Non-coronary Heart Disease Research Articles

Abnormal nondetect zone myocardial thallium washout ratio in patients with reversible thallium defects and normal coronary arteriograms

Thallium myocardial defects in patients with no angiographic coronary artery stenosis have been attributed to attenuation effects and other artifacts. Of 323 patients having thallium myocardial imaging following dipyridamole infusion, 10 of 159 patients with a segmental perfusion abnormality were found to have no luminal diameter stenosis >20% on coronary angiography and no electrocardiographic (ECG) evidence of myocardial infarction or left bundle branch block. A time-standardized regional thallium washout ratio was calculated as thallium myocardial counts with dipyridamole to counts without dipyridamole. In comparison to 10 age-matched control patients with no evidence of cardiac disease and no myocardial thallium defect, study patients had a lower regional myocardial thallium washout ratio from both the defect and nondefect (1.57 ± 0.40 versus 2.27 ± 0.92, p = 0.041) zones. Nine of the 10 study patients had independent evidence of noncoronary heart disease, including echocardiographic or ECG evidence of left ventricular hypertrophy in six patients. In patients with thallium defects and normal coronary arteriograms, a time-standardized regional thallium myocardial washout ratio for the nondefect zone may aid in the differentiation of patients with noncoronary heart disease from those with soft tissue artifacts.

Thallium-201 Single Photon Emission Computed Tomography in Patients with Symptoms of Heart Disease and Non-Significant Coronary Artery Lesions

Polar presentations of coronary angiograms and myocardial 201Tl SPECT were compared in 44 patients without significant coronary artery disease (less than 50% stenosis at angiography). Regions of reduced isotope activity (defects) were present in 18 patients (41%). Nine of these had angiographic and/or clinical evidence of non-coronary heart disease, such as documented or suspected myocardial infarction, dilated cardiomyopathy or other myocardial diseases. Such defects could be caused by impaired small vessel blood flow, abnormalities in cell membrane transport or relative differences in left ventricular wall thickness. In 9 patients defects were probably due to attenuation artifacts. Defects in patients with heart diseases were significantly larger than in those without obvious disease. The information content in coronary angiography and 201Tl SPECT overlap but are not congruent. Coronary angiography describes morphology of large coronary vessels, whereas 201Tl SPECT contains information of large and small vessel perfusion as well as membrane transport of 201Tl ions.

Evaluation of left ventricular diastolic function using an ambulatory radionuclide monitor: Relationship to left ventricular systolic performance

Abnormalities of left ventricular (LV) filling may occur prior to systolic dysfunction in patients with both coronary and noncoronary heart disease. To determine the incidence of diastolic dysfunction and to assess the relationship of such dysfunction to systolic performance, we measured systolic and diastolic function at rest in a series of healthy volunteers ( n = 10) and in patients with cardiovascular disease ( n = 42). Twenty patients had coronary artery disease (CAD) with prior myocardial infarction, six patients had CAD without myocardial infarction, and the remaining 16 patients had a variety of noncoronary heart diseases, including valvular heart disease, dilated cardiomyopathy, and hypertensive disease. The 42 patients manifested a wide variation in LV systolic function (ejection fractions ranged from 6% to 65%). Patients with reduced LV ejection fraction (EF) manifested a reduction in cardiac output and peak ejection rate proportionate to the reduction in EF. Diastolic function showed a fall in LV peak (PFR) and average (AFR) filling rates; these were reduced in proportion to the fall in EF. Heart rate was an insensitive index of the magnitude of impairment of LV systolic function. These data suggest that measurements of diastolic function do not provide additional information in patients with impaired systolic function.

Feasibility and cost-saving potential of outpatient cardiac catheterization

To determine the feasibility and cost-saving potential of substituting outpatient for inpatient cardiac catheterization, 986 consecutive procedures were studied at a large referral hospital. Patients were classified prospectively as to their eligibility for outpatient cardiac catheterization according to published guidelines. Resource consumption was recorded, and cost savings were then calculated by analyzing the specific supply and personnel costs that could change as a result of inpatient versus outpatient status. Of the total of 986 patients who underwent diagnostic catheterization, 240 (24%) were outpatients, 279 (28%) were inpatients but had no exclusion criteria for outpatient catheterization and 467 (47%) were inpatients who had one or more exclusions for outpatient catheterization. The most common reasons for exclusion from outpatient catheterization were congestive heart failure (22%), unstable angina (15%), noncoronary heart disease (14%), recent myocardial infarction (11%) and severe noncardiac disease (9%). Inpatients with no exclusions for the outpatient procedure tended to be sicker than outpatients because they were older (p = 0.002), had a lower ejection fraction (p = 0.009) and had more triple vessel coronary artery disease (p less than 0.0001). The cost of the catheterization procedure itself was not different between inpatients and outpatients. Laboratory testing was more frequent among inpatients, however, and "room and board" costs were significantly higher. Although the difference in hospital charges for inpatients and outpatients was $580, a rigorous analysis indicated that the potential cost savings was only 38% of this amount, or $218 per eligible patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial scintigraphy--25 years after start.

The development of myocardial scintigraphy (MS) reflects the clinical success of a representative procedure in nuclear medicine. Radiopharmaceuticals for visualizing vital and damaged myocardium and techniques (planar-qualitative, planar-quantitative, SPECT-qualitative-quantitative with comparative sensitivities) are briefly reviewed with the main focus on their clinical application in coronary (CHD) and noncoronary heart disease, where recent literature from the United States and Europe is considered. The limited value of MS for screening of CHD is outlined and its present and future role in detecting asymptomatic (silent) ischemia/infarction and symptomatic patients at professional risk is stressed. The present state of MS in coronary heart disease is discussed for single and multivessel disease, previous infarction, and risk stratification (myocardial washout, pulmonary uptake, ischemic dilation, absent heart sign), reflecting the importance of the procedure in exercise-induced ischemia as well as in ischemia at rest for prognostication of the natural and therapeutic course, i.e., therapy control (angioplasty, bypass, lysis, cardiac drugs). More marginal but upcoming clinical indications are mentioned, such as progressive systemic sclerosis, cardiac transplantation, pediatric cardiology, and problems of nephrology/urology. The "normal" values and the impact of digital radiology and of contrast cardiography are touched upon. Preliminary cases with 111In-antimyosin and 99mTc-Isonitriles are presented including correlative results between global ejection fraction determination according to gated 99mTc-isonitrile and conventional 99mTc-erythrocyte ventriculogram (r = 0.75; n = 10).

Quantitative electrocardiographic and vectorcardiographic study on newly-diagnosed non-insulin-dependent diabetic and non-diabetic control subjects.

Quantitative electrocardiographic (ECG) and vectorcardiographic (VCG) analysis was carried out in 113 newly diagnosed, middle-aged, non-insulin-dependent diabetics (61 men, 52 women) and 125 non-diabetic control subjects (56 men, 69 women) in order to explore changes attributable to non-coronary heart disease (diabetic cardiomyopathy) in diabetics. Diabetic men had a prolonged PQ interval and women a more negative P-terminal force and a more leftward frontal QRS axis than their non-diabetic counterparts, but no other significant differences we found between diabetic and non-diabetic subjects in various quantitative ECG and VCG variables when the effect of confounding factors (age, obesity, coronary heart disease, hypertension, drugs) was taken into account. The more negative P-terminal force and left axis deviation in diabetic women could be explained by a concomitant left ventricular hypertrophy among them. Non-insulin-dependent (type 2) diabetes, which is commonly preceded by a long duration of asymptomatic hyperglycaemia, is not associated, early in its clinical course, with major ECG and VCG abnormalities suggestive of diabetic cardiomyopathy.

Drinking and mortality. The Albany Study.

The relation of alcohol consumption to mortality was examined in a cohort of 1,910 employed men aged 38-55 years, enrolled in the Albany Study, a prospective investigation of factors related to cardiovascular disease. Two follow-up periods were examined, one between 1953-1954 and 1971-1972 and the other after 1971-1972. In both periods, there was a positive relation between the rate of alcohol consumption and noncoronary heart disease death, not assignable to any specific cause. Coronary heart disease death was not associated with drinking during the initial follow-up but was negatively associated with drinking in the later follow-up. All-cause mortality was positively associated with alcohol consumption in the earlier follow-up, because of the greater cigarette use among drinkers, but not in the later follow-up. There was a significant positive relation of drinking to deaths from liver cirrhosis and diabetes but not to deaths from motor vehicle accidents.

Quantification of thallium-201 myocardial uptake using serial dynamic imaging at rest and during exercise.

The thallium-201 myocardial uptake ratio was measured using serial dynamic imaging of the initial uptake phase following an intravenous bolus injection. It revealed no significant difference at rest between non-coronary heart disease and coronary artery disease, while it was greater in cases with left ventricular hypertrophy. With exercise loading, this value significantly increased in non-coronary heart disease, whereas less increase was observed in coronary artery disease. This increasing capability was lower in multivessel disease compared with single-vessel disease.

A Prospective Study of Heart Disease in Diabetes Mellitus

Six hundred and twenty-five patients with diabetes mellitus were studied by standardised clinical methods, resting and exercise electrocardiography (ECG) and digitised echocardiography to determine the prevalence of coronary and non-coronary heart disease. Clinical evidence of coronary artery disease (angina and infarction) was present in 110 (18 per cent) normotensive patients. Hypertension (blood pressure greater than 165/95 mmHg) was present in 172 (27 per cent) of whom 32 had cardiac symptoms. Heart failure or left ventricular dilatation was seen in 18 of whom 11 had either hypertension or coronary artery disease and six asymptomatic patients had unexplained ventricular hypertrophy. Echocardiograms in 245 of 290 asymptomatic patients with normal ECG showed that relaxation was prolonged (p less than 0.001) and mitral valve opening delayed (p less than 0.001) from normal especially in those with severe microangiopathy (proliferative retinopathy and/or heavy proteinuria). The peak rates of cavity dimension increase and posterior wall thinning were reduced from normal (both p less than 0.001) and patients with severe microangiopathy had the most marked changes. Redivision of these 245 diabetics by abnormalities of left ventricular function showed that 147 had normal function in whom only one of 23 (random 15 per cent sample) had a positive exercise ECG. Prolonged relaxation or delayed mitral valve opening alone (a nonspecific abnormality) was present in 41 and only three of 28 had a positive exercise ECG. Thirty-one had delayed mitral valve opening with inco-ordinate relaxation (abnormalities very suggestive of coronary artery disease) of whom 20 of 29 had a positive exercise ECG. Twenty-six had delayed mitral valve opening with slow cavity dimension increase or wall thinning (without hypertrophy) of whom 21 of 25 had a negative exercise ECG. This is a relatively specific abnormality similar to that found in left ventricular hypertrophy. Coronary artery disease is common in symptomatic and asymptomatic forms in diabetes mellitus. Non-coronary left ventricular diseases, such as dilation and hypertrophy, are probably no more common in diabetics than non-diabetics. A small number of diabetics with severe microangiopathy had abnormal relaxation and reduced peak rate of dimension increase or wall thinning which may represent left ventricular disease due to microangiopathy.

虚血性心疾患の成因に関する研究 (第1報)

This study was undertaken to evaluate the relationship between serum lipoprotein concentration and angiographic severity of coronary artery sclerosis in adult male.HDL-, LDL-, and VLDL-cholesterol were measured in normal subjects (N=47, average age 44 y/o), non-coronary heart disease (Non-CHD, N=23, average age 38 y/o) and coronary heart disease (CHD, N=72, average age 52y/o) by means of heparin-CaCl and O-phthaladehyde method.All patients of Non CHD and CHD were studied by selective coronary cine-angiography. And as an index of severity of coronary artery sclerosis, coronary score of modified Friesinger method was applied to those who underwent selective coronary cine-angiography. The results were as follows:1) HDL-cholesterol concentrations of CHD group was 28.5±7.3mg/dl and apparently lower than that of normal subject (47.5±10.4mg/dl) or of Non-CHD group (45.4±6.5mg/dl). LDL-cholesterol concentrations of CHD group, normal subjects and Non-CHD group were 140.3±30.7mg/dl, 121.1±27.1mg/dl, 117.9±27.4mg/dl, respectively.2) No significant correlation was found between HDL-cholesterol and coronary score among CHD group. However HDL-C/LDL-C ratio was inversely related to severity of coronary artery disease.In CHD group, all patients with less than 2.50 of the ratio (HDL-C/LDL-C×10) showed severe coronary artery sclerosis more than coronary score 5, whereas no patients with the ratio of over 4.0 showed severe coronary artery sclerosis.

Type A behaviour pattern: relationship to coronary heart disease, personality and life adjustment.

Sixty male subjects, all under age 60, taken consecutively from a cardiologist's referral practice were studied in terms of A Behaviour pattern using the Rosenman-Friedman Stress Interview. Subsequently they all underwent personality, temperament and life stress assessment by questionnaire using the MMPI, Thurstone Temperament Schedule, Holmes-Rahe Schedule of Recent Experience, Rosenman Life Satisfaction Questionnaire and a number of demographic measures. They were examined medically and divided into coronary heart disease (CHD) and non-coronary heart disease (NCHD) groups. There were many more A Behaviour subjects reflecting the sampling bias from the cardiologist's practice. There were significantly more A subjects found in the group with CHD than in the NCHD group. A Behaviour subjects were more dissatisfied with their marriages and attainment of life goals and preferred respect and recognition to love and affection. The A Behaviour subjects were considered more open, self-critical, dissatisfied and passive than the non-A cohorts as interpreted from the L, K and Mf scales of the MMPI. The finding of an association between A Behaviour and CHD validates the research of others. The greater dissatisfaction in certain areas of the A subjects’ lives fits in with other research evidence and is discussed in this vein. The passive, aesthetic interests of A subjects although difficult to explain in the light of the contrasting behaviour style, is discussed with reference to earlier psychoanalytic theories. The lack of psychopathology and personality differences in A subjects points up the difficulty of recognizing the A pattern using personality tests and points to the need of improved behavioural measures.

Incidence and significance of decreases in systolic blood pressure during graded treadmill exercise testing

The incidence of decreases in peak systolic blood pressure during treadmill exercise was investigated in 460 patients with definite or suspected coronary heart disease. All patients were studied with coronary cineangiography. Exercise was continued to one of the following end points: chest pain, 85 to 90 percent of the patient's age-predicted maximal heart rate, ventricular tachycardia or a sustained decrease of 10 mm Hg or more below the peak level of systolic blood pressure. Twenty-two patients with 75 percent or greater stenosis of one or more major coronary arteries manifested a decrease in systolic pressure 10 mm Hg or more during exercise. These included 15 (17 percent) of 88 patients with three vessel, 7 (7 percent) of 101 with two vessel and 0 of 90 with single vessel disease. The decrease in pressure was reproducible in the seven patients who underwent a second exercise test before alteration of therapy; this decrease was abolished in the six patients who exercised again after coronary bypass graft surgery. A decrease in systolic pressure of 10 mm Hg or more also occurred during exercise testing in 3 of 23 patients with noncoronary organic heart disease; all 3 had an obstructive cardlomyopathy that had not been suspected clinically. Only 1 of 158 subjects with chest pain and no demonstrable heart disease had a decrease in systolic blood pressure with exercise. Declines in blood pressure were not observed during 650 maximal exercise tests performed on 560 clinically normal men. In conclusion, if one excludes subjects with cardiomyopathy or significant heart valve disease, a sustained exercise-induced decrease in peak systolic blood pressure of 10 mm Hg or more is a highly specific sign of multiple vessel coronary artery disease. This phenomenon is best explained by acute left ventricular pump failure secondary to extensive myocardial ischemia.

Effects of isometric exercise on the end-diastolic pressure, volumes, and function of the left ventricle in man.

Changes induced in left ventricular (LV) hemodynamics by isometric exercise were analyzed in 43 patients: 30 with coronary heart disease (CAD), four with noncoronary heart disease, nine normal. Volumes were angiographically determined and correlated with left ventricular end-diastolic pressure (LVEDP) both at rest and during the fifth minute of 30% sustained handgrip (HNG). All normals and eight with CAD improved LV function during HNG. LVEDP decreased or remained constant, end-diastolic volume (EDV) decreased, end-systolic volume (ESV) decreased, as ejection fraction (EF) remained constant. None of these eight CAD cases altered their regional LV contraction pattern during HNG. Twenty-five patients, 21 CAD and four nonCAD, showed diminished LV function during HNG. LVEDP increased, EDV decreased, ESV increased, as EF declined. In these 21 CAD patients, at least one major coronary vessel was narrowed 70% or more and, with but two exceptions, was not supported by adequate collaterals. In 18, new asynergic zones developed in previously normally contracting areas or pre-existing asynergic zones extended during HNG.

Total and effective coronary blood flow in coronary and noncoronary heart disease.

There are no data available concerning total coronary blood flow to the whole heart (CBF) in man. "Effective" or "nutrient" coronary blood flow to the whole heart (MBF), supposedly a measure of flow through exchanging channels of the coronary circulation, has been measured but its validity has not been established. Accordingly, CBF and MBF were measured in 9 normal subjects, 26 patients with coronary heart disease (CHD), and 19 with noncoronary, mostly valvular heart disease (NCHD), by coincidence counting 84Rb technique. Two methods were used: single bolus (24 cases) and continuous infusion (30 cases). Various other parameters including myocardial oxygen utilization (MVO2) and lactate extraction ratio were determined. In the normal subjects CBF (386 +/- 77 ml/min) was significantly higher (P < 0.05) than in CHD (288 +/- 124 ml/min) and NCHD (292 +/- 111 ml/min). Likewise the normal MBF (380 +/- 81 ml/min) was significantly higher (P < 0.01) than in CHD (251 +/- 105 ml/min) as well as NCHD (258 +/- 104 ml/min). The myocardial Rb extraction ratio epsilon Rb) was significantly lower in normal subjects (39 +/- 9%) than in CHD (50 +/- 7%) and NCHD (52 +/- 11%) and this supports the view that epsilon Rb is flow-dependent. In both CHD and NCHD there was significant diminution of MVO2 as well as CBF. In CHD this was accompanied by a significant anaerobic trend but in NCHD it was not. It might therefore appear that in CHD, MVO2 is determined by perfusion whereas in NCHD, perfusion is determined by MVO2. In comparing CBF with MBF by paired observation testing, there was no significant difference in the normals (P > 0.3), whereas the differences were significant in CHD (P < 0.01) and NCHD (P < 0.02). This was merely a reflection of a reduced ratio of myocardial to total body epsilon Rb in CHD and NCHD, and available evidence indicates that this may be an expression of depressed transport of Rb+ rather than true shunting.

Antimyocardial antibodies in patients with coronary heart disease

Clinical and monitored data were collected from 173 patients admitted to a Medical Intensive Care Unit for suspected acute myocardial infarction. Infarction was proven in 117, and 56 had coronary insufficiency. Sera obtained on the first, fifth, and fourteenth days of hospitalization were tested for antimyocardial antibodies by the indirect fluorescent antibody and antiglobulin consumption methods. Fifty of the 117 patients with infarcts and 28 of 56 with coronary insufficiency had antibodies. None was found in 11 of 13 patients with non-coronary heart disease and in 15 normal controls. Antimyocardial antibodies were identified in patients with coronary disease whether they had acute myocardial infarction or not. This finding indicates that myocardial damage often accompanies non-infarctive myocardial ischemia. The detection of antimyocardial antibodies in patients without overt evidence of infarction may, therefore, aid in the diagnosis of coronary insufficiency. While antibodies to components of heart muscle are not specific for coronary disease, other conditions in which they occur are relatively rare and can usually be excluded on clinical grounds. Finally, our studies show that many patients with coronary disease already have antimyocardial antibodies in their serum when they arrive at the hospital. Subclinical myocardial damage may thus precede the onset of symptoms. Periodic tests for antimyocardial antibodies could reveal these prodromal events and indicate the need for therapeutic intervention.

Plasma Insulin Response to An Oral Glucose Load in Noncoronary Heart Disease

Fourteen patients with noncoronary heart disease (mean age 46 years) and 14 controls (mean age 46 years) had oral glucose tolerance tests with plasma glucose and plasma immunoreactive insulin levels determined. None of the 28 subjects was obese, malnourished, or had a history of angina or diabetes, a family history of diabetes, liver, renal, thyroid disease, hypokalemia, or was on diuretics. Eight of 14 patients (57 percent) with noncoronary heart disease had abnormal plasma insulin response compatible with maturity-onset diabetes, and one of these 14 patients (7 percent) had a diabetic glucose tolerance curve. Three of 14 control subjects (21 percent) had a plasma insulin response compatible with maturity-onset diabetes, and none of these controls (0 percent) had abnormal glucose tolerance. These results indicate that the abnormal plasma insulin response to an oral glucose load found in many patients with noncoronary heart disease represents a nonspecific metabolic abnomality.

Year Book of Cardiovascular Medicine and Surgery.

Summaries of important contributions, 1965 through 1968, in all fields of clinical and experimental cardiovascular problems are presented with cogent discussion by the editors following most items. These latter comments are invaluable even when very brief, for they correlate what is new with related observations, and they emphasize significant features. A general discussion of normal and altered function (89 pages) includes pharmacology and cardiac pacing; 41 pages are devoted to heart disease in the fetus, infant, and child; 53 pages to (noncoronary) heart disease in adults; 31 pages to coronary disease; 19 to pulmonary arteries and cor pulmonale; 37 to hypertension; 40 to peripheral vascular disease, including 12 on thrombosis and embolism; 82 pages to surgical problems; and 28 pages to techniques for studying cardiovascular functions in man. Even for the cardiologist who keeps an eye on periodicals and attends meetings, this authoritative book is useful for an overview of