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The clinical spectrum and hemodynamics of women with chest pain and normal coronary arteries
ABSTRACTS
CORONARY RISK PROFILE IN THE YOUNG ADULT POPULATION: THE MAJOR IMPORTANCE OF SERUM CHOLESTEROL. Antone F. Salel, MD; Dean T. Mason, MD, FACC; Carolyn K. Clifford, PhD; Andrew J. Clifford, PhD; Ashfaq Husain, PhD; Thomas Y. Cooper, MD.; Nemat 0. Borhani, MD, FACC and Robert Zelis, MD, FACC. Univ. of Calif. School of Medicine, Davis, Ca. Epidemiologic studies have established a strong relationship between serum cholesterol (CHOL) and premature coronary artery disease (CAD) in middle-age populations. In order to investigate the implications of this relationship in a young adult population, a total of 1456 entering UCD students (mean age 22 yrs) were screened. The screening included CHOL (true CHOL by the automated Levine-Zak method following isopropanol extraction) and a multiple risk factor (MRF) self-administered questionnaire. CHOL was correlated (simple, partial, multiple) with multiple risk factors (age, sex, obesity, smoking history, nutritional history, serum glucose, serum uric acid). Mean CHOL was 184 f. 40 mg/dl (+ SD) (mode 180. median 189). A striking proportion of the population had significantly elevated CHOL, 2.3% greater than 275 mg/dl, 5.9% over 250, 15.9% over 225 and 35% over 200. Significant correlates (Pc.01) of serum cholesterol for males and females were obtained only in the populations of individuals with a family history of CAD. No significant correlation was observed with the other family histories such as diabetes and hypertension. Therefore, serum CHOL. an established risk factor of premature CAD in an older population is significantly elevated in a large percentage of this young adult population. In addition, a strong relationship between serum CHOL and a family history of CAD was detected. Since the yield for risk factor screening was so high, it seems prudent to direct major primary prevention efforts to this age group where the likelihood of finding minimal or reversible coronary vascular disease is high.
iHE CLINICAL SPECTRUM AND HEMODYNAMICS OF WOMEN WITH CHEST PAIN AND NORMAL CORONARY ARTERIES. Karen Sample, MD; H. Dominic Covvey; E. Douglas Wigle, MD; Allan G. Adelman,MD, Toronto General Hospital, Toronto, Canada. Forty-nine women with chest pain and suspected ischemic heart disease were found to have normal coronary arteries by selective coronary angiography. Twenty-five had an alternative clinical or hemodynamic basis for chest pain: 10 had significant gastroesophageal disease; 2 had recurrent tachyarrhythmias; 5 had a prolapsed mitral valve leaflet on left ventricular angiography; 3 had cardiomyopathies with significantly elevated left ventricular enddiastolic pressures (mean (m) 24.7 mmHg); and 5 had hyperkinetic heart syndromes with high cardiac indices (CI)(m 5.59 L/min/m2), increased ejection fractions (EF)(m 84.6%) and low arterial-venous oxygen (A-V 02) differences (m 2. 75 vol%). Twenty of the remaining 24 patients (pts) had non-specific ST-T changes on their electrocardiogram. These pts had normal intracardiac pressures, CI's and A-V 02 differences but, increased heart rates (HR)(m 92/min), prolonged corrected ejection times (ET)(m 426.1 msec) and decreased ejection rates (ER)(m 127.5 ml/sec/m2). As a result the tension time index (TTI) was increased (m 1906.5 mmHg/sec/ min), the diastolic pressure time index (DPTI) was reduced (m 2473.3 nnnHg/sec/min) and the ratio of DPTI/TTI (an indication of the myocardial 02 supply and demand relationship) was decreased (m 1.3). These pts also had small hearts with decreased end-diastolic (m 84.4 cc's), endsystolic (m 19 cc's), and stroke volumes (m 65.3 cc's) and high EF's (m 77.9%). The prolonged ET in the presence of an increased HR results in increased 02 demand, diminished supply and may produce subendocardial ischemia and angina in these pts.
166
January 1974
The American Journal of CARDIOLOGY
RESECTION OF LEFT VENTRICULAR ANEURYSM: REPORT OF 275 PATIENTS Frank M. Sandiford, MD; George J. Reul, Jr., MD, FACC; John T. Dawson, MD; Don C. Wukasch, MD; Luigi Chiariello, MD; Grady L. Hallman, MD, FACC; Denton A. Cooley, MD, FACC. Texas Heart Institute, Houston, Texas To evaluate the efficacy of combined aortocoronary bypass (ACB) with left ventricular aneurysm (LVA) resection, 275 patients (pts) who had LVA resection from 1958 to I972 were reviewed and divided into 3 groups. Group I consisted of 102 pts who underwent LVA resection alone during the pre-ACB period from 1958 to 1969. From 1969 to 1972 there were 122 pts (Group II) who had LVA resection with ACB and 51 pts (Group III) who had LVA resection alone because of insignificant associated coronary artery disease Multiple vessel CAD was present (CAD) in other vessels. in 96% of Group II and in 77% of those pts in Group I who Preoperative congesunderwent selective arteriography. tive heart failure was present in 95% of Groups I and III while angina was present in 32% and in 66% of Group II, of Group I and in 90% of Group II. In Group I there was an early operative mortality of 17% as compared to Group II (12%) and Group III (10%). Follow-up data from 1 to 12 years demonstrated significantly higher late mortality in Group I. Factors affecting early and late survival in all groups included age, cardiac index, size of LVA, ejeccoronary artery score and length of time tion fraction, after myocardial infarction. The anatomic location of the aneurysm in relation to the occluded and bypassed vessels and the estimated size of the left ventricle after resection have also been related to early and late mortality. Combined ACB with LVA resection significantly improved survival when compared to LVA resection alone.
AORTIC VALVE REPLACEMENT WITH CONCOMITANT AORTOCORONARY BYPASS Frank M. Sandiford, MD; George J. Reui, Jr., MD, FACC; Don C. Wukasch, MD; Luigi Chiariello, MD; Grady L. Hallman, MD, FACC; Denton A. Cooley, MD, FACC. Texas Heart Institute, Houston, Texas. One hundred consecutive cases of aortic valve replacement (AVR) with aortocoronary artery bypass (ACB) were reviewed to evaluate factors that influence early and late survival. Of these patients (pts), 65 had aortic stenosis (AS); 21 aortic insufficiency (Al); and 14 combined AS and Al. The majority (64%) were in Functional Class (FC) III and 44% were in FC IV. The predominant manifestations were angina and congesN!ive heart failure (CHF) in 68%, angina alone in 17% and severe CHF alone in 15%. Of the All pts had significant coronary artery disease. 100 pts, 64 had single ACB; 33, double ACB; and 3, triple ACE performed simultaneously with AVR. Early surgical mortality was directly related to the FC IV status [IS deaths among 34 pts (23%)] and to the predominant presenting symptom of CHF alone [8 deaths among I5 pts (53%1. In the group of pts in FC III who had combined symptoms of angina and CHF (43%), tt,eearly surgical mortality was Long-term follow-up of the survivors from I to only 7%. 4 years (mean 2.5 years) demonstrated that in 85% of the pts symptoms had disappeared or significantly decreased while in 8.5% symptoms remained unchanged or became worse. The late mortality of 6.4%, mainly due to progressive myocardial failure in FC IV pts, reflected a similar postoperative attrition of 2.5% per year observed in another group of 2273 pts who underwent ACB without concomitant procedures at this Institution. Despite the high operative risk in pts with advanced stages of coexisting aortic valve and CAD, the observed late survival rate appears to justify surgical therapy.
Volume 33
CORONARY RISK PROFILE IN THE YOUNG ADULT POPULATION: THE MAJOR IMPORTANCE OF SERUM CHOLESTEROL. Antone F. Salel, MD; Dean T. Mason, MD, FACC; Carolyn K. Clifford, PhD; Andrew J. Clifford, PhD; Ashfaq Husain, PhD; Thomas Y. Cooper, MD.; Nemat 0. Borhani, MD, FACC and Robert Zelis, MD, FACC. Univ. of Calif. School of Medicine, Davis, Ca. Epidemiologic studies have established a strong relationship between serum cholesterol (CHOL) and premature coronary artery disease (CAD) in middle-age populations. In order to investigate the implications of this relationship in a young adult population, a total of 1456 entering UCD students (mean age 22 yrs) were screened. The screening included CHOL (true CHOL by the automated Levine-Zak method following isopropanol extraction) and a multiple risk factor (MRF) self-administered questionnaire. CHOL was correlated (simple, partial, multiple) with multiple risk factors (age, sex, obesity, smoking history, nutritional history, serum glucose, serum uric acid). Mean CHOL was 184 f. 40 mg/dl (+ SD) (mode 180. median 189). A striking proportion of the population had significantly elevated CHOL, 2.3% greater than 275 mg/dl, 5.9% over 250, 15.9% over 225 and 35% over 200. Significant correlates (Pc.01) of serum cholesterol for males and females were obtained only in the populations of individuals with a family history of CAD. No significant correlation was observed with the other family histories such as diabetes and hypertension. Therefore, serum CHOL. an established risk factor of premature CAD in an older population is significantly elevated in a large percentage of this young adult population. In addition, a strong relationship between serum CHOL and a family history of CAD was detected. Since the yield for risk factor screening was so high, it seems prudent to direct major primary prevention efforts to this age group where the likelihood of finding minimal or reversible coronary vascular disease is high.
iHE CLINICAL SPECTRUM AND HEMODYNAMICS OF WOMEN WITH CHEST PAIN AND NORMAL CORONARY ARTERIES. Karen Sample, MD; H. Dominic Covvey; E. Douglas Wigle, MD; Allan G. Adelman,MD, Toronto General Hospital, Toronto, Canada. Forty-nine women with chest pain and suspected ischemic heart disease were found to have normal coronary arteries by selective coronary angiography. Twenty-five had an alternative clinical or hemodynamic basis for chest pain: 10 had significant gastroesophageal disease; 2 had recurrent tachyarrhythmias; 5 had a prolapsed mitral valve leaflet on left ventricular angiography; 3 had cardiomyopathies with significantly elevated left ventricular enddiastolic pressures (mean (m) 24.7 mmHg); and 5 had hyperkinetic heart syndromes with high cardiac indices (CI)(m 5.59 L/min/m2), increased ejection fractions (EF)(m 84.6%) and low arterial-venous oxygen (A-V 02) differences (m 2. 75 vol%). Twenty of the remaining 24 patients (pts) had non-specific ST-T changes on their electrocardiogram. These pts had normal intracardiac pressures, CI's and A-V 02 differences but, increased heart rates (HR)(m 92/min), prolonged corrected ejection times (ET)(m 426.1 msec) and decreased ejection rates (ER)(m 127.5 ml/sec/m2). As a result the tension time index (TTI) was increased (m 1906.5 mmHg/sec/ min), the diastolic pressure time index (DPTI) was reduced (m 2473.3 nnnHg/sec/min) and the ratio of DPTI/TTI (an indication of the myocardial 02 supply and demand relationship) was decreased (m 1.3). These pts also had small hearts with decreased end-diastolic (m 84.4 cc's), endsystolic (m 19 cc's), and stroke volumes (m 65.3 cc's) and high EF's (m 77.9%). The prolonged ET in the presence of an increased HR results in increased 02 demand, diminished supply and may produce subendocardial ischemia and angina in these pts.
166
January 1974
The American Journal of CARDIOLOGY
RESECTION OF LEFT VENTRICULAR ANEURYSM: REPORT OF 275 PATIENTS Frank M. Sandiford, MD; George J. Reul, Jr., MD, FACC; John T. Dawson, MD; Don C. Wukasch, MD; Luigi Chiariello, MD; Grady L. Hallman, MD, FACC; Denton A. Cooley, MD, FACC. Texas Heart Institute, Houston, Texas To evaluate the efficacy of combined aortocoronary bypass (ACB) with left ventricular aneurysm (LVA) resection, 275 patients (pts) who had LVA resection from 1958 to I972 were reviewed and divided into 3 groups. Group I consisted of 102 pts who underwent LVA resection alone during the pre-ACB period from 1958 to 1969. From 1969 to 1972 there were 122 pts (Group II) who had LVA resection with ACB and 51 pts (Group III) who had LVA resection alone because of insignificant associated coronary artery disease Multiple vessel CAD was present (CAD) in other vessels. in 96% of Group II and in 77% of those pts in Group I who Preoperative congesunderwent selective arteriography. tive heart failure was present in 95% of Groups I and III while angina was present in 32% and in 66% of Group II, of Group I and in 90% of Group II. In Group I there was an early operative mortality of 17% as compared to Group II (12%) and Group III (10%). Follow-up data from 1 to 12 years demonstrated significantly higher late mortality in Group I. Factors affecting early and late survival in all groups included age, cardiac index, size of LVA, ejeccoronary artery score and length of time tion fraction, after myocardial infarction. The anatomic location of the aneurysm in relation to the occluded and bypassed vessels and the estimated size of the left ventricle after resection have also been related to early and late mortality. Combined ACB with LVA resection significantly improved survival when compared to LVA resection alone.
AORTIC VALVE REPLACEMENT WITH CONCOMITANT AORTOCORONARY BYPASS Frank M. Sandiford, MD; George J. Reui, Jr., MD, FACC; Don C. Wukasch, MD; Luigi Chiariello, MD; Grady L. Hallman, MD, FACC; Denton A. Cooley, MD, FACC. Texas Heart Institute, Houston, Texas. One hundred consecutive cases of aortic valve replacement (AVR) with aortocoronary artery bypass (ACB) were reviewed to evaluate factors that influence early and late survival. Of these patients (pts), 65 had aortic stenosis (AS); 21 aortic insufficiency (Al); and 14 combined AS and Al. The majority (64%) were in Functional Class (FC) III and 44% were in FC IV. The predominant manifestations were angina and congesN!ive heart failure (CHF) in 68%, angina alone in 17% and severe CHF alone in 15%. Of the All pts had significant coronary artery disease. 100 pts, 64 had single ACB; 33, double ACB; and 3, triple ACE performed simultaneously with AVR. Early surgical mortality was directly related to the FC IV status [IS deaths among 34 pts (23%)] and to the predominant presenting symptom of CHF alone [8 deaths among I5 pts (53%1. In the group of pts in FC III who had combined symptoms of angina and CHF (43%), tt,eearly surgical mortality was Long-term follow-up of the survivors from I to only 7%. 4 years (mean 2.5 years) demonstrated that in 85% of the pts symptoms had disappeared or significantly decreased while in 8.5% symptoms remained unchanged or became worse. The late mortality of 6.4%, mainly due to progressive myocardial failure in FC IV pts, reflected a similar postoperative attrition of 2.5% per year observed in another group of 2273 pts who underwent ACB without concomitant procedures at this Institution. Despite the high operative risk in pts with advanced stages of coexisting aortic valve and CAD, the observed late survival rate appears to justify surgical therapy.
Volume 33