<0.001 and p<0.003). Evaluation of BNP using Gensini Score showed a strong relation between BNP and coronary disease extension (r=0.38 p<0.0001).This trend was maintained in all CAD groups (SA=r 0.54; UA r=0.36 NSTE-ACS r=0.28). ConclusionsCirculating BNP levels appear elevated in ACS with diffuse coronary involvement, even in the absence of systolic dysfunction. BNP is also associated with multi-vessel disease and the extension of coronary disease.

Family history, diabetes and extension of coronary atherosclerosis are strong predictors of adverse events after PTCA: A one-year follow-up study

In this study we addressed some open questions in patients with coronary artery disease (CAD). First, we analysed which of the traditional risk factors was associated with the spreading of coronary stenosis and second, we aimed to identify if any variable was predictive of post-percutaneous transluminal coronary angioplasty (PTCA) clinical events. We collected a consecutive series of patients with CAD (n=301) and in the subgroup of patients undergoing PTCA (n=135) we performed a prospective one-year follow-up study recording cardiovascular morbidity and total mortality. According to the extension of coronary atherosclerosis, we found a significant relationship with the prevalence of diabetes in men and with plasma HDL-cholesterol concentrations in women. The follow-up was completed in 95% of patients; we did not document any death whereas clinical events were registered in 16% of patients. At univariate analysis, we found that patients with clinical events had a higher prevalence of family history of CAD (43% vs 14%, p<0.005), diabetes (52% vs 21%, p<0.005) and multivessel disease (52% vs 35%, p<0.05). Multivariate analysis (logistic regression) confirmed that family history of CAD (OR 4.6, 95% CI 1.7-12.8, p<0.005), diabetes (OR 4.0, 95% CI 1.5-10.6, p<0.01) and multivessel disease (OR 2.8, 95% CI 1.1-7.4, p<0.05) were the only variables predictive of clinical events. In this study, factors associated with the spreading of coronary stenosis were different according to the gender. Moreover, the presence of diabetes and multivessel disease had a negative impact on the long-term prognosis of patients undergoing PTCA. In addition, the family history of CAD represented in our study a strong predictor of clinical events. We suggest that in the management of post-PTCA patients, the role of individual baseline clinical characteristics must be taken into account and that subjects with a family history of premature CAD, diabetes and a wide extension of coronary disease represent those with the highest risk.

Periodontal disease among patients with acute coronary syndrome

Epidemiological studies suggest an association between periodontal disease and coronary heart disease. It is possible that periodontal disease may contribute to plaque destabilization in patients with acute coronary syndrome. To assess the association between severity of periodontal disease, the number of acute plaques and extension of coronary artery disease in patients with acute coronary syndrome. The severity of periodontal disease was assessed by skilled independent observers in patients with acute coronary syndrome subjected to coronary angiography. The periodental disease was classified as mild or severe. Acute plaques were defined on angiography as those with thrombi, ulcers or flow alterations. The extension of coronary disease was analyzed using the Sullivan score. Forty three patients (35 males) aged 41 to 83 years, were studied. Mild and severe periodontal disease was present in 18 (42%) and 25 (58%) patients respectively. Seventy six percent of those with severe disease had two or more acute plaques, compared with 17% of those with mild disease (p<0.001). Median Sullivan score was 80.6 and 57.2 in patients with severe or mild periodontal disease respectively (p=0.001). Severe periodontal disease was associated with a higher number of acute coronary plasques and a higher extension of coronary artery disease, in patients with acute coronary syndromes.

Enfermedad periodontal en pacientes con síndrome coronario agudo

Epidemiological studies suggest an association between periodontal disease and coronary heart disease. It is possible that periodontal disease may contribute to plaque destabilization in patients with acute coronary syndrome.To assess the association between severity of periodontal disease, the number of acute plaques and extension of coronary artery disease in patients with acute coronary syndrome.The severity of periodontal disease was assessed by skilled independent observers in patients with acute coronary syndrome subjected to coronary angiography. The periodental disease was classified as mild or severe. Acute plaques were defined on angiography as those with thrombi, ulcers or flow alterations. The extension of coronary disease was analyzed using the Sullivan score.Forty three patients (35 males) aged 41 to 83 years, were studied. Mild and severe periodontal disease was present in 18 (42%) and 25 (58%) patients respectively. Seventy six percent of those with severe disease had two or more acute plaques, compared with 17% of those with mild disease (p<0.001). Median Sullivan score was 80.6 and 57.2 in patients with severe or mild periodontal disease respectively (p=0.001).Severe periodontal disease was associated with a higher number of acute coronary plasques and a higher extension of coronary artery disease, in patients with acute coronary syndromes.

Relation of C-reactive protein to extent and complexity of coronary narrowing in patients with non-ST elevation acute coronary syndromes. A prospective cohort study

Inflammatory markers have been associated with adverse clinical outcome in patients with acute coronary syndromes (ACS). In addition, angiographic plaque morphology and extension of coronary artery disease has been related to worse prognosis in this group of patients. The aim of the present study was to determine if the clinical prognostic value of C-reactive protein (CRP), an inflammatory marker, can by associated with the angiographic findings in patients with non-ST elevation ACS. This prospective multicenter cohort study included 1253 patients with non-ST elevation ACS. CRP, which was considered positive (+) if >/=3 mg/l, was measured at a median of 9 h from symptoms onset and were kept blinded until the end of the study. Coronary angiography was performed in 633 patients (50%). The presence of complex coronary lesions (CCLs) was defined as the presence of any of the following: thrombus (+), Thrombolysis In Myocardial Infarction (TIMI) flow </=2, and/or ulcerated plaque (UP). The extension of coronary disease was defined as one, two or three vessel disease. CRP was found to be (+) in 354 patients (60%). CCLs were present in 266 patients (46%), 166 (47%) in CRP (+) and 100 (42%) in CRP negative (-) patients, P=0.31. There was also no association between the extension of coronary disease and the CRP levels. In this large consecutive cohort of non-ST elevation ACS patients, CRP, an inflammatory marker, does not predict either the extension or the complexity of coronary disease. Even though CRP is a strong predictor of worse clinical outcome in patients with ACS, this could not be explained by the angiographic anatomic findings.

Plasma brain natriuretic peptide levels in coronary heart disease with preserved systolic function

We evaluated the circulating levels of brain natriuretic peptide (BNP) in stable angina, unstable angina, and myocardial infarction relating hormone levels to extension of coronary disease and number of vessels involved after angiographic examination. We studied 86 patients consecutively undergoing angiographic coronary examination and echocardiographic evaluation for coronary heart disease. These included 15 control subjects (group 0), 21 with stable angina (group I), 26 with unstable angina (group II), and 24 with non-Q myocardial infarction (group III). Patients with heart failure, a history of myocardial infarction, or recent myocardial damage with electrocardiographic S-T elevation were excluded. BNP levels in patients with unstable angina and myocardial infarction were significantly increased with respect to the group with stable angina (P<0.01). There were no differences between the groups with unstable angina and myocardial infarction. Analysis of peptide levels in relation to the number of involved vessels demonstrated a significant increase in patients with three-vessel disease compared with subjects with one or two vessels involved (P<0.03); among subjects with mono-vessel disease, patients with left descendent anterior stenosis had a more-marked BNP elevation than subjects with stenosis in other regions (P<0.01). Hence, BNP levels appear to be elevated in coronary disease, especially in acute coronary syndromes, even in the absence of systolic dysfunction. BNP levels also seem to be related to the severity of coronary atherosclerosis and number of vessels involved. BNP could prove a novel marker for risk stratification, not only in heart failure but also in coronary heart disease.

Significado do supradesnivelamento ST de esforço em doentes com enfarte do miocárdio.

In 52 patients with previous myocardial infraction, 49 men and 3 women (mean age 56 +/- 7.1 years) the significance of ST-segment elevation during the stress-test, was evaluated. Of the 52 patients 15 (29%) showed St-segment elevation and 37(71%), showed no alteration of the ST-segment. Extension of coronary disease, degree of obstruction, wall motion abnormalities and the presence of residual ischemia were evaluated by coronary angiography, technetium-99M pyrophosphate imaging and exercise TL-201 scintigraphy. From the results of the study one may conclude that, in patients with previous myocardial infraction exercise, ST-segment elevation is a consequence of sub-occlusion of the left anterior descending coronary artery with severe ventricular dysfunction either in patients with one or multiple vessel disease.

Evaluation of left ventricular performance in coronary heart disease: Use of isometric handgrip stress test

The usefulness of isometric handgrip exercise in the assessment of left ventricular function was studied in 27 patients, all of whom had angiographically documented coronary artery disease. The effect of extensiveness of coronary disease and presence or absence of collaterals (both delineated by coronary arteriography) on the response to handgrip stress was also evaluated. Of 11 patients with a normal handgrip response, 4 exhibited a normal left ventriculogram and 7 were abnormal. Of these 7, 6 had inferior hypokinesis. Conversely, of 16 patients with an abnormal response to handgrip, 15 had abnormal ventriculograms. Of these, 9 had anterior akinesis. Of patients with a normal handgrip response 82% had two- or three-vessel coronary disease, and 94% with an abnormal response exhibited two- or three-vessel obstruction. There was no observed correlation between the presence or absence of collaterals and the response to handgrip. This study indicates that (1) handgrip stress, when combined with left ventriculography, often yields important additional information regarding the effect of localized contraction abnormalities on overall left ventricular performance; (2) the extent of coronary obstructive disease or the presence of collaterals per se do not appear to be the primary determinants of left ventricular performance; (3) it is possible that the location as well as severity and extent of left ventricular contraction abnormality may play an important role in determining overall left ventricular performance.