Occurrence Of Angina Research Articles

P1107 ST-segment elevation in the intracoronary electrocardiogram and the occurrence of angina during angioplasty for detection of myocardial viability

P1107 ST-segment elevation in the intracoronary electrocardiogram and the occurrence of angina during angioplasty for detection of myocardial viability

Use of the SF36 general health status survey to document health-related quality of life in patients with coronary artery disease: Effect of disease and response to coronary artery bypass graft surgery

Objective: The purpose of this study was to determine if the SF36 general health status survey has the sensitivity to detect physical function impairments before surgery and the expected improvement in health-related quality of life variables after elective coronary artery bypass graft (CABG) surgery. Design: A prospective, nonrandomized study design was used. Outcome Measures: The SF36 general health status survey comprises 36 multiple choice questions sorted into 8 categories, or subscales, that describe overall health status. The scores of this survey were used to measure the outcome. Intervention: The SF36 was administered before surgery and at 12-month follow-up. Patients were also queried about the occurrence of angina with normal activities of daily living. Results: Before surgery (n = 81), scores for all SF36 subscales (with the exception of mental health) were lower than published normative data, indicating the disease burden of coronary artery disease. At 12-month follow-up, scores in 6 of 8 subscales improved significantly; general health and role-emotional scores did not change. These changes in SF36 scores at follow-up paralleled a decreased occurrence of angina; before CABG surgery, 75% of patients (61 of 81) had angina; at 12-month follow-up, only 3.7% of patients (3 of 81) had angina. Conclusions: The SF36 can be used effectively to document changes in health-related quality of life variables in patients with coronary artery disease after CABG surgery. (Heart Lung® 2002;31:207-13.)

Coronary artery bypass grafting using the gastroepiploic artery in 1,000 patients

Background. The gastroepiploic artery (GEA) has been used as a graft in 1,000 patients in our institution, and the clinical outcome and the angiographic long-term results were reviewed. Methods. Between June 1, 1991, and June 30, 2001, 1,000 consecutive isolated coronary artery bypass grafting procedures using the GEA were performed in the Shin-Tokyo Hospital Group. The perioperative data were retrospectively analyzed, and the late angiographic results, cardiac related events, and survival were examined. The end points of the follow-up study were death or the occurrence of a cardiac-related event. Results. The GEA was used in 767 men and 233 women (mean age, 63.8 ± 9.4 years). The GEA was used as an in situ graft in 99.6% of patients and was anastomosed to the right coronary artery in 87.8% and the circumflex artery in 10.0%. In addition, the left internal mammary artery was used in 96.9% of patients, the right internal mammary artery in 28.5%, the radial artery in 41.7%, the inferior epigastric artery in 1.4%, and the saphenous vein in 40.1%. The hospital morbidity and mortality rates were 10.8% and 0.8%, respectively. No abdominal complications were observed. Postoperative myocardial infarction associated with GEA graft failure occurred in 2 patients. During the late follow-up of 4.0 ± 2.3 years, cardiac-related events were observed in 155 patients. The actuarial 3- and 5-year event-free rates were 91.2% and 84.2%, respectively. There were 86 late deaths, 36 of which were cardiac related deaths. The actuarial 3- and 5-year survival rates were 96.6% and 92.6%, respectively. Angiography was performed on 437 patients within 1 year after operation and in 221 patients more than 1 year postoperatively (mean interval, 3.1 ± 1.8 years). The actuarial 1-, 3-, and 5-year GEA graft patency rates were 98.7%, 91.1%, and 84.4%, respectively, and the actuarial 1-, 3-, and 5-year LIMA graft patency rates were 99.6%, 98.8%, and 97.0%, respectively ( p < 0.0005). Conclusions. The GEA was used for coronary artery bypass grafting with good perioperative results. However, the angiographic patency rate of the GEA was inferior to that of the internal mammary arteries. The late occurrence of angina attributed to GEA graft failure should be carefully monitored.

Coronary microvascular spasm causes myocardial ischemia in patients with vasospastic angina

ObjectivesWe aimed to test the hypothesis that coronary microvascular spasm (MVS) alone causes myocardial ischemia in patients with angina attributable to epicardial coronary spasm, and to determine whether there is a difference in clinical characteristics between those with and without microvascular spasm. BackgroundPatients with “vasospastic angina” have epicardial coronary artery spasm, but it is unknown whether coronary microvessel disease also contributes to the occurrence of angina in these patients. MethodsWe studied 55 consecutive patients with angina in whom epicardial coronary spasm was provoked by intracoronary acetylcholine (ACH). ResultsIn 14 patients (25.5%, Group 1), submaximal dose of ACH induced myocardial ischemia (chest pain, ischemic electrocardiogram changes, lactate production) without large epicardial spasm, suggesting the occurrence of coronary microvascular spasm. By contrast, the remaining 41 patients (Group 2) had evidence of myocardial ischemia only when epicardial spasm was angiographically demonstrated. The Group 1 patients were predominantly women (p < 0.05) and had a history of prolonged (>30 min) chest pain (p < 0.05), whereas the Group 2 patients were more likely men and smokers (p < 0.01). ConclusionsMyocardial ischemia most probably due to coronary MVS was demonstrated in a sizable portion of patients with epicardial vasospasm, preferentially in women having both typical and prolonged anginal pain. The result suggests that coronary microvascular disease may also contribute to angina in patients with “vasospastic angina.”

Influencia de la angina en la semana previa al primer infarto agudo de miocardio sobre su pronóstico intrahospitalario y a medio plazo

The implications of early angina on the prognosis of myocardial infarction are controversial. The aim of this study was to assess the effect of angina one week before the first myocardial infarction on short and medium-term prognosis. A total of 290 consecutive patients (107 with previous angina and 183 without it) with the first myocardial infarction were studied to determine the effect of preceding angina on short and medium-term prognosis. Further criteria for inclusion were no previous history of angina > 1 week before the first myocardial infarction, and no evidence of prior structural cardiopathy. The end points studied were death and congestive heart failure in the acute phase of myocardial infarction and during the follow-up. Patients with a history of prodromal angina were less likely to experience in-hospital death, heart failure or combined end-point (3.7 vs 11.5%; 4.6 vs 15.8%; 7.5 vs 21.3%) (p = 0.002). There was also a difference between groups in the follow-up (4.1 vs 13.2%; p = 0.03). Multivariate analysis confirmed that the presence of preinfarction angina was an independent predictor of death and heart failure in the acute phase of myocardial infarction as well as in the follow-up. The occurrence of angina one week before the first myocardial infarction protects against death and heart failure in the acute phase of myocardial infarction as well as in the medium follow-up.

Does angina the week before protect against first myocardial infarction in elderly patients?

Mortality rates for coronary artery disease are greater in elderly patients. Although prodromal angina occurring shortly before an acute myocardial infarction (MI) has protective effects against ischemia, this effect has not been well documented in older patients. This study investigated whether angina 1 week before a first MI provides protection in this group of patients. A total of 290 consecutive elderly (>64 years old, n = 143) and adult patients (<65 years old, n = 147) with a first MI were examined to assess the effect of preceding angina on the short- and long-term prognosis. Elderly patients with a history of prodromal angina were less likely than those without angina to experience in-hospital death, heart failure, or the combined end point of in-hospital death and heart failure (6% vs 20.4%, p = 0.02; 10% vs 23.7%, p = 0.07; 14% vs 32.3%, p = 0.01, respectively). Left ventricular function was more frequently depressed (ejection fraction <40%) in elderly patients without (44.8%) than with (26%, p = 0.04) preinfarction angina, and the incidence of arrhythmias (complete heart block and ventricular fibrillation) was greater in the former group (16.1% vs 4%, p = 0.03). Multivariate analysis confirmed that the presence of preinfarction angina was an independent predictor of in-hospital death and heart failure in older patients (odds ratio 0.28, p = 0.009). The occurrence of angina 1 week before a first MI may confer protection against in-hospital adverse outcomes, and may preserve left ventricular function in older patients.

Impact of exercise-induced coronary vasomotion on anti-ischemic therapy.

Coronary vasomotion has an important role in the regulation of myocardial perfusion. During dynamic exercise, normal coronary arteries dilate, whereas stenotic arteries constrict. This exercise-induced vasoconstriction has been associated with the occurrence of myocardial ischemia and has been believed to be the result of endothelial dysfunction, with a reduced release or production of EDRF, increased sympathetic stimulation, enhanced platelet aggregation with release of thromboxane A2 and serotonin, or a passive collapse of the disease-free wall segment within the stenosis (the Bernoulli effect), or a combination of any of these. More recently, it has been realized that pharmacological treatment might prevent exercise-induced vasoconstriction and, thus, reduce myocardial ischemia and the occurrence of angina pectoris. Vasodilators such as nitrates, calcium antagonists or alpha-receptor blockers dilate the coronary arteries and prevent coronary stenosis narrowing during exercise. In contrast, beta-blocking agents are associated with coronary vasoconstriction at rest, but--conversely--can induce coronary vasodilatation during exercise. Pharmacological treatment in patients with stable angina pectoris may improve myocardial ischemia by reducing pre- and afterload, myocardial contractility, oxygen consumption, and vasomotor tone. However, coronary collateral perfusion can modify these effects by shunting blood from the non-ischemic to the ischemic region (collateral flow) or by shunting blood from the ischemic to the non-ischemic zone (coronary steal phenomenon). Typically, a steal phenomenon has been reported in patients receiving either dipyridamole or calcium antagonists, whereas a reversed steal has been described after beta-blockade, with an increase in contralateral tone shunting blood from the non-ischemic to the ischemic zone (reverse steal phenomenon).

Coronary artery bypass grafting in patients with advanced left ventricular dysfunction

Objective. The aim of this study was to determine the long-term survival and control of angina in patients with coronary artery disease and sequentially decreased ejection fractions (EF) after first-time coronary artery bypass grafting. Methods. Between 1981 and 1995, 156 (1.3%) patients with an EF less than 0.25 (group 1), 588 (5%) patients with an EF of 0.25 to 0.34 (group 2), 2,438 (20.6%) patients with an EF of 0.35 to 0.49 (group 3), and 8,648 (73.1%) patients with an EF equal to or greater than 0.50 (group 4) underwent coronary artery bypass grafting. The EFs were determined by uniplanar or biplanar left ventriculography. For each group, the clinical and angiographic characteristics and the operative and outcome data were compared. Survival curves were derived and compared for each group. Correlates of angina, and of early (30-day) and long-term mortality, for all groups were analyzed. Results. For all groups the mean age was approximately 60 ± 10 years. Group 1 had the highest percentage of patients who were men (88%), had congestive heart failure (34%), had hypertension (53%), and had left main coronary artery disease (24%). Groups 1 through 3, compared with group 4, had a lower percentage of complete revascularization ( p < 0.0001), a lower percentage of internal mammary artery grafts ( p < 0.0001), and a greater use of intraaortic balloon pump ( p < 0.0001), but had similar cross-clamp and cardiopulmonary bypass times, number of grafts, incidences of myocardial infarction, and stroke. Hospital mortality for groups 1, 2, 3, and 4 was 3.8% (n = 6), 3.4% (n = 20), 3% (n = 72), and 1.6% (n = 134), respectively. Groups 1 through 3, compared with group 4, had similar incidences of angina during follow-up (31% to 40% versus 33%, respectively; p < 0.06). Survival was greatest for group 4 compared with groups 1 through 3 at 1, 5, and 10 years ( p < 0.0001). Patients in group 1 had 1-, 5-, and 7-year survivals of 90%, 64%, and 49%. Multivariate correlates of early mortality were advanced age, female sex, decreased EF, hypertension, diabetes, and emergency operation. Multivariate correlates of long-term mortality included severity of preoperative angina class, congestive heart failure, number of diseased vessels, and incomplete revascularization. The strongest correlates of angina at follow-up were younger age, female sex, previous myocardial infarction, lower ejection fraction, and incomplete revascularization. The absence of an internal mammary artery graft did not predict the occurrence of angina or influence long-term survival. Conclusions. In the long term there is a higher mortality in patients with sequentially decreased left ventricular function undergoing coronary artery bypass grafting, although more than 60% of patients with an EF less than 0.25 were alive and had good control of angina at 5 years despite having a higher percentage of risk factors, poorer functional status, and more complex coronary disease. Failure of symptom control and survival beyond 5 years appeared to be influenced by preexisting medical conditions and factors that affect the ability to completely revascularize the myocardium. These results suggest that in selected patients with ischemia and poor left ventricular function, coronary artery bypass grafting may preserve remaining viable myocardium, provide relief of symptoms, and offer survival greater than 60% at more than 5 years.

Risk of myocardial infarction, angina and stroke in users of oral contraceptives: an updated analysis of a cohort study.

To investigate risk of myocardial infarction, angina and stroke in users of contraceptive pills compared with users of other methods of contraception. Prospective cohort study, with recruitment between 1968 and 1974 and annual follow up until the age of 45 years. After this age, only women who had never used oral contraception or those who had used it for eight or more years continued to be followed up annually until July 1994. Seventeen family planning clinics in England and Scotland. 17,032 women aged between 25 and 39 years at entry to the study. Occurrence of angina, myocardial infarction or stroke that was associated with either hospital admission or outpatient referral to hospital or death. Increased risk of myocardial infarction in oral contraceptive users was observed only in women who were heavy smokers at entry to the study. In this subgroup the relative risk of a myocardial infarction was 4.2 (95% CI 1.4-16.6) in ever users of oral contraception compared with non-users, 4.9 (1.2-23.6) in current users, and 4.0 (1.3-16.2) in ex-users. In all current users the relative risk of angina was 0.5 (0.1-1.4), and the relative risk of ischaemic stroke was 2.9 (1.3-6.7). The increased risk of ischaemic stroke did not persist in ex-users. Use of oral contraception is associated with increased risk of ischaemic stroke and increased risk of myocardial infarction (only in heavy smokers), but no increased risk of angina. These increased risks need to be considered within the context of the very low absolute risks of cardiovascular disease in this population. 5880 women need to take oral contraception for one year to cause one extra stroke, and 1060 women who are heavy smokers need to take it for one year to cause one extra myocardial infarction.

Enalaprilat Improves the Impaired Left Ventricular Pump Function during Exercise in Hypertensives with Coronary Microangiopathy and with Coronary Artery Disease

Background: The pump function during exercise can be disturbed not only in hypertensives with coronary artery disease (CAD), but also in those with a normal angiogram. Methods: In 10 hypertensive patients (group 1; aged 52±4 years, 1 men, 9 women) with ST segment depression during exercise and concomitant angina pectoris but normal coronary angiograms (microangiopathy) and without left ventricular hypertrophy (LVMI <110 g/m²), the left ventricular function at rest and during exercise was studied by cardiac catheterization and compared with 10 hypertensives with CAD (group 2; aged 57.6±4 years, 7 men, 3 women) and 10 hypertensives without ST segment depression (group 3; aged 51.8±5 years, 10 men) before and after intravenous administration of 1.25 mg enalaprilat. Results: The pulmonary capillary wedge pressure (PCWP) was normal at rest and pathologically increased at 60±13 W only in groups 1 and 2 (27.2±3 and 32.2±8 mm Hg, respectively), but not in group 3 (12.2±4 mm Hg; p<0.001). At the identical load level, the PCWP in patients with microangiopathy (group 1) was significantly (p<0.01) reduced after enalaprilat (–21.7%) and even normalized in 5 of 10 patients. This was accompanied by a significant (p>0.01) decrease in ST segment depression (–73.9%) and in the occurrence of angina pectoris, despite the fact that the rate–pressure product as a measure of myocardial oxygen consumption was significantly (p<0.05) increased. Also in patients with CAD enalaprilat had a significant effect on PCWP (p<0.01), ST segment depression (p<0.01), occurrence of angina pectoris (p<0.001), cardiac index (p<0.05), and stroke index (p<0.05) during exercise. In group 3 there were no significant changes in PCWP, cardiac index, and stroke index after enalaprilat either at rest or during exercise. Conclusion: The functional improvement under the action of enalaprilat suggests that the advantages of the drug may be mediated mainly through an increase in myocardial blood flow and that angiotensin II might be involved in the restricted increase in coronary blood flow during dynamic exercise in hypertensives with coronary microangiopathy.

Angina pectoris with normal coronary arteries

The occurrence of angina pectoris in patients with normal coronary angiograms is a subject of investigation since its first description as an entity in 1967. Its etiology remains unknown but, in the absence of disease of the epicardial coronary arteries, dysfunction of the small, most distal vessels and the endothelium appear to be incriminated. In this review, the most recent knowledge and understanding of the pathophysiology, clinical presentation and management of this syndrome is presented.

Nitrate-Induced Headache in Patients with Stable Angina Pectoris: Beneficial Effect of Starting on a Low Dosage

Nitrates, although important for the management of angina pectoris, cause significant headache in many patients. In a randomized, double-blind, crossover study, 89 patients with stable angina pectoris were studied to compare two different dosage strategies of isosorbide-5-mononitrate (5-ISMN). Patients were randomized to either 60 mg 5-ISMN once daily (od) for two weeks or to 30 mg 5-ISMN od for one week followed by 60 mg 5-ISMN od for one week. Then, there was a two-week placebo washout, after which the alternative treatment was given. The authors assessed the occurrence of angina pectoris and headache by diary cards while taking into account the number of isosorbide dinitrate sublingual puffs and paracetamole tablets required. Data were assessed for carryover and time effects. The two dosage regimens were equally efficient for the relief of angina pectoris without development of tolerance. Thirty percent of the patients never experienced headache from the given dosages. In the remainder of them there was a highly significant time effect: the overall numbers of headache attacks in the first period of active treatment versus the second were 2,380 vs 1,400 (P < 0.003). Yet significantly fewer patients had headache on low dosage than on high dosage (45 vs 57, P < 0.02). (1) Starting on a low dosage was associated with a reduced frequency and severity of headache and did not notably influence the beneficial effect on angina pectoris. (2) One in 3 patients never experienced headache from the given dosages. (3) The overall number of headache attacks in the first period of active treatment was significantly higher than in the second period irrespective of the dosages given.

Vitamin E deficiency in variant angina.

Oxidative modification of LDL has been suggested to increase coronary vasoreactivity to agonists. A deficiency of vitamin E, a major antioxidant, may be related to the occurrence of coronary artery spasm. Vitamin E levels were determined with the use of high-performance liquid chromatography in normolipidemic subjects, including 29 patients with active variant angina (group 1), 13 patients with inactive stage of variant angina without anginal attacks during the past 6 months (group 2), 32 patients with a significant (>75%) organic coronary stenosis and stable effort angina (group 3), and 30 patients without coronary artery disease (group 4). Total lipid levels in blood were calculated as total cholesterol plus triglyceride levels. The plasma alpha-tocopherol levels as well as alpha-tocopherol/lipids were significantly lower in group 1 than in groups 2 through 4. Also, the plasma gamma-tocopherol levels were significantly lower in group 1 than in groups 2 through 4. The vitamin E levels were not significantly different between group 1 patients with and those without a significant organic stenosis. In group 1, both alpha- and gamma-tocopherol levels were significantly elevated after a > or = 6-month angina-free period. The alpha-tocopherol levels in the LDL fraction were significantly lower in group 1 than in group 4. Plasma alpha-tocopherol levels were significantly correlated with those in the LDL fractions. In 6 patients of group 1 still having anginal attacks while receiving calcium channel blockers, the addition of vitamin E acetate (300 mg/d) significantly elevated plasma alpha-tocopherol levels and inhibited the occurrence of angina. Plasma vitamin E levels were significantly lower in patients with active variant angina than in subjects without coronary spasm, suggesting an association between vitamin E deficiency and coronary artery spasm.

A comparison of nifedipine once daily (Adalat LA), isosorbide mononitrate once daily, and isosorbide dinitrate twice daily in patients with chronic stable angina

The efficacy of nifedipine gastrointestinal therapeutic system (GITS), 60–90 mg o.d., isosorbide dinitrate, 40–60 mg b.d., and isosorbide mononitrate slow-release, 50–100 mg o.d. was assessed in a six week double-blind, parallel-group study in patients with stable angina on chronic β-blocker treatment. Of 339 patients who entered the study, 229 were eligible for the valid case analysis of efficacy and 335 for the safety analysis. Nifedipine GITS was significantly better than isosorbide dinitrate ( P ≤ 0.025) in prolonging time to 1 mm ST-segment depression, time to maximum ST-segment depression, time to occurrence of angina and total exercise duration, in addition to reducing the number of angina attacks and glyceryl trinitrate consumption after six weeks therapy. Nifedipine GITS was also significantly better than isosorbide mononitrate ( P ≤ 0.025) in prolonging time to occurrence of angina and time to 1 mm ST-segment depression after six weeks therapy. The incidence of headache was considerably higher in both the isosorbide dinitrate and isosorbide mononitrate groups (40% and 41%, respectively) than in the nifedipine GITS group (9.5%, P ≤ 0.001), and was the main reason for withdrawal from the study (isosorbide dinitrate 18 99 , isosorbide mononitrate 17/99, nifedipine GITS 2 95 ). Peripheral oedema was more common in patients treated with nifedipine GITS (12.5%) compared to nitrates (2% in both groups, P ≤ 0.01), but resulted in withdrawal of only one patient (treated with nifedipine GITS). This study suggests that the efficacy and tolerability of nifedipine GITS is superior to long acting nitrates as second-line therapy to β-blockade in the treatment of chronic stable angina.

Dobutamine Stress-Induced Angina in Patients With Denervated Cardiac Transplants: Clinical and Angiographic Correlates

The clinical consequences of cardiac denervation include the inability of the heart transplant recipient to sense cardiac pain. This is due mainly to interruption of ventricular sympathetic afferents normally responsible for transmission of cardiac pain. Although angina has been reported in transplant recipients, to our knowledge, its temporal relationship to myocardial ischemia has not been previously demonstrated. Eighty-two patients with heart transplants were serially evaluated by dobutamine stress echocardiography (DSE). In patients who developed angina during DSE, we sought to determine if the onset of angina was related to myocardial ischemia as demonstrated by stress-induced wall motion abnormalities. Coronary angiography was performed within 48 h of DSE in 45 of 82 patients. Mean patient age and time since transplant were 53.1 +/- 1.1 years and 57.7 +/- 30.4 months, respectively (mean +/- SEM). Eleven patients developed typical angina during DSE. Three of the 11 (27%) had diagnostic ECG changes. All 11 had stress-induced regional wall motion abnormalities (WMA). Nine of the 11 patients (82%) had coronary angiographic data available that demonstrated significant coronary artery disease (CAD) in 8 (89%). All coronary lesions matched the observed segmental WMA. There was no difference between the angina (n = 11) and no angina (n = 71) groups with respect to peak heart rate (HR) (141 +/- 7 vs 145 +/- 3 beats/min; p = NS), peak systolic blood pressure (SBP) (155 +/- 8 vs 149 +/- 3 mm Hg; p = NS), or rate pressure product (21,699 +/- 1,490 vs 21,646 +/- 621 mm Hg x beats/min; p = NS). However, the mean time since transplant was significantly higher in patients with DSE-induced angina (80.3 +/- 6.2 vs 57.3 +/- 3.5 months; p < 0.05). These data suggest that (1) the occurrence of angina in long-term transplant recipients with CAD is directly related to myocardial ischemia despite anatomic ventricular denervation, and (2) sympathetic reinnervation in the long-term may account for the occurrence of angina in cardiac transplant recipients.

Nifedipine in Ischemic Heart Disease

Until the 1980s, Prinzmetal’s variant angina was difficult to treat—nitrates and β-blockers usually did not control symptoms or signs of ischemia. In 1980, Antman et al1 reported the first clinical experience in the United States of the use of nifedipine in patients with Prinzmetal’s angina. They used nifedipine capsules to treat 127 patients with Prinzmetal’s angina, which reduced the weekly occurrences of angina from 16 to 2, reduced nitroglycerin requirements, completely controlled angina in 63% of patients, and reduced the frequency of angina by at least 50% in 87% of cases. Since that time, a number of trials with different calcium channel blockers, including nifedipine, diltiazem, verapamil, amlodipine, and others, have consistently shown that these agents are efficacious in reducing the morbidity of Prinzmetal’s variant angina.2 Additional studies showed that calcium channel blockers, including nifedipine, were effective in patients with chronic stable angina pectoris3 ; they not only reduced symptoms but also reduced objective evidence of ischemia on exercise treadmill tests,4 5 reduced ST-segment changes on ambulatory ECG monitoring,6 increased coronary artery blood flow,7 8 9 and improved ventricular dysfunction associated with ischemia.10 Numerous studies showed that the calcium channel blockers were effective as antihypertensive agents and lacked many of the side effects of diuretics and β-blockers.11 Of course, all drugs have limits, and not all cardiovascular drugs are appropriate for all cardiovascular situations. Calcium channel blockers are no exception. In 1984, Muller et al11 showed for the first time that nifedipine capsules did not reduce the size of myocardial infarction (MI) and did not prevent patients with threatened MIs from infarcting. Patients who received nifedipine capsules in the setting of myocardial infarction had a higher 2-week mortality (7.5%) versus placebo (2.3%) but 6-month mortality was similar between nifedipine-treated (10.8%) and …

Risk stratification of patients with coronary artery disease and left ventricular dysfunction by exercise radionuclide angiography and exercise electrocardiography.

The results of multicenter trials indicate that patients with left ventricular dysfunction and either three-vessel or left main coronary artery disease have improved prognosis when treated surgically. As part of a larger evaluation and follow-up study of coronary artery disease, the objective of this investigation was to determine whether exercise radionuclide angiography can be used, in patients with mild symptoms of coronary artery disease and left ventricular dysfunction at rest, to identify patients with three-vessel or left main coronary artery disease. Eighty-four consecutive patients were studied with angiographically defined coronary artery disease in whom left ventricular ejection fraction at rest ranged from 20% to 40%. Patients underwent exercise electrocardiography, rest and exercise radionuclide angiography, and 24-hour electrocardiographic monitoring. There were 22 patients with one-vessel, 31 with two-vessel, 27 with three-vessel, and four with left main coronary artery disease. All but four patients had a documented history of myocardial infarction. By univariate analysis, the following parameters were related to the anatomic severity of coronary artery disease: magnitude of ST segment depression with exercise (p < 0.001), magnitude of change in ejection fraction with exercise (p < 0.005), and occurrence of angina during exercise (p < 0.005). However, because of the extensive overlap among anatomic subgroups, no single factor had both a satisfactory sensitivity and a satisfactory specificity in identifying patients with three-vessel and left main coronary artery disease. Multivariate stepwise regression analysis also failed to predict three-vessel or left main coronary artery disease satisfactorily (sensitivity 73% and specificity 73%; positive predictive accuracy 59% and negative predictive accuracy 83%). Nonetheless, this multivariate analysis provided important prognostic information. During medical therapy (mean follow-up 56 months), the patients with a high likelihood of three-vessel or left main coronary artery disease had a greater risk of death or reinfarction than had patients with a low likelihood (p < 0.05). These functional data were better than coronary anatomy alone in providing risk stratification. Four of six patients with two-vessel disease who died were classified incorrectly by the multivariate analysis in the high-likelihood group for three-vessel or left main coronary artery disease, but classified correctly as being at high risk; whereas none of the patients with three-vessel disease who were misclassified in the low-likelihood group died during medical therapy. Although exercise radionuclide angiography in patients with minimal symptoms of coronary artery disease and left ventricular dysfunction is not precise in predicting three-vessel or left main coronary artery disease, it provides important functional information regarding subsequent prognosis during medical therapy.

Patients' reactions to angioplasty: realistic or not?

A major problem limiting the success of angioplasty is the high restenosis rate. In addition, coronary artery disease is an ongoing process requiring lifestyle changes to prevent disease progression. To examine patient concerns and risk factor modification behaviors during early recovery from angioplasty. Specific attention was directed to: (1) expectation of restenosis, (2) occurrence of angina, (3) achievement of expected benefits, (4) tension/anxiety levels, (5) self-efficacy for and actual performance of needed lifestyle changes. For this descriptive study the Self-Report of Recovery (a project-derived questionnaire) and the Profile of Mood States were mailed to 54 patients at 1, 6, and 12 weeks of recovery. The study group comprised 37 men and 17 women (mean age, 57 years) who had undergone first-time successful angioplasty at a midwestern medical center. At 12 weeks 78% remained. A majority of patients did not expect restenosis to occur. At 3 months 83% reported that they were angina-free, 90% reported that they would repeat the procedure if needed, all scores on the tension/anxiety scale were normal, and 86% had achieved some benefits they had expected. Most expressed high confidence in their ability to reduce risk factors, with 90% reporting initiation of at least one lifestyle change. We concluded that patients had positive feelings about their angioplasty experience and were not overly concerned about restenosis.

Hemodynamic and Metabolic Responses to Two Modes of Load Transport in Patients with Cardiac Disease

To evaluate the hemodynamic and metabolic requirements of activities of daily living (ADL), specifically simulated grocery carrying, 11 cardiac patients volunteered to perform three randomly assigned, 8 minute steady state treadmill trials at 53.6 m/minute. Trial 1 consisted of treadmill walking (No Load). Trial 2 required carrying a 4 kg load clutched to the chest by elbow flexion (Flex). Trial 3 required carrying 4 kg at the level of the thigh with the elbow extended (Extend). Open circuit spirometry was employed for the measurement of oxygen consumption. Blood pressure was obtained by auscultation. There were no occurrences of angina, ST-T wave changes, or ectomy. Statistical analysis by ANOVA with repeated measures (P < 0.05) demonstrated that Trial 2 (Flex) elicited a systolic blood pressure significantly greater than Trials 1 (No Load) and 3 (Extend). Rate pressure product (RRP) and VO2 during Trials 2 (Flex) were significantly greater than Trial 1 (No Load). The greater reliance on the small elbow flexor group during the Flex trial may have stimulated a greater pressor response in addition to the elevated metabolic demand. To minimize metabolic and hemodynamic demands, cardiac patients should modify load carry to the extended elbow position while transporting groceries.

Beta-endorphins during coronary angioplasty in patients with silent or symptomatic myocardial ischemia

Objectives. The aims of this study were to correlate betaendorphin plasma levels and anginal pin in patients with ischemia induced by percutaneous transluminal coronary angioplasty and to detect eventual endorphin variations during balloon occlusion.Background. The opioid system appears involved in the absence of pain occurring in silent myocardial ischemia.Methods. Beta-endorphin plasma levels were measured 24 h before, just before, during and after coronary angioplasty (performed on the left anterior descending artery) in 53 men with documented coronary artery disease and exercise-induced myocardial ischemia.Results. Group 1 (33 patients) reported symptoms; group 2 (20 patients) was asymptomatic during angioplasty. In these patients, the prevalence of exercise-induced silent ischemia was 57%. The occurrence of angina during exercise or angioplasty was related to the frequency of angina during daily life when patients were subgrouped. The severity and distribution of coronary artery disease did not differ between the two groups. During angioplasty, the number of balloon inflations and the Inflation time and pressure were similar in symptomatic and asymptomatic patients. In each group, no short-term variability of baseline betaendorphin plasma levels was observed during 2 consecutive days. Corresponding beta-endorphin plasma levels (at baseline and during and after angioplasty) were significantly in Group 2. During balloon occlusion, the levels decreased significantly in the symptomatic group at the onset of angina but remained stable in the asymptomatic group.Conclusions. Methodologic variables and the severity of coronary artery disease did not influence the presence of symptoms during angioplasty-induced ischemia. Beta-endorphin plasma levels were higher and more stable in patients with silent ischemia during angioplasty, suggesting that opiate levels and their variation during ischemia are associated with individual attitude toward anginal pain.