Predictor Of Significant Coronary Artery Disease Research Articles

Abstract 1776: Peripheral Arterial Disease Determined by Screening Ankle Brachial Index Testing Predicts High Risk Findings On Stress Myocardial Perfusion SPECT Imaging

Background: Peripheral arterial disease (PAD) as determined by ankle brachial index (ABI) testing is a potent marker of adverse cardiovascular prognosis. Stress myocardial perfusion SPECT (MPS) testing allows diagnosis of coronary artery disease (CAD) and stratification of cardiovascular risk. The stress MPS findings in patients (pts) with occult PAD are unknown. Accordingly, our goal was to determine the prevalence high risk (HR) MPS findings in pts with occult PAD diagnosed by screening ABI who are referred for MPS testing. Methods: As part of a prospective data collection, 679 male pts referred for MPS were screened for PAD with ABI evaluation. Pts with non-diagnostic ABIs (>1.3) or prior known PAD were excluded. PAD was defined as an ABI ≤ 0.9. PAD severity (mild [ABI 0.8 – 0.9], moderate [ABI 0.4 – 0.8], severe [<0.4]) and symptoms of PAD were also noted. CAD was defined as mild (summed stress score (SSS) ≥ 4) or severe (SSS>8), and the composite of any HR finding (SSS>8, left ventricular ejection fraction [LVEF] < 40%, or TID) was recorded. Results: PAD was present in 28%. Of pts found to have PAD, 65% reported no lower extremity symptoms. Compared to no PAD, pts with PAD were found to have significantly more mild or greater CAD (51% vs. 36%, p<0.01), severe CAD (35% vs. 19%, p<0.01), LV dysfunction [LVEF < 40%] (14% vs 7%, p < 0.01), and composite HR MPS findings (40% vs. 22%, p<0.01). On multivariate logistic regression analysis considering age, HTN, diabetes, tobacco use, hypercholesterolemia, and prior coronary artery disease, PAD was found to be an independent predictor of mild or greater CAD (OR 1.6, 95% CI 1.1–2.4, p<0.01), severe CAD (OR 1.9 95% CI 1.3–3.0, p<0.01), and any HR MPS finding (OR 2.0 95% CI 1.3–3.0, p<0.01). Conclusions: Among men referred for stress testing, occult PAD is common, and is an independent predictor of significant CAD and HR findings on MPS testing. Further study is needed to determine if PAD in pts without an indication for stress testing may benefit from screening MPS.

Sex hormone ratio changes in men and postmenopausal women with coronary artery disease

The goal of this study was to investigate the potential role of sex hormones in coronary atherosclerosis in both men and postmenopausal women. A total of 258 male and 236 female postmenopausal participants with angiographically defined stable coronary artery disease (CAD) were enrolled. We measured the levels of estradiol (E2), progesterone (P), testosterone (T), follicle-stimulating hormone, and luteinizing hormone in the participants and in 156 male and 132 female disease-free and age-matched controls using commercially available radioimmunoassay kits. In the male study participants and control subjects, the levels of E2 and P differed slightly in opposing directions; however, these differences were not significantly different, nor were there significant differences in T. However, the ratio of E2 to P in participants was significantly (P < 0.01) lower (even after adjustments for age and body mass index) than in the control subjects (mean +/- SEM: 70.2 +/- 56.4 vs 90.7 +/- 59.5, respectively). In the postmenopausal women, a slight decrease in E2 and increases in P and T in participants were not significantly different from levels in the control group. However, the E2 to P and E2 to T ratios were significantly (P < 0.01) lower (before and after adjustments for age and body mass index adjustments) in the participants relative to the control subjects (38.7 +/- 28.4 vs 49.6 +/- 36.3 and 46.5 +/- 37.6 vs 60.6 +/- 40.8, respectively). Correlation analyses demonstrated that the sex hormone ratio changes in both men and postmenopausal women were related with atherogenic blood lipoprotein changes. In both the male and female groups, levels of follicle-stimulating hormone and luteinizing hormone did not differ significantly between the participants and controls, and correlation analyses revealed no association between these hormones and the ratio of E2 to P in males and the ratios of E2 to P and E2 to T in females (r < 0.2, P > 0.05). Multiple regression analyses demonstrated that age and the presence of CAD were significantly and independently associated with the E2-to-P ratio in men and the E2-to-P and E2-to-T ratios in women and that E2-to-P ratio and low-density lipoprotein cholesterol level were significant independent predictors of CAD in males; E2-to-P and E2-to-T ratios and low-density lipoprotein cholesterol level were significant predictors of CAD in women. In both men and postmenopausal women with angiographic CAD, there were significant differences (relative to age-matched control subjects) in sex hormone ratios, suggesting an abnormality that could influence coronary health. A lower E2-to-P ratio may be associated with the male disposition to coronary atherosclerosis, whereas lower E2-to-P and E2-to-T ratios may be associated with the same condition in females.

Predicting significant coronary artery disease in patients with left ventricular dysfunction

Because coronary artery disease (CAD) is a prevalent comorbidity in patients with low ejection function (EF), a number of patients with heart failure undergo diagnostic cardiac catheterization. The objective of this study was to develop a model to assist clinicians in determining the likelihood of CAD before cardiac catheterization. This study was a retrospective analysis using the Duke Databank for Cardiovascular Disease. From the databank, 2054 patients who underwent cardiac catheterization between 1992 and 2002 that was preceded by echocardiography with an EF of < 45% were identified. The patients' median age was 63 years, and the median EF was 30%. Patients were considered to have significant CAD if any major epicardial vessel had > or = 75% stenosis. A multivariable model of CAD was generated using stepwise logistic regression. We included demographic, clinical, electrocardiographic, and echocardiographic parameters, including segmental wall motion abnormality. Of the patients who met the criteria, 1184 (58%) had significant CAD and 870 (42%) did not. Significant predictors of CAD, in the order of their ability to predict significant CAD, included history of myocardial infarction, age, diabetes mellitus, Q wave on electrocardiogram, male sex, and segmental wall motion abnormality (all P < .0001). The area under the receiver operating characteristic curve was 0.865. By using baseline demographic and clinical characteristics, we developed a highly discriminatory diagnostic model for predicting CAD in patients with heart failure. Given the high prevalence of patients without CAD in this cohort, accurate baseline assessment of patients with left ventricular dysfunction for CAD might avoid unnecessary invasive procedures.

Polymorphism of angiotensin converting enzyme in Han populations and its relevance to the severity of coronary atherosclerosis

To explore the polymorphism angiotensin converting enzyme (ACE) in Han populations and its relevance to the severity of coronary atherosclerosis. The ACE genotype distribution was detected in 169 patients [aged (62.0 +/-9.9) years] with coronary artery disease (CAD) confirmed with angiography and in 168 normal controls [aged (61.0 +/-7.7) years]. The severity of coronary lesions in the patients was assessed by the number of major coronary arteries with more than 50% luminal obstructions and by the Gensini coronary score. Associations of the severity of coronary artery lesions with the ACE I/D polymorphism in the patients were analyzed. The frequencies of the ACE genotype in the CAD patients were 0.296 for DD, 0.391 for ID, and 0.314 for II genotypes, while in the normal controls the genotype distribution was in Hardy-Weinberg equilibrium (DD, 0.161; ID, 0.512; II, 0.327); a significantly excess of the DD genotype in CAD patients was found (P<0.01). No associations were observed between the ACE polymorphism and the number of significantly stenosed coronary arteries. The ACE gene polymorphism is a significant predictor for CAD in the Han population but is not a marker for the severity of coronary atherosclerosis.

Is Bridging to Transplantation With a Left Ventricular Assist Device a Risk Factor for Transplant Coronary Artery Disease?

Left ventricular assist device (LVAD) support is associated with coagulopathy, bleeding, increased blood transfusion, and increased anti-HLA antibody production. Increased anti-HLA antibody production is associated with early transplant rejection, transplant coronary artery disease (CAD), and decreased post-transplant survival rates. We asked whether bridging to transplantation with an LVAD increases the risk of transplant CAD. We reviewed data for all adults (>18 years old) who underwent heart transplantation at our institution between 1988 and 2000. After exclusion of transplant recipients who survived <3 years, we divided the remaining cohort into 2 groups: those bridged to transplantation with LVADs (mean duration of support, 149 +/- 107 days, n = 29) and those in United Network for Organ Sharing Status 1 bridged to transplantation without LVADs (controls, n = 86). We compared groups in terms of disease cause, age, sex, donor age, panel-reactive antibody testing, crossmatching, pre- and post-transplant cholesterol concentrations, diagnosis of diabetes mellitus or treated hypertension, infections, calcium channel blocker use, transplant rejection, ischemic time, cytomegalovirus infection, pre-transplant transfusion, and incidence of transplant CAD (defined as any coronary lesion identified by coronary angiography). We considered p < 0.05 to be significant. The bridged and control groups were similar in all respects except mean ischemic time (217 +/- 58 minutes vs 179 +/- 67 minutes, p = 0.007), post-transplant cholesterol concentration (212 +/- 55 mg/dl vs 171 +/- 66 mg/dl, p = 0.007), and pre-transplant transfusion incidence (100% vs 22%, p < 0.001). The incidence of transplant CAD was similar in both groups during a 3-year follow-up period (28% vs 17%, p = 0.238) and during total follow-up (34% vs 35%, p = 0.969). Multivariate logistic regression analysis identified cholesterol concentration at 1 year after transplantation as a significant predictor of CAD at 3 years after heart transplantation (p = 0.0029, odds ratio = 0.984). Bridging to transplantation with an LVAD does not increase the risk of transplant CAD. Nevertheless, aggressive prophylactic therapy to minimize potential risk factors for transplant CAD, such as increased cholesterol concentration, is warranted in all transplant recipients.

Serum homocysteine, methylenetetrahydrofolate reductase gene polymorphism and cardiovascular disease in heterozygous familial hypercholesterolemia

Mild hyperhomocysteinemia is considered an important risk factor for vascular disease. A common polymorphism (677C → T) in the methylenetetrahydrofolate reductase (MTHFR) gene is associated with a decreased enzyme activity and consequent higher circulating levels of homocysteine. We hypothesized that the serum levels of homocysteine and/or the MTHFR polymorphism could influence the risk for coronary artery disease (CAD) in patients with heterozygous familial hypercholesterolemia (FH), who are genetically prone to atherosclerosis. We determined the MTHFR genotype and fasting total serum homocysteine level in 249 adult patients (103 males and 146 females) with heterozygous FH. MTHFR polymorphism was a major determinant of serum homocysteine in adult FH of both sexes. The logistic regression analysis showed that in FH patients a high level of homocysteine (>12 μmol/l, corresponding to the upper quartile of serum distribution) was the most significant predictor of CAD ( n = 99) in all the groups considered (all CAD, previous myocardial infarction, myocardial infarction plus angiographically confirmed CAD). The adjusted odds ratio (OR (95% CI)) for the homocysteine-associated risk of CAD (upper quartile versus lower quartiles) was 3.27 (1.60–6.62) in males and females considered together, 5.67 (1.50–21.3) in males and 2.78 (1.17–6.62) in females. LDL cholesterol (upper quartile versus lower quartiles) and hypertension were the other variables independently associated with CAD. In both sexes MTHFR polymorphism was not an independent predictor of CAD. Plasma concentration of serum homocysteine, but not MTHFR genotype, is associated with an increased risk of CAD in male and female patients with heterozygous FH.

Thoracic aortic plaques, transoesophageal echocardiography and coronary artery disease.

The purpose of this study was to assess whether the detection of atherosclerotic aortic plaques by transoesophageal echocardiography (TEE) could be used as a marker of coronary artery disease (CAD), relying on their number, cross-sectional surface, depth and localisation. The thoracic aortas of 102 consecutive patients (77 men, mean age 67 +/- 12 years) undergoing elective cardiac surgery were assessed by TEE. Atherosclerotic plaques were defined as > or = 5 mm thick focal hyperechogenic zones of the aortic intima and/or lumen irregularities with mobile structures or ulcerations. All patients had undergone prior coronary angiography. Thoracic aortic plaques were present in 73 patients, 66 of whom had CAD. The presence of aortic plaques detected by TEE identified significant coronary artery disease with a sensitivity of 90% and a specificity of 76%. The maximum transverse cross-sectional plaque area, the maximum plaque depth and the total plaque number all correlated significantly with the presence of CAD, but not with its severity. Multivariate regression analysis showed that aortic plaques, hypertension and hypercholesterolaemia were significant predictors of CAD, but aortic plaques were the most significant predictor regardless of age and sex. This study suggests that detection of atherosclerotic aortic plaques is a useful marker of significant coronary artery disease. Absence of plaques in the patients aged over 70 identified a subgroup with a very low probability of CAD.

Duration of residence in the United States as a new risk factor for coronary artery disease (The Konkani Heart Study)

A survey conducted in a relatively homogeneous group of 527 Konkani subjects revealed a high prevalence of coronary artery disease (CAD) despite a lack of smoking and significant obesity. Traditional risk factors (age, gender, high cholesterol, hypertension, and diabetes) were significant predictors of CAD. In addition, duration of residence in the United States (US) emerged as a new independent risk factor. Independent predictors of CAD included age, gender, ever smoking, and duration of residence in the US. We conclude that acculturation may be a major risk factor for CAD in immigrant populations.

12 lead ECG abnormalities in patients undergoing polysomnography

To examine the occurrence of sleep apnea and nocturnal hypoxemia in men with symtomatic coronary artery disease (CAD) and to evaluate the relationship between disordered breathing and coronary artery disease.Case-control study. Cases were randomly selected from men undergoing coronary angiography because of angina pectoris. Controls were age matched and selected from the population registry. Pulse oximetry, oronasal thermistors, body position indicator, and recording of body and respiratory movements were used to quantify desaturations and apneas.Norrland University Hospital, a referral center for northern Sweden.One hundred forty-two men with angina pectoris and angiographically verified CAD and 50 controls without known heart disease.The number of arterial oxygen desaturations of 4% or more per hour of sleep, oxygen desaturation index (ODI), and the number of apneas or hypopneas per hour of sleep, apnea-hypopnea index (AHI).Men with CAD had a high occurrence of sleep-disordered breathing measured as ODI of 5 or more, 39% (n=55), or AHI of 10 or more, 37% (n=50), while the same proportions in controls were 22% (n=ll, p<0.05) and 20% (n=10, p<0.05). Mean values of ODI in cases and controls were 6.4 and 2.7, respectively (p<0.001). Multiple logistic regression analysis identified ODI, AHI, body mass index, and hypertension as significant predictors of CAD (p<0.05).Sleep-disordered breathing is common in men with CAD. A significant association between sleep apnea with nocturnal hypoxemia and CAD remains after adjustment for age, hypertension, body mass index, diabetes, and smoking.

Predicting obstructive coronary artery disease with serum sphingosine-1-phosphate

Background Sphingolipids are emerging as important signaling molecules that may be produced by cardiac tissue during ischemic stress or as a consequence of inflammation. Because both inflammation and myocardial ischemia are associated with coronary artery disease (CAD), a study was designed to test the ability of serum sphingolipids to predict obstructive CAD. Methods The study consisted of 308 consecutive patients undergoing coronary angiography for all indications. The primary data points were the assessment of coronary artery stenosis with angiography and the measurements of serum sphingolipids. Results In this diverse population, serum sphingosine-1-phosphate (S1P) was a significant predictor of CAD ( P <.001). Multivariate analysis with logistic regression demonstrated that serum S1P was more predictive of obstructive CAD (odds ratio = 7.61) than the traditional risk factors (age, sex, family history of CAD, diabetes mellitus, lipid profile, hypertension, etc.). A 3-variable S1PC composite score was derived by combining the power of the S1P marker with the 2 most important risk factors, age and sex. The relationship between the S1PC and CAD scores was continuous and progressive, such that patients with elevated S1PC scores had higher occurrences of obstructive CAD. S1PC was also predictive of disease severity; 53.2% of patients in the fourth S1PC quartile had 2 to 3 vessel CAD, whereas only 5.2% of patients in the first S1PC quartile had 2 to 3 vessel disease (RR = 10.2 for severity). Conclusions Serum S1P is a remarkably strong and robust predictor of both the occurrence and severity of coronary stenosis. An S1P-based composite score may be useful as a novel, non-invasive indicator of obstructive CAD.

The association of cholesteryl ester transfer protein polymorphism with high-density lipoprotein cholesterol and coronary artery disease in Koreans.

Cholesteryl ester transfer protein (CETP) is a key protein involved in high-density lipoprotein cholesterol (HDL-C) metabolism. It is known to affect plasma HDL-C levels, and its genetic regulation may be involved in the development of coronary artery disease (CAD). The aim of this study was to determine the frequency of the CETP Taq1B polymorphism in Koreans, and to investigate its relationship with plasma HDL-C levels and CAD. One-hundred and nineteen patients with significant CAD and 106 controls were examined with respect to their genotypes, lipid profiles and other risk factors of CAD. The genotype frequencies of B1B1:B1B2:B2B2 in males and females were 35.5%:50%:14.5% and 34.7%:42.6%:22.7%, respectively, which is comparable to previous reports in other ethnic groups. The B1B1 homozygote was associated with significantly lower HDL-C levels in females (p = 0.049) and non-smoking males (p = 0.037). After controlling for gender, body mass index (BMI) and smoking, the TaqIB polymorphism was still significantly associated with HDL-C levels (p = 0.046) and explained 5.4% of the HDL-C variation in this study. By univariate analysis, the B1B1 homozygote was a significant predictor of CAD (p = 0.043), and this was confirmed by multivariate analysis with traditional risk factors, i.e. the B1B1 homozygote was an independent predictor of CAD (p = 0.026, odds ratio = 1.97, 95% confidence interval: 1.08-3.57). In conclusion, the B1B1 homozygote of the CETP Taq1B polymorphism is associated with low HDL-C levels in females and non-smoking males, and may be an independent genetic risk factor of CAD in the Korean population.

Clinical importance of risk factors and exercise testing for prediction of significant coronary artery stenosis in women recovering from unstable coronary artery disease: The Stockholm Female Coronary Risk Study

Background The objectives of this study were to investigate the relation between coronary risk factors, exercise testing parameters, and the presence of angiographically significant coronary artery disease (CAD) (≥50% luminal stenosis) in female patients previously hospitalized for an acute CAD event. Methods and Results All women younger than age 66 years in the greater Stockholm area in Sweden who were hospitalized for acute coronary syndromes during a 3-year period were recruited. Besides collection of clinical parameters, coronary angiography and a symptom-limited exercise test were performed in 228 patients 3 to 6 months after the index hospitalization. The mean age was 56 ± 7 years. Angiographically nonsignificant CAD (stenosis <50%) was verified in 37% of the patients; significant CAD was found in 63%. The clinical parameters that showed the strongest relation with the presence of significant CAD after adjusting for age were history of myocardial infarction (odds ratio [OR] 4.91, 95% confidence interval [CI] 2.35 to 7.49), history of diabetes mellitus (OR 3.83, 95% CI 1.63 to 14.31), serum high-density lipoprotein cholesterol <1.4 mmol/L (OR 2.11, 95% CI 1.20 to 3.72), and waist-to-hip ratio >0.85 (OR 1.78, 95% CI 1.02 to 3.10). A low exercise capacity and associated low change of rate-pressure product from rest to peak exercise were the only exercise testing parameters that were significantly related to angiographically verified significant CAD (<90% of the predicted maximal work capacity adjusted for age and weight, OR 1.91, 95% CI 1.04 to 3.50). Conclusions In female patients recovering from unstable CAD, exercise capacity was the only exercise testing parameter of value in the prediction of significant CAD. The consideration of certain clinical characteristics and coronary risk factors offer better or complementary information when deciding on further coronary assessment. (Am Heart J 2000;139:971-8.)

Increased carotid artery intimal-medial thickness in asymptomatic older subjects with exercise-induced myocardial ischemia.

Previous studies have shown an association between symptomatic coronary artery disease (CAD) and increased intimal-medial thickness of the common carotid artery (CCA IMT), a purported index of atherosclerosis. This study determines whether CCA IMT is increased in asymptomatic older subjects with an ischemic ST-segment response to treadmill exercise. CCA IMT was measured by B-mode ultrasound in community-dwelling volunteers from the Baltimore Longitudinal Study of Aging, including 397 healthy subjects (age, 58.5+/-15.8 years) with normal ECG responses to maximum treadmill exercise, 72 asymptomatic subjects (age, 66.1+/-13.4 years) with exercise-induced horizontal or downsloping ST-segment depression >/=1 mm, and 38 subjects (age, 77. 4+/-7.8 years) with clinically manifest CAD as diagnosed by medical history and resting ECG. Forty-three subjects with abnormal exercise ECGs also underwent exercise thallium scintigraphy. Exercise-induced ST-segment depression was associated with increased IMT (P<0.0001) independent of age and manifest CAD. After adjustment for age, IMT values progressively increased from healthy subjects to asymptomatic subjects with positive exercise ECG alone to those with concordant positive ECG and thallium scintigraphic findings who had virtually identical IMT to subjects with manifest CAD. Each 0.1-mm increase in IMT was associated with a 1.91-fold (95% CI, 1.46 to 2.50; P<0.0001) increased risk for concordant positive exercise tests or manifest CAD, independent of other significant predictors of CAD. CCA IMT is increased in older subjects with asymptomatic myocardial ischemia as evidenced by exercise ECG alone or in combination with thallium scan. Carotid ultrasound may help to identify asymptomatic individuals with CAD.

Sleep-Disordered Breathing in Men With Coronary Artery Disease

To examine the occurrence of sleep apnea and nocturnal hypoxemia in men with symptomatic coronary artery disease (CAD) and to evaluate the relationship between disordered breathing and coronary artery disease. Case-control study. Cases were randomly selected from men undergoing coronary angiography because of angina pectoris. Controls were age matched and selected from the population registry. Pulse oximetry, oronasal thermistors, body position indicator, and recording of body and respiratory movements were used to quantify desaturations and apneas. Norrland University Hospital, a referral center for northern Sweden. One hundred forty-two men with angina pectoris and angiographically verified CAD and 50 controls without known heart disease. The number of arterial oxygen desaturations of 4% or more per hour of sleep, oxygen desaturation index (ODI), and the number of apneas or hypopneas per hour of sleep, apnea-hypopnea index (AHI). Men with CAD had a high occurrence of sleep-disordered breathing measured as ODI of 5 or more, 39% (n=55), or AHI of 10 or more, 37% (n=50), while, the same proportions in controls were 22% (n=11, p<0.05) and 20% (n=10, p<0.05). Mean values of ODI in cases and controls were 6.4 and 2.7, respectively (p<0.001). Multiple logistic regression analysis identified ODI, AHI, body mass index, and hypertension as significant predictors of CAD (p<0.05). Sleep- disordered breathing is common in men with CAD. A significant association between sleep apnea with nocturnal hypoxemia and CAD remains after adjustment for age, hypertension, body mass index, diabetes, and smoking.

Relationships between triglycerides, lipoproteins, glucose and coronary artery disease

We examined the relationship of apolipoprotein B (apo B), glucose, triglycerides and other lipoprotein lipids to coronary artery disease (CAD). Using receiver-operating characteristic curves (ROC), we noticed that the triglyceride ROC curve crossed above other lipoprotein curves at a triglycerides level of ∼ 1.4 g/l. We examined subgroups of < 1.4 g/l and > 1.4 g/l. ANOVA ( F = 18.9, P < 0.0001) and stepwise logistic regression ( P = 0.0002) indicated that triglycerides were the best predictor in the < 1.4 g/l group. The best markers in the > 1.4 g/l group were low density lipoprotein cholesterol and apo B. Glucose did not appear to significantly alter the predictive power of triglycerides. These data suggest that triglyceride appears to be an overall significant univariate marker for CAD because of its effect at lower concentrations. The strong relationship between CAD and triglycerides at low triglyceride levels may reflect increased levels of very low density lipoprotein metabolites in some individuals. We conclude that some triglyceride-rich particles are independently atherogenic, that glucose did not alter this relationship and that when the samples were split into those with high and low levels of triglycerides, triglycerides and apo B but not HDLC was a significant predictor of CAD.

1015-75 Detection of Aortic Plaques is not Predictive of Coronary Artery Disease In the Elderly: A Biplane Transesophageal Echocardiographic Study

Atherosclerotic aortic plaques detected by transesophageal echocardiography (TEE) have been reported to be a marker for coronary artery disease (CAD). Its significance may particularly be important in elderly population, though there are no data yet available. To elucidate the significance of aortic plaques in the elderly, we performed TEE on 84 patients (pts) (44 men, 40 women, age 61 ± 11 years) who had previously undergone coronary arteriography. (1) Significant CAD (≥ 75% stenosis) was detected in at least one major coronary artery in 26 of the 84 pts. Aortic plaques were detected by TEE in 24 of the 26 pts with CAD (92%) and in 32 of 58 pts without CAD (55%) (p &lt; 0.01). (2) In pts aged 70 years (n = 25), aortic plaques were present in 13 of 14 pts with CAD (93%) and 10 of 11 pts without CAD (91%) (p = ns). In pts aged &lt; 70 years (n = 59), aortic plaques were present in 10 of 12 pts with CAD (83%) and 22 of 47 pts without CAD (47%) (p = 0.02). (3) The independent association between CAD and age, the presence of aortic plaques on TEE and other coronary risk factors was examined by multiple regression analysis. In pts aged ≥ 70 years, the presence of aortic plaques on TEE failed to be a predictor of significant CAD, although it was indeed a strong predictor of CAD in pts aged ≥ 70 years (p &lt; 0.01). In elderly pts, atherosclerotic aortic plaque detected by transesophageal echocardiography is not useful in predicting significant coronary artery disease. It is useful only in a relatively younger population.

Coronary angiography prior to renal transplantation

Summary: A retrospective analysis of coronary angiography in 89 patients (57 male, 32 female) on regular dialysis treatment, prior to their acceptance onto the cadaveric renal transplant waiting list, was performed. Patients studied included those older than 40 years and those symptomatic of coronary artery disease (CAD) or diabetics. Thirty patients (34%) had significant CAD: 18 one‐vessel, 8 two‐vessel, 3 three‐vessel and 1 four‐vessel disease. Significant predictors of CAD were a history of cardiac ischaemic symptoms, a diagnosis of diabetes mellitus, and a family history of CAD. There was no difference in survival between those with and those without CAD. Total mortality, and that due to myocardial infarction, was similar in patients with one‐ and two‐vessel disease and those without CAD, but increased in those with three‐ or four‐vessel disease (P&lt;0.001). Thirteen patients (11 with CAD) were excluded from the transplant waiting list, and their survival was significantly worse (P&lt;0.001). Restriction of coronary angiography to patients who were either symptomatic or diabetic would have resulted in 63% fewer angiograms without altering acceptance onto the transplantation waiting list for any patient.

Angina pectoris and coronary artery disease in isolated, severe aortic regurgitation

Seventy-eight patients with isolated, severe aortic regurgitation (AR) were studied retrospectively to determine the prevalence of angiographically significant coronary artery disease (CAD) and its relation to angina pectoris (AP). Angiographically, significant CAD was present in 29 of 78 patients (37%), and 36 patients (46%) had AP. Twenty-one of 36 patients (58%) with AP and 8 of 42 patients (19%) without AP had angiographically significant CAD. AP as a predictor of significant CAD had a sensitivity of 73%, specificity of 69% and a risk ratio of 3:1. The predictive accuracy of detecting CAD in the absence of AP was 81%. The benefit from concomitant coronary artery bypass grafting at the time of aortic valve replacement for AR has not been clearly demonstrated; therefore, routine coronary angiography is still recommended for all AR patients older than 40 years undergoing aortic valve replacement.