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Prognosis in severe angina pectoris due to triple coronary artery disease treated medically
ABSTRACTS
CLINICAL IMPLICATIONS OF WOCARDIAL PERFUSION SCANNING CORONARY ARTERY DISEASE. Donald A. Rothbaum, MD; Henry N. Wellman, MD; Suzanne B. Knaebel, MD, FACC. Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana.
PROGNOSIS IN SEVERE ANGINA PECTORIS DUE TRIPLE CORONARY ARTERY DISEASE TREATED
IN
MEDICALLY Henry I. Russek, MD, FACC, College, New York, N. Y.
To assess the clinical significance of myocardial perfusion scan (MPS) defects in coronary artery disease (CAD), 63 patients (pts) had resting MI'S prior g;, coronary arteriography and left ventriculography. Rubidium MPS were done in anterior, left anterior oblique and left lateral projections. Quantitative estimate of MPS defect was made by analysis of 7 zones for no (01, decreased (1) or normal (2) perfusion. Pts were divided into groups according to MPS score with a score of 14 representing a normal MPS. Also ventricular wall asvnerq~ (LVA) was (H) graded for aneurysm (AN), akinesis (H) o;-hypokinesis for each of 5 zones. The table summarizes the relationship of MPS score to LVA and to surgical outcome of saphenous vein bypass (SVB) or aneurysmectomy (ANX). Surgical MPS LVA Mortality Score Pts AN A H :2 zones SVB ANX 14 21 0 3 4 0 o/9 11-13 14 12 3 1 O/8 O/l 8-10 16 5 9 2 12 o/7 O/2 4-7 12 8 31 12 l/2 214
in 55 patients
1976
The American
Journal
of CARDIOLOGY
followed
for
5 to 9 years
to date
or
until
THE COMPARATIVE UTILITY OF ECHOCARDIOGFWHIC INDICES FOR THE DETECTION OF DEPRESSED LEFT VENTRICULAR FUNCTION IN CHILDREN. David J. Sahn, MD; Hugh D. Allen, MD; Stanley J. Goldberg, MD, FACC; Department of Pediatrics, Univ. of Arizona-Medical Center, Tucson, Arizona Abnormal left ventricular (LV) function was detected echocardiographically in 14 children (M group) with documented acute myocarditis (N=8) or chronic cardiomyopathy (N=6) (mean age 5.4 + .07 (SE) years) when indices were compared to 38 age matched normal children. Percent systolic LV shortening (AD) 0.22 k .Ol was significantly depressed when compared to the normal group, 0.32 f. .06 (~~0.01) despite digitalis maintenance in all M children. Diagnostic separation of the M group was also achieved utilizing mean velocity of circumferential LV fiber shortening determined with aortic valve ejection time (ET), Vcf-Ao=0.94 + .03 vs 1.33 + .03 in normals (p
MD, York
and early VPB, and Detection of VPB in runs, of multiform of bigeminy is strongly associated with number of VPB in the monitoring hour. Among patients with 50 or more VPB the proportion exhibiting runs or bigeminy is about 20 times that found among men with l-9 VPB during the hour, and about 3 times that among the men showing lo-49 VPB. The specified four qualitative features of VPB are also These associations strongly associated with each other. mandate caution in attempts to assess the prognostic significance of qualitative and quantitative aspects of VPB The data nevertheless suggest that relative activity. increases in mortality associated with increasing VPB frequency are found only in the presence of complex VPB. Approaches to a useful classification based on VPB characteristics frcm one hour of monitoring are discussed.
January
Medical
time of death. All subjects presented with severe angina pectorls and showed obstructions of 70% or more in the three major coronary branches. Ages ranged from 29 to 68; 42 were male and 13 female. Striking symptomatic impro\,ement with intensive medical therapy, which Included a combination of isosorbide dinitrate and propranolol, was observed in all but 2 of the 55 patients. The 5-year survival among 34 patients with relatively normal left ventricular function on ventriculography was 88%. Three of the 4 deaths were due to coronary events, one to cancer. Non-fatal myocardial infarction occurred in 12 of the surviving patients. Among the 21 subjects with significant degrees of asynergy, there were no survivors at the end of 4 years. Average annual mortality was 25%. These findings indicate that (1) TVD with good left ventricular function appears to have a better prognosis than has been recognized, (2) all cases with TVD should not be classified into one prognostic category and (3) coronary anatomy alone does not provide an accurate index of prognosis in anglna pectoris.
The relative importance of VPB frequency and of qualitative features of VP8 (runs, early VPB, bigeminy, multiformity) in defining excess mortality risk of men with CHD is examined with data from an ongoing study in a population of 120,000 men enrolled in HIP. Men aged 35-74 with recent MI or angina have a baseline examination which VPB are identified includes one hour of ECG monitoring. and characterized through a methodology utilizing both computer processing and trained ECG readers. Patients are remonitored at 6-month intervals and followed for mortalAmong 1217 men observed for periods up to 2.5 years ity. (mean 13.5 months) mortality of those showing VPB during the baseline monitoring hour is twice that of the patients free of VPB(8.5 vs 4.4 per 100 person-years.age-adjusted). Excess mortality among men with VPB is found consistently in many different subgroups.
166
York
The assumption that triple vessel disease (TVD), regardless of myocardial function, is of ominous prognostic signlflcance has been tested by a prospecti\re study
Surgical mortality only occurred in those pts with a large defect (MPS score 4-7, p<.O5) despite the similar magnitude of LVA in pts with a moderate defect (NPS score E-10). An additional 8 pts, 4 with moderate and 4 with large defects were rejected for surgery. Because of its potential value in estimating the extent of myocardial scarring in CAD, MPS may have prognostic implications in the evaluation of pts for CAD surgery.
CHARACTERISTICS OF VENTRICULAR PREMATURE BEATS AND PROGNOSIS OF MEN WITH CORONARY HEART DISEASE William Ruberman MD; Eve Weinblatt AB;Charles W.Frank FACC:Judith D.Goldberq ScD. Health Insurance Plan.New
New
TO
Volume
37
CLINICAL IMPLICATIONS OF WOCARDIAL PERFUSION SCANNING CORONARY ARTERY DISEASE. Donald A. Rothbaum, MD; Henry N. Wellman, MD; Suzanne B. Knaebel, MD, FACC. Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana.
PROGNOSIS IN SEVERE ANGINA PECTORIS DUE TRIPLE CORONARY ARTERY DISEASE TREATED
IN
MEDICALLY Henry I. Russek, MD, FACC, College, New York, N. Y.
To assess the clinical significance of myocardial perfusion scan (MPS) defects in coronary artery disease (CAD), 63 patients (pts) had resting MI'S prior g;, coronary arteriography and left ventriculography. Rubidium MPS were done in anterior, left anterior oblique and left lateral projections. Quantitative estimate of MPS defect was made by analysis of 7 zones for no (01, decreased (1) or normal (2) perfusion. Pts were divided into groups according to MPS score with a score of 14 representing a normal MPS. Also ventricular wall asvnerq~ (LVA) was (H) graded for aneurysm (AN), akinesis (H) o;-hypokinesis for each of 5 zones. The table summarizes the relationship of MPS score to LVA and to surgical outcome of saphenous vein bypass (SVB) or aneurysmectomy (ANX). Surgical MPS LVA Mortality Score Pts AN A H :2 zones SVB ANX 14 21 0 3 4 0 o/9 11-13 14 12 3 1 O/8 O/l 8-10 16 5 9 2 12 o/7 O/2 4-7 12 8 31 12 l/2 214
in 55 patients
1976
The American
Journal
of CARDIOLOGY
followed
for
5 to 9 years
to date
or
until
THE COMPARATIVE UTILITY OF ECHOCARDIOGFWHIC INDICES FOR THE DETECTION OF DEPRESSED LEFT VENTRICULAR FUNCTION IN CHILDREN. David J. Sahn, MD; Hugh D. Allen, MD; Stanley J. Goldberg, MD, FACC; Department of Pediatrics, Univ. of Arizona-Medical Center, Tucson, Arizona Abnormal left ventricular (LV) function was detected echocardiographically in 14 children (M group) with documented acute myocarditis (N=8) or chronic cardiomyopathy (N=6) (mean age 5.4 + .07 (SE) years) when indices were compared to 38 age matched normal children. Percent systolic LV shortening (AD) 0.22 k .Ol was significantly depressed when compared to the normal group, 0.32 f. .06 (~~0.01) despite digitalis maintenance in all M children. Diagnostic separation of the M group was also achieved utilizing mean velocity of circumferential LV fiber shortening determined with aortic valve ejection time (ET), Vcf-Ao=0.94 + .03 vs 1.33 + .03 in normals (p
MD, York
and early VPB, and Detection of VPB in runs, of multiform of bigeminy is strongly associated with number of VPB in the monitoring hour. Among patients with 50 or more VPB the proportion exhibiting runs or bigeminy is about 20 times that found among men with l-9 VPB during the hour, and about 3 times that among the men showing lo-49 VPB. The specified four qualitative features of VPB are also These associations strongly associated with each other. mandate caution in attempts to assess the prognostic significance of qualitative and quantitative aspects of VPB The data nevertheless suggest that relative activity. increases in mortality associated with increasing VPB frequency are found only in the presence of complex VPB. Approaches to a useful classification based on VPB characteristics frcm one hour of monitoring are discussed.
January
Medical
time of death. All subjects presented with severe angina pectorls and showed obstructions of 70% or more in the three major coronary branches. Ages ranged from 29 to 68; 42 were male and 13 female. Striking symptomatic impro\,ement with intensive medical therapy, which Included a combination of isosorbide dinitrate and propranolol, was observed in all but 2 of the 55 patients. The 5-year survival among 34 patients with relatively normal left ventricular function on ventriculography was 88%. Three of the 4 deaths were due to coronary events, one to cancer. Non-fatal myocardial infarction occurred in 12 of the surviving patients. Among the 21 subjects with significant degrees of asynergy, there were no survivors at the end of 4 years. Average annual mortality was 25%. These findings indicate that (1) TVD with good left ventricular function appears to have a better prognosis than has been recognized, (2) all cases with TVD should not be classified into one prognostic category and (3) coronary anatomy alone does not provide an accurate index of prognosis in anglna pectoris.
The relative importance of VPB frequency and of qualitative features of VP8 (runs, early VPB, bigeminy, multiformity) in defining excess mortality risk of men with CHD is examined with data from an ongoing study in a population of 120,000 men enrolled in HIP. Men aged 35-74 with recent MI or angina have a baseline examination which VPB are identified includes one hour of ECG monitoring. and characterized through a methodology utilizing both computer processing and trained ECG readers. Patients are remonitored at 6-month intervals and followed for mortalAmong 1217 men observed for periods up to 2.5 years ity. (mean 13.5 months) mortality of those showing VPB during the baseline monitoring hour is twice that of the patients free of VPB(8.5 vs 4.4 per 100 person-years.age-adjusted). Excess mortality among men with VPB is found consistently in many different subgroups.
166
York
The assumption that triple vessel disease (TVD), regardless of myocardial function, is of ominous prognostic signlflcance has been tested by a prospecti\re study
Surgical mortality only occurred in those pts with a large defect (MPS score 4-7, p<.O5) despite the similar magnitude of LVA in pts with a moderate defect (NPS score E-10). An additional 8 pts, 4 with moderate and 4 with large defects were rejected for surgery. Because of its potential value in estimating the extent of myocardial scarring in CAD, MPS may have prognostic implications in the evaluation of pts for CAD surgery.
CHARACTERISTICS OF VENTRICULAR PREMATURE BEATS AND PROGNOSIS OF MEN WITH CORONARY HEART DISEASE William Ruberman MD; Eve Weinblatt AB;Charles W.Frank FACC:Judith D.Goldberq ScD. Health Insurance Plan.New
New
TO
Volume
37