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Evidence for coronary steal during dipyridamole infusion in patients with coronary artery disease
ABSTRACTS
OUTPATIENT CARDIAC CATHETERIZATION AND CORONARY ARTERIOGRAPHY: SAFE AND COST-EFFECTIVE - REPORT OF 1000 CASES Stephen A. Pierce, MD; S.A.Kinard, Jr., MD, FACC; E.B.Diethrich, MD, FACC, FACS; R.Koopot, MD, FACC, FACS, Arizona Heart Institute,,Phoenix, Arizona.
The recognition of left ventricular (LV) mural thrombi in patients (pts) with LV aneurysms is of therapeutic importance, but the relative diagnostic value of invasive and noninvasive techniques for identifying LV mural thrombi compared to anatomic confirmation is uncertain. Accordingly, we evaluated LV biplane cineangiography (CINE), 2dimensional echocardiography (2DE) and gated equilibrium radionuclide angiography (RNA) in 18 pts undergoing surgery for aneurysmectomy or autopsy within one week. Strict criteria for LV mural thrombus in the aneurysm were used to avoid false positive readings: CINE and RNA-luminal defect surrounded by contrast on 3 sides; 2DE - an echo producing structure distinct from the myocardium protruding intothe lumen. At direct inspection 10 of the 18 pts (56%) had LV mural thrombi. No false positive thrombus identifications were made by the 3 techniques. CINE detected LV mural thrombi in 5 of 10 pts for a sensitivity of 50% and an overall test accuracy of 72%. 2DE identified 6 of 10 pts with an LV mural thrombus for a sensitivity of 60% and an overall test accuracy of 78%. RNA had a sensitivity of 40% (4 of 10 pts) and a test accuracy of 65%. 2DE and RNA combined improved sensitivity to 80% (8 of 10 pts) and test accuracy of 89%. We conclude that in a population of patients with LV aneurysms and a high prevalence of LV mural thrombi: 1) strict diagnostic criteria can avoid false positive readings of CINE, 2DE and RNA; 2) 2DEismore sensitive than either CINE or RNA alone for detecting LV mural thrombi; and 3) 2DE and RNA combined are more sensitive and accurate than either technique alone for detecting LV mural thrombi.
A major challenge facing medical care today is the need to reduce health care costs without lowering the quality of health care. This requires innovative approaches to reduce the costs of providing modern high technologyhigh quality health care without compromising patient safety. A free-standing facility, the Arizona Heart Institute was designed to include facilities for Outpatient Cardiac Catheterization (OPCC). 1000 OPCC's were done by Sones technique excluding only patients with poorly controlled class IV angina pectoris, marked ST segment depression and hypotension with submaximal exercise, poorly compensated congestive heart failure, or poorly controlled high-grade ventricular arrhythmias. Findings of coronary arteriography and complications were analyzed and compared to other laboratories. Our OPCC patients experienced only 1% significant complications. The cost for OPCC at this facility and three other facilities were compared with the cost of the procedure at four hospitals in Phoenix and 14 other institutions nationwide, demonstrating a cost reduction of 35-37% for OPCC. We projected a potential savings of at least $52 million, assuming that Z/3 of all cardiac catheterizations could be performed as OPCC's. OPCC is a viable concept of health care delivery providing modern, high quality health care at reduced cost without compromising patient safety.
EVIDENCE FORCORONARYSTEAL DURING DIPYRIDAMOLE INFUSION IN PATIENTS WITH CORONARYARTERY DISEASE Michael 5. Lux, M.D., Lewis C. Bedcar, M.D.,FACC Johrw Hopkins University School of Medicine, Baltimore, Md.
TEE INCIDENCE OF THE NORMAL WALL SEGMENT IN CORONARY OBSTRUCTIONS. A POSTMORl'BW ANALYSIS. Hermann Freudenherg, MU; Paul R. Lichtlen, MO; Joachim Klapper,MU Hannover Medical School, West-Germany
Dipyridamale
Alterations in arterial tone superimposed on arteriosclerotic plaques are thought to be an important factor in producing angina pectoris. One of the preconditions for this is a "nearly normal wall segment" with an intact media (NWS) in the area of obstruction. We therefore studied 384 stenoses (ST) W 50% by areas in histology(plani.metry) and quantified the extend of the NWS defined as a segment with an intact media and an intima not thicker than 0,2 (0,l - 0,5) mm. Results: With respect to the circumference of the total cross section of the artery 74p ef all ST ha4 ad_NWSZ8%; in 45% of ST the NWS was even)25%.With respect to the circumference of the residual lumen 7t% of all ST had an MWS+16%; in 25% of ST the NWS was even s 50%. A NWS was more often seen in the left (left main 87%, LAU 70%, LCX 75%) than in the right artery (65%). where the concentric type of ST dominated. Conclusions: In coronary stenoses of.50% by areas the extent of the "nearlv normal wall seament" is unexoectedly high. This fact might he important for the pathogenesis of angina and also for the Possibility of medical and mechanical dilatation of coronary stenoses.
938
March 1982
The American Journal of CARDIOLOGY
DETECTION 0F LEFT VENTRICULAR MURAL THROM~US: COMPARATIVE VALUE OF INVASIVE AND NONINVASIVE TECHNIQUES Mark R. Starling, MO, FACC; Michael H. Crawford, MD, FACC; Sherman G. Sorensen, MD, FACC; Frederick L. Grover, MD, University of Texas Health Science Center, San Antonio TX
(DYP) is a potent coronary vasodilotar
which
causes
a several-fold
increase_ in flow in normal vessels but which can
paradoxically
cause ischemia
disease (CAD).
DYP-induced
sion,
myocardial
increased
in patients
(pts) with coronary artery
ischemio could be due to hypotenoxygen demands,
or a redistribution
of
coronary flow away from obstructed vascular beds (coronary steal). To investlgate the cause of DYP-induced ischemia we coqxrred the results of treadmill exercise(Ex) and DYP infusion (0.15 mg/ kg/min far 4 min) in 22 pts with ongiogmphically documentedCAR All pts were receiving
lnderol
(mean dose 240 w).
Angina
or
ischemic ECG changes occurred in 17/22 (77%) during Ex ond 15/ 22 (68%) during DYP. TI-201 scintigroms obtained as part of the study were nat significantly different between DYP and Ex. At the onset of ischemia, hemodynamic parameten were o follows (mean + SD): l&art Rate (beats/min) Rest Ex DYP
Rate Pressure Blood Pressure mmHg
70+10
lOO+l4
127%?9* 87rl5*t
118%*
*p <.001
93712 t Rest,
+p <.OOl
Product 9287+2240 21022%5868* 1084472305 7
vsTx
Ischemia occurred at a markedly lower mean rate-pressure product with DYP than with Ex, at a value only minimally elevated from resting levels (p=,O56). Thus, DYP-induced myocardial ischemio was not associated with an important increase in heart rate ar mtepressure product, nor with a significant decrease in perfusion presThese results implicate a coronary steal mechanism in the sure. etiology of DYP-induced myacardial ischemio.
Volume 49
OUTPATIENT CARDIAC CATHETERIZATION AND CORONARY ARTERIOGRAPHY: SAFE AND COST-EFFECTIVE - REPORT OF 1000 CASES Stephen A. Pierce, MD; S.A.Kinard, Jr., MD, FACC; E.B.Diethrich, MD, FACC, FACS; R.Koopot, MD, FACC, FACS, Arizona Heart Institute,,Phoenix, Arizona.
The recognition of left ventricular (LV) mural thrombi in patients (pts) with LV aneurysms is of therapeutic importance, but the relative diagnostic value of invasive and noninvasive techniques for identifying LV mural thrombi compared to anatomic confirmation is uncertain. Accordingly, we evaluated LV biplane cineangiography (CINE), 2dimensional echocardiography (2DE) and gated equilibrium radionuclide angiography (RNA) in 18 pts undergoing surgery for aneurysmectomy or autopsy within one week. Strict criteria for LV mural thrombus in the aneurysm were used to avoid false positive readings: CINE and RNA-luminal defect surrounded by contrast on 3 sides; 2DE - an echo producing structure distinct from the myocardium protruding intothe lumen. At direct inspection 10 of the 18 pts (56%) had LV mural thrombi. No false positive thrombus identifications were made by the 3 techniques. CINE detected LV mural thrombi in 5 of 10 pts for a sensitivity of 50% and an overall test accuracy of 72%. 2DE identified 6 of 10 pts with an LV mural thrombus for a sensitivity of 60% and an overall test accuracy of 78%. RNA had a sensitivity of 40% (4 of 10 pts) and a test accuracy of 65%. 2DE and RNA combined improved sensitivity to 80% (8 of 10 pts) and test accuracy of 89%. We conclude that in a population of patients with LV aneurysms and a high prevalence of LV mural thrombi: 1) strict diagnostic criteria can avoid false positive readings of CINE, 2DE and RNA; 2) 2DEismore sensitive than either CINE or RNA alone for detecting LV mural thrombi; and 3) 2DE and RNA combined are more sensitive and accurate than either technique alone for detecting LV mural thrombi.
A major challenge facing medical care today is the need to reduce health care costs without lowering the quality of health care. This requires innovative approaches to reduce the costs of providing modern high technologyhigh quality health care without compromising patient safety. A free-standing facility, the Arizona Heart Institute was designed to include facilities for Outpatient Cardiac Catheterization (OPCC). 1000 OPCC's were done by Sones technique excluding only patients with poorly controlled class IV angina pectoris, marked ST segment depression and hypotension with submaximal exercise, poorly compensated congestive heart failure, or poorly controlled high-grade ventricular arrhythmias. Findings of coronary arteriography and complications were analyzed and compared to other laboratories. Our OPCC patients experienced only 1% significant complications. The cost for OPCC at this facility and three other facilities were compared with the cost of the procedure at four hospitals in Phoenix and 14 other institutions nationwide, demonstrating a cost reduction of 35-37% for OPCC. We projected a potential savings of at least $52 million, assuming that Z/3 of all cardiac catheterizations could be performed as OPCC's. OPCC is a viable concept of health care delivery providing modern, high quality health care at reduced cost without compromising patient safety.
EVIDENCE FORCORONARYSTEAL DURING DIPYRIDAMOLE INFUSION IN PATIENTS WITH CORONARYARTERY DISEASE Michael 5. Lux, M.D., Lewis C. Bedcar, M.D.,FACC Johrw Hopkins University School of Medicine, Baltimore, Md.
TEE INCIDENCE OF THE NORMAL WALL SEGMENT IN CORONARY OBSTRUCTIONS. A POSTMORl'BW ANALYSIS. Hermann Freudenherg, MU; Paul R. Lichtlen, MO; Joachim Klapper,MU Hannover Medical School, West-Germany
Dipyridamale
Alterations in arterial tone superimposed on arteriosclerotic plaques are thought to be an important factor in producing angina pectoris. One of the preconditions for this is a "nearly normal wall segment" with an intact media (NWS) in the area of obstruction. We therefore studied 384 stenoses (ST) W 50% by areas in histology(plani.metry) and quantified the extend of the NWS defined as a segment with an intact media and an intima not thicker than 0,2 (0,l - 0,5) mm. Results: With respect to the circumference of the total cross section of the artery 74p ef all ST ha4 ad_NWSZ8%; in 45% of ST the NWS was even)25%.With respect to the circumference of the residual lumen 7t% of all ST had an MWS+16%; in 25% of ST the NWS was even s 50%. A NWS was more often seen in the left (left main 87%, LAU 70%, LCX 75%) than in the right artery (65%). where the concentric type of ST dominated. Conclusions: In coronary stenoses of.50% by areas the extent of the "nearlv normal wall seament" is unexoectedly high. This fact might he important for the pathogenesis of angina and also for the Possibility of medical and mechanical dilatation of coronary stenoses.
938
March 1982
The American Journal of CARDIOLOGY
DETECTION 0F LEFT VENTRICULAR MURAL THROM~US: COMPARATIVE VALUE OF INVASIVE AND NONINVASIVE TECHNIQUES Mark R. Starling, MO, FACC; Michael H. Crawford, MD, FACC; Sherman G. Sorensen, MD, FACC; Frederick L. Grover, MD, University of Texas Health Science Center, San Antonio TX
(DYP) is a potent coronary vasodilotar
which
causes
a several-fold
increase_ in flow in normal vessels but which can
paradoxically
cause ischemia
disease (CAD).
DYP-induced
sion,
myocardial
increased
in patients
(pts) with coronary artery
ischemio could be due to hypotenoxygen demands,
or a redistribution
of
coronary flow away from obstructed vascular beds (coronary steal). To investlgate the cause of DYP-induced ischemia we coqxrred the results of treadmill exercise(Ex) and DYP infusion (0.15 mg/ kg/min far 4 min) in 22 pts with ongiogmphically documentedCAR All pts were receiving
lnderol
(mean dose 240 w).
Angina
or
ischemic ECG changes occurred in 17/22 (77%) during Ex ond 15/ 22 (68%) during DYP. TI-201 scintigroms obtained as part of the study were nat significantly different between DYP and Ex. At the onset of ischemia, hemodynamic parameten were o follows (mean + SD): l&art Rate (beats/min) Rest Ex DYP
Rate Pressure Blood Pressure mmHg
70+10
lOO+l4
127%?9* 87rl5*t
118%*
*p <.001
93712 t Rest,
+p <.OOl
Product 9287+2240 21022%5868* 1084472305 7
vsTx
Ischemia occurred at a markedly lower mean rate-pressure product with DYP than with Ex, at a value only minimally elevated from resting levels (p=,O56). Thus, DYP-induced myocardial ischemio was not associated with an important increase in heart rate ar mtepressure product, nor with a significant decrease in perfusion presThese results implicate a coronary steal mechanism in the sure. etiology of DYP-induced myacardial ischemio.
Volume 49