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Prognostic significance of left main equivalent stenosis
ABSTRACTS
LEFT VENTRICULAR RESPONSE TO EXERCISE AFTER ANTERIOR MYOCARDIAL INFARCTION: DIFFERENCES BETWEEN PATIENTS WITH SINGLE AND MULTIVESSEL CORONARY ARTERY DISEASE. Arthur T.H. Tan MB, Norman Sadick MB, Roger F. Uren MB Phillip J. Harris MB FACC, David T. Kelly M8 FACC. Hallstrom Institute of Cardiology, Sydney, Australia. Patients with single or multivessel disease may have impaired LV function at rest after anterior transmural myocardial infarction. To determine whether the LV response to exercise was different in these two groups, 26 patients with previous extensive anterior myocardial infarction from total left anterior descending artery (LAD) occlusion underwent exercise testing with equilibrium radionuclide ventriculography. Fifteen patients (SVD) had isolated occlusion and 11 patients (MVD) had one or more additional 270% stenosed coronary arteries. The mean maximum heart rates in SVD (14825) and MVD (14625) patients were similar. Seven m patients but no SW patients developed angina and/or ischaemic ST changes with exercise. In SVD patients, ejection fraction (EF) did not change from rest (0.32+0.03) to peak exercise (0.3eO.03) because there was a similar increase in end systolic volume (ESV; 19%+4X) and end diastolic volume (EDV; 16%24%). In MVD patients EF decreased from 0.322 0.03 to 0.23+0.02 (~~0.01) because of a disproportionate increase in ESV (45%513%) compared to EDV (27%27X). After extensive anterior myocardial infarction resting EF is a poor index of exercise capacity. The increase in cardiac output during exercise in patients'with SVD and previous anterior infarction is heart rate dependent because stroke volume does not change. In patients with MVD the cardiac output response to exercise is attenuated because end systolic volume increases and stroke volume decreases. This response to stress after myocardial infarction may be important for early identification of patients with a poor prognosis due to residual ischaemic myocardium.
ASYMPTDMATIC LEFT MAIN CORONARY ARTERY DISEASE Fayaz A. Shawl. MD; MRCP; Mitchell L. Mutter, MD; Dennis J. Donahue, MD; Robert 0. Slama, MD; Rus ZaJtchuk MD; James E. Davis, MD; Walter Reed Army Medlcal Center, Washington, D.C.
PROGNOSTIC SIGNIFICANCE OF LEFT MAIN EQUIVALENT STENOSIS Martin J. Conley, M.D., Victor S. Behar, M.D., F.A.C.C., Frank E.,Harrell, Ph.D., Robert M. Califf, M.D., Robert A. Rosati, M.D., Duke University Medical Center, Durham, North Carolina
TOTAL OCCLUSION OF THE LEFT MAIN CORONARY ARTERY: THECASS EXPERIENCE. Samuel H. Zimmern,M.D, William J. Rogers, M.D., F.A.C.C., Peter R. Bream, M.D., Bernard R. Chaitman. M.D., F.A.C.C.. Martial G. Bourassa. M.D., F.A.C.C., Kathrin A. davis, Ph.D:, Denis H.Tyras, M.D.; Robert Berger, M.D., F.A.C.C., Lloyd Fisher, Ph.D., F.A.C.C., Melvin P. Judkins, M.D., F.A.C.C., Michael B. Mock, M.D., F.A.C.C., and Thomas Killip, M.D., F.A.C.C. University of Alabama in Birmingham, Birmingham, Alabama. Total occlusion of the left main coronary artery (lOO%LMCA) was confirmed on review of cineangiograms in I2 (0.05%) of the 23,349 patients (pts) entered into the Coronary Artery Surgery Study (CASS) prior to coronary surgery. These 12 pts are the largest reported group with lOO%-LMCA. Mean age at presentation was 58.9 yrs (range 44-80). Ten pts were male. Eleven pts had angina pectoris (AP) as their presenting complaint; 10 had Class II! or IV AP; 4 had unstable AP. Chest pain first had been noted a mean of 231 wks (range 3 wks-I4 yrs) prior to entry; the presenting level of Symptoms had existed a mean of 24.4 wks (2-104 wkg). Six pts had a myocardial infarction and 2 had congestive failure prior to entry. One pt presented with only a changed ECG. During follow rp 4 pts died a mean of 43.5 days after entry; 8 were living a mean of 37.6 mos after entry. The mean age ” entry in the group that died was 70 yrs and in the surviving group 53.2 yrs. Seven pts had coronary artery bypass graft surgery (CABG); of these, 6 (86%) were surviving a mean 41.7 mos after CABC; 4 of these pts were free of angina. Five pts did not have CABG; of these, 2 (40%) were surviving a mean of 24 mos after entry, and 1 was free of angina. Conclusions: 1.) Total occlusion of the left main coronary artery is a rare lesion. 2.) Most pts present with severe angina 3.) Advanced age worsens long-term of prolonged duration. 4.) Prolonged survival and improvement of symptoms prognosis. 5.) Long-term survival without may occur following CABC. angina is possible even without CABC.
Concomitant 275% stenosis of the left circumflex proximal to the first marginal and ,75% stenosis of the left anterior descending proximal to the first septal perforator and the first anterolateral have been considered to carry risk equivalent to 275% left main stenosis. The purpose of this study was to determine the prognostic significance of left main equivalent (LME) stenosis. Among 1527 consecutive.medically treated patients with significant (275%) coronary artery disease, long-term survival was significantly (p-0.001) lower for 90 patients with 275% left main (LM) stenosis than for 57 patients with LME stenosis:
LM LME
6 mo. 73x 84%
a. 66% 76%
25;;s.
34;;s.
44;;s.
72%
63%
61%
*. 54%
Multivariable analysis using a series of baseline characteristics which we have previously demonstrated to be independent predictors of survival (including left ventricvlar ejection fraction and number of vessels with significant stenoses) confirmed the prognostic importance of LM stenosis (p
400
February 1081
The American Journal of CARDIOLOGY
The prognosis, detectton, and natural history of severe, asymptomatic coronary astroy disease remain difficult clinical problems. Epidemiologic studies of unexpected death and post-mortem studies of silent myocardial infarction suggest that this entity may be mOre common. We reviewed 89 consecutive patients with significant left main coronary artery disease (LMD), defined as 50% or greater reduction of luminal diameter. Of this group IO pts (II%) were asymptomatic (ALMD) and 79 pts (88%) were symptomatic. All IO ALMD pts were males with a mean age of 53 years (range 40-65). Treadmi I I test (TM) were performed in this group for the following reasons: EKG abnormalities, 6; pre-jogging evaluatlon 2: risk factor evaluation 2. The TMT showed 2mm or greater ST depression In 7/lO (70%) and I-2mm in 3/10 (30%). Similar TMT results were obtained in the SLMD group, although 2 patients had negative responses. The degree of stenosis of the left main coronary artery and the frequency of 3-vessel disease was similar in both groups. LV functions in ALMD group was excellent as manifested by a normal ejection fraction and normal wall motion in all IO pts and a normal left ventricular end-diastolic pressure (LVEDP) in 708, whereas in SLMD group 63% had an abnormal eJection fraction, 62% had wall motion abnorrnallties.and 57% had a normal LVED. In conclusion I) II% of LMD patients were asymptomatic 2) No significant difference was found in the TMT response and anatomy in the ALMD and SLMD group and 3) the ALMD group had much better LV functions when compared to the SLMD group.
Volume 47
LEFT VENTRICULAR RESPONSE TO EXERCISE AFTER ANTERIOR MYOCARDIAL INFARCTION: DIFFERENCES BETWEEN PATIENTS WITH SINGLE AND MULTIVESSEL CORONARY ARTERY DISEASE. Arthur T.H. Tan MB, Norman Sadick MB, Roger F. Uren MB Phillip J. Harris MB FACC, David T. Kelly M8 FACC. Hallstrom Institute of Cardiology, Sydney, Australia. Patients with single or multivessel disease may have impaired LV function at rest after anterior transmural myocardial infarction. To determine whether the LV response to exercise was different in these two groups, 26 patients with previous extensive anterior myocardial infarction from total left anterior descending artery (LAD) occlusion underwent exercise testing with equilibrium radionuclide ventriculography. Fifteen patients (SVD) had isolated occlusion and 11 patients (MVD) had one or more additional 270% stenosed coronary arteries. The mean maximum heart rates in SVD (14825) and MVD (14625) patients were similar. Seven m patients but no SW patients developed angina and/or ischaemic ST changes with exercise. In SVD patients, ejection fraction (EF) did not change from rest (0.32+0.03) to peak exercise (0.3eO.03) because there was a similar increase in end systolic volume (ESV; 19%+4X) and end diastolic volume (EDV; 16%24%). In MVD patients EF decreased from 0.322 0.03 to 0.23+0.02 (~~0.01) because of a disproportionate increase in ESV (45%513%) compared to EDV (27%27X). After extensive anterior myocardial infarction resting EF is a poor index of exercise capacity. The increase in cardiac output during exercise in patients'with SVD and previous anterior infarction is heart rate dependent because stroke volume does not change. In patients with MVD the cardiac output response to exercise is attenuated because end systolic volume increases and stroke volume decreases. This response to stress after myocardial infarction may be important for early identification of patients with a poor prognosis due to residual ischaemic myocardium.
ASYMPTDMATIC LEFT MAIN CORONARY ARTERY DISEASE Fayaz A. Shawl. MD; MRCP; Mitchell L. Mutter, MD; Dennis J. Donahue, MD; Robert 0. Slama, MD; Rus ZaJtchuk MD; James E. Davis, MD; Walter Reed Army Medlcal Center, Washington, D.C.
PROGNOSTIC SIGNIFICANCE OF LEFT MAIN EQUIVALENT STENOSIS Martin J. Conley, M.D., Victor S. Behar, M.D., F.A.C.C., Frank E.,Harrell, Ph.D., Robert M. Califf, M.D., Robert A. Rosati, M.D., Duke University Medical Center, Durham, North Carolina
TOTAL OCCLUSION OF THE LEFT MAIN CORONARY ARTERY: THECASS EXPERIENCE. Samuel H. Zimmern,M.D, William J. Rogers, M.D., F.A.C.C., Peter R. Bream, M.D., Bernard R. Chaitman. M.D., F.A.C.C.. Martial G. Bourassa. M.D., F.A.C.C., Kathrin A. davis, Ph.D:, Denis H.Tyras, M.D.; Robert Berger, M.D., F.A.C.C., Lloyd Fisher, Ph.D., F.A.C.C., Melvin P. Judkins, M.D., F.A.C.C., Michael B. Mock, M.D., F.A.C.C., and Thomas Killip, M.D., F.A.C.C. University of Alabama in Birmingham, Birmingham, Alabama. Total occlusion of the left main coronary artery (lOO%LMCA) was confirmed on review of cineangiograms in I2 (0.05%) of the 23,349 patients (pts) entered into the Coronary Artery Surgery Study (CASS) prior to coronary surgery. These 12 pts are the largest reported group with lOO%-LMCA. Mean age at presentation was 58.9 yrs (range 44-80). Ten pts were male. Eleven pts had angina pectoris (AP) as their presenting complaint; 10 had Class II! or IV AP; 4 had unstable AP. Chest pain first had been noted a mean of 231 wks (range 3 wks-I4 yrs) prior to entry; the presenting level of Symptoms had existed a mean of 24.4 wks (2-104 wkg). Six pts had a myocardial infarction and 2 had congestive failure prior to entry. One pt presented with only a changed ECG. During follow rp 4 pts died a mean of 43.5 days after entry; 8 were living a mean of 37.6 mos after entry. The mean age ” entry in the group that died was 70 yrs and in the surviving group 53.2 yrs. Seven pts had coronary artery bypass graft surgery (CABG); of these, 6 (86%) were surviving a mean 41.7 mos after CABC; 4 of these pts were free of angina. Five pts did not have CABG; of these, 2 (40%) were surviving a mean of 24 mos after entry, and 1 was free of angina. Conclusions: 1.) Total occlusion of the left main coronary artery is a rare lesion. 2.) Most pts present with severe angina 3.) Advanced age worsens long-term of prolonged duration. 4.) Prolonged survival and improvement of symptoms prognosis. 5.) Long-term survival without may occur following CABC. angina is possible even without CABC.
Concomitant 275% stenosis of the left circumflex proximal to the first marginal and ,75% stenosis of the left anterior descending proximal to the first septal perforator and the first anterolateral have been considered to carry risk equivalent to 275% left main stenosis. The purpose of this study was to determine the prognostic significance of left main equivalent (LME) stenosis. Among 1527 consecutive.medically treated patients with significant (275%) coronary artery disease, long-term survival was significantly (p-0.001) lower for 90 patients with 275% left main (LM) stenosis than for 57 patients with LME stenosis:
LM LME
6 mo. 73x 84%
a. 66% 76%
25;;s.
34;;s.
44;;s.
72%
63%
61%
*. 54%
Multivariable analysis using a series of baseline characteristics which we have previously demonstrated to be independent predictors of survival (including left ventricvlar ejection fraction and number of vessels with significant stenoses) confirmed the prognostic importance of LM stenosis (p
400
February 1081
The American Journal of CARDIOLOGY
The prognosis, detectton, and natural history of severe, asymptomatic coronary astroy disease remain difficult clinical problems. Epidemiologic studies of unexpected death and post-mortem studies of silent myocardial infarction suggest that this entity may be mOre common. We reviewed 89 consecutive patients with significant left main coronary artery disease (LMD), defined as 50% or greater reduction of luminal diameter. Of this group IO pts (II%) were asymptomatic (ALMD) and 79 pts (88%) were symptomatic. All IO ALMD pts were males with a mean age of 53 years (range 40-65). Treadmi I I test (TM) were performed in this group for the following reasons: EKG abnormalities, 6; pre-jogging evaluatlon 2: risk factor evaluation 2. The TMT showed 2mm or greater ST depression In 7/lO (70%) and I-2mm in 3/10 (30%). Similar TMT results were obtained in the SLMD group, although 2 patients had negative responses. The degree of stenosis of the left main coronary artery and the frequency of 3-vessel disease was similar in both groups. LV functions in ALMD group was excellent as manifested by a normal ejection fraction and normal wall motion in all IO pts and a normal left ventricular end-diastolic pressure (LVEDP) in 708, whereas in SLMD group 63% had an abnormal eJection fraction, 62% had wall motion abnorrnallties.and 57% had a normal LVED. In conclusion I) II% of LMD patients were asymptomatic 2) No significant difference was found in the TMT response and anatomy in the ALMD and SLMD group and 3) the ALMD group had much better LV functions when compared to the SLMD group.
Volume 47