- Email: [email protected]
Silent angina and coronary bypass surgery
Annotations
Fig. 3. Right coronary artery at the level of the bifurcation at the crux cordis. Embedded within the thromboembolus is a loose, embolized fragment of arterial wall. Elastic tissue, x50. Right: detail of the embolized fragment which is identified as the fibroelastic inner layer of the proximal segment of the right coronary artery. Elastic tissue stain, x500.
technique. The ever grams made all over atic investigation as what other measures complication.
increasing number of coronary angiothe world, however, requires a systemto what technique should be used and should be taken to avoid this dreadful
A. E. Becker, M.D. H. J J Wellens, M.D. R. M. Schuiknburg, MD. D. Durrer, MD. Labomtory for Pathological Anatomy and Department of Cardiology and Clinical Physiology Wilhelmina Gasthuk Amsterdam, The Netherlands REFERENCES
1.
angina and coronary
bypass
6.
surgery
The relief of chest pain or discomfort characteristic of angina pectoris by coronary bypass surgery does not necessarily imply a “cure” or relief of the angina pectoris or even improvement of the myocardial circulation. This is well illustrated by
530
5.
7.
Giddings, J. A., See, J. R., Lewis, R. D.: Thromboembolism following coronary arteriography, Chest 61:235, 1972.
Silent
4.
Takaro, T., Pifarre, R., Wuertlein, R. D., Hall, A. D., Gage, A. A., Scott, S. M., Dart, Ch. H., and PrestonPrice, H.: Acute coronary occlusion following coronary arteriography: mechanism and surgical relief, Surgery 72:1018, 1972. Preston-Price, H., Sollad, N., Scott, S. M., and Takaro, T.: Unusual coronary emboli associated with coronary arteriography, Chest 63698, 1973. Judkins, M. P.: Percutaneous tranafemoral selective coronary arteriography, Radiol. Clin. North Am. 6:467, 1968. Sones, F. M., Jr.: Cinecoronary arteriography, Anesth. Analg. 48:499, 1967. Chahine, R. A., Herman, M. V., and Gorlin, R.: Complications of coronary arteriography. Comparison of the brachial to the femoral approach, Ann. Intern. Med. 76:862, 1972. Walker, W. J., Mundall, S. L., Broderick, H. G., Prasad, B., Kim, T., and Ravi, J. M.: Systemic heparinization for femoral percutaneous coronary arteriography, N. Engl. J. Med. 288:826, 1973.
the patient described here who had silent angina pectoris after coronary bypass surgery. D. C., a 46-year-old man, had typical angina pectoris which became progressively worse with inadequate medical man-
October,
1974, VoL 88, No. 4
Annotations
BEFORE
AF TEf?
DI After
CORONARY
BYPASS
D.C., 46 WM
SURGERY
axbrcice
Fig. 1.
ECG of Patient D. C. before and after operation.
agement. Because of “intractable” angina pectoris he had coronary angiography and triple venous-aorta-coronary bypass surgery. His pain was relieved, but he continued to have dyspnea on exertion and was impressed by the fact that he felt no better, if not worse. He sought other medical advice 16 months later and was found to have even more angina pectoris, but it was “silent,” i.e., without the characteristic pain, the patient experiencing only dyspnea. A Master twostep test showed greater ST-segment and T-wave changes associated with marked dyspnea during the test and an inability to walk the entire number .of prescribed steps for the test (Fig. 1). An echocardiogram showed a hypokinetic to akinetic septum while the patient was at rest and free from dyspnea. He is now receiving medical treatment for active “silent” angina pectoris.
American
SURGERY
Heart Journal
This patient is described briefly to emphasize the fact that absence of angina1 pain or chest discomfort does not indicate the absence of angina pectoris. This patient also emphasizes the importance of careful and thoughtful history taking and the need to realize that many patients with ischemic heart disease have “silent” angina, manifested by dyspnea upon stress which is relieved quickly with rest and also with sublingual nitroglycerin. George E. Burch, M.D. Lkpartnwnt of iUe&cine Wane University School of Medicine New Orleans. La 70112
531
Fig. 3. Right coronary artery at the level of the bifurcation at the crux cordis. Embedded within the thromboembolus is a loose, embolized fragment of arterial wall. Elastic tissue, x50. Right: detail of the embolized fragment which is identified as the fibroelastic inner layer of the proximal segment of the right coronary artery. Elastic tissue stain, x500.
technique. The ever grams made all over atic investigation as what other measures complication.
increasing number of coronary angiothe world, however, requires a systemto what technique should be used and should be taken to avoid this dreadful
A. E. Becker, M.D. H. J J Wellens, M.D. R. M. Schuiknburg, MD. D. Durrer, MD. Labomtory for Pathological Anatomy and Department of Cardiology and Clinical Physiology Wilhelmina Gasthuk Amsterdam, The Netherlands REFERENCES
1.
angina and coronary
bypass
6.
surgery
The relief of chest pain or discomfort characteristic of angina pectoris by coronary bypass surgery does not necessarily imply a “cure” or relief of the angina pectoris or even improvement of the myocardial circulation. This is well illustrated by
530
5.
7.
Giddings, J. A., See, J. R., Lewis, R. D.: Thromboembolism following coronary arteriography, Chest 61:235, 1972.
Silent
4.
Takaro, T., Pifarre, R., Wuertlein, R. D., Hall, A. D., Gage, A. A., Scott, S. M., Dart, Ch. H., and PrestonPrice, H.: Acute coronary occlusion following coronary arteriography: mechanism and surgical relief, Surgery 72:1018, 1972. Preston-Price, H., Sollad, N., Scott, S. M., and Takaro, T.: Unusual coronary emboli associated with coronary arteriography, Chest 63698, 1973. Judkins, M. P.: Percutaneous tranafemoral selective coronary arteriography, Radiol. Clin. North Am. 6:467, 1968. Sones, F. M., Jr.: Cinecoronary arteriography, Anesth. Analg. 48:499, 1967. Chahine, R. A., Herman, M. V., and Gorlin, R.: Complications of coronary arteriography. Comparison of the brachial to the femoral approach, Ann. Intern. Med. 76:862, 1972. Walker, W. J., Mundall, S. L., Broderick, H. G., Prasad, B., Kim, T., and Ravi, J. M.: Systemic heparinization for femoral percutaneous coronary arteriography, N. Engl. J. Med. 288:826, 1973.
the patient described here who had silent angina pectoris after coronary bypass surgery. D. C., a 46-year-old man, had typical angina pectoris which became progressively worse with inadequate medical man-
October,
1974, VoL 88, No. 4
Annotations
BEFORE
AF TEf?
DI After
CORONARY
BYPASS
D.C., 46 WM
SURGERY
axbrcice
Fig. 1.
ECG of Patient D. C. before and after operation.
agement. Because of “intractable” angina pectoris he had coronary angiography and triple venous-aorta-coronary bypass surgery. His pain was relieved, but he continued to have dyspnea on exertion and was impressed by the fact that he felt no better, if not worse. He sought other medical advice 16 months later and was found to have even more angina pectoris, but it was “silent,” i.e., without the characteristic pain, the patient experiencing only dyspnea. A Master twostep test showed greater ST-segment and T-wave changes associated with marked dyspnea during the test and an inability to walk the entire number .of prescribed steps for the test (Fig. 1). An echocardiogram showed a hypokinetic to akinetic septum while the patient was at rest and free from dyspnea. He is now receiving medical treatment for active “silent” angina pectoris.
American
SURGERY
Heart Journal
This patient is described briefly to emphasize the fact that absence of angina1 pain or chest discomfort does not indicate the absence of angina pectoris. This patient also emphasizes the importance of careful and thoughtful history taking and the need to realize that many patients with ischemic heart disease have “silent” angina, manifested by dyspnea upon stress which is relieved quickly with rest and also with sublingual nitroglycerin. George E. Burch, M.D. Lkpartnwnt of iUe&cine Wane University School of Medicine New Orleans. La 70112
531