Usefulness of echocardiographic left ventricular ejection fraction and silent myocardial ischemia in predicting new coronary events in elderly patients with coronary artery disease or systemic hypertension

Usefulness of Echocardiographic Left Ventricular Ejection Fraction and Silent Myocardial lschemia in Predicting New Coronary Events in Elderly Patients with Coronary Artery Disease or Systemic Hypertension Wilbert S. Aronow,

MD,

Stanley Epstein,

MD,

and Mordecai Koenigsberg,

eft ventricular (LV) ejection fraction (EF) reL mains normal in elderly persons with no evidence of heart disease.‘,2 We reported that an abnormal echocardiographic LVEF3 and silent myocardial ischemia4 significantly correlated with new coronary events in elderly patients with heart disease. In this report we give the results from our prospective study of 393 patients >62 years old with coronary artery disease (CAD) or systemic hypertension correlating LVEF and silent ischemia with development of new cardiac events at 40-month mean follow-up.

MD

TABLE I Association of Abnormal Left Ventricular Ejection Fraction and of Silent lschemia with New Cardiac Events in Elderly Patients with Coronary Artery Disease or Systemic Hypertension New Cardiac

Abnormal LVEF Normal LVEF SI No SI

Events

No.

%

102/117 102/276 87/ 106 117/287

87’ 37 82* 41

Patients were considered to have CAD at entry into ‘p62 years old with CAD or systolic or diastolic hypertension in a long-term health care facility. Echocardiographic studies and 24-hour ambulatory electrocardiographic p I .5 mm) were excluded from the study. Silent ischLVEF and silent ischemia with new cardiac events in emia was diagnosed if horizontal or downsloping STsegment depression 21 .O mm below the resting level patients with CAD or systemic hypertension, An abnormal LVEF is an important independent preoccurred at 80 ms after the J point, lasted for II .O dictor of survival in patients with medically treated minute and was unassociated with angina1 symptoms. If CAD.9,‘o Abnormalities in regional and global LV wall resting ST-segment depression occurred, an additional 2.0 mm of ischemic ST-segment depression below the motion are similar in CAD patients with and without silent ischemia. ’ ’ The prognosis of silent ischemia in paresting level at 80 ms after the J point was required.

1p~~~~~~~ z1 ii 1

From the Hebrew Hospital for Chronic Sick and Albert Einstein College of Medicine, 2200 Givan Avenue, Bronx, New York 10475. Manuscript received October 13, 1989; revised manuscript received and accepted November 27, 1989.

tients with CAD depends on the extent of CAD and LV dysfunction. I? We previously reported that an abnormal LVEF significantly correlated with new cardiac events in elderly patients with heart disease.’ Data from this study THE AMERICAN

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of elderly patients with CAD or systemic hypertension showed that at a mean follow-up of 40 months, new cardiac events occurred in 87% of patients with abnormal LVEF and in 37% of patients with normal LVEF (p
An Angiographic

and Histologic

tachycardia and complex ventricular arrhythmias in predicting new coronary events in patients over 62 years of age. Am J Cardiol 1988,61:1349-1351. 4. Aronow WS, Epstein S. Usefulness of silent myocardial ischemia detected by ambulatory electrocardiographic monitoring in predicting new coronary events in elderly patients. Am J Cardiol 1988,62:1292-1296. 5. Teichholz LE. Kreulen T, Herman MV, Gorlin R. Problems in echocardiographic volume determinations: echocardiographic-angiographic correlations in the presence or absence of asynergy. Am J Cardiol 1976:37:7-11. 6. Spielman SR, Greenspan AM, Kay HR. Discigil KF, Webb CR, Sokoloff N M, Rae AP, Morganroth J, Horowitz LN. Electrophysiologic testing in patients at high risk for sudden cardiac death. 1. Nonsustained ventricular tachycardia and abnormal ventricular function. JACC /985,6;3/-39. 7. Aronow WS. Prevalence of presenting symptoms of recognized acute myocardial infarction and of unrecognized healed myocardial infarction in elderly patients. Am J Cardiol 1987,60:1182. 8. Roberts WC. Sudden cardiac death: definitions and causes. Am J Cardiol 1986;57:1410-1413. 9. Hammermeister KE, DeRouen TA, Dodge HT. Variables predictive of survival in patients with coronary disease. Selection by univariate and multivariate analyses from the clinical, electrocardiographic, exercise, arteriographic, and quantitative angiographic evaluations. Circulation /979;59:421-430. 10. Mock MB, Ringqvist I, Fisher LD, Davis K, Chaitman BR, Kouchoukos NT, Kaiser KC, Alderman E. Survival of medically treated patients in the Coronary Artery Surgery Study (CASS) registry. Circulation 1982,66:562-568. 11. Cohn PF, Brown EJ Jr. Wynne JA, Holman BL, Atkins HL. Global and regional left ventricular ejection fraction abnormalities during exercise in patients with silent myocardial ischemia. JACC /983:/:93/-933. 12. Cohn PF. Detection and prognosis of the asymptomatic patient with silent myocardial &hernia. Am J Cardiol 1988,6/:48-68. 13. Gottlieb SO, Weisfeldt ML, Ouyang P, Mellits ED, Gerstenblith G. Silent ischemia predicts infarction and death during 2 year follow-up of unstable angina. JACC 1987:10:756-760. 14. Nademanee K, Intarachot V, Josephson MA, Rieders D, Mody FV, Singh BN. Prognostic signiticance of silent myocardial ischemia in patients with unstable angina. JACC 1987;10:1-9. 15. Gottlieb SO, Gottlieb SH, Achuff SC, Baumgardner R, Mellits ED, Weisfeldt ML, Gerstenblith G. Silent ischemia on Hotter monitoring predicts mortality in high-risk postinfarction patients. JAMA /988;259:/030-1035. 16. Tzivoni D, Gavish A, Zin D, Gottlieb S, Moriel M, Keren A, Banai S, Stern S. Prognostic significance of ischemic episodes in patients with previous myocardial infarction. Am J Cardiol 1988,62:661-664. 17. Rocco MB, Nabel EG, Campbell S, Goldman L. Barry J, Mead K, Selwyn AP. Prognostic importance of myocardial ischemia detected by ambulatory monitoring in patients with stable coronary artery disease. Circulation /988;78:877-

884.

Study of Cocaine-Induced

Chest Pain

Pirzada A. Majid, MBBS, PhD, Bharat Patel, MD, Han-Seob Kim, MD, PhD, Janice L. Zimmerman, and R. Philip -Dellinger, MD hest pain is not an uncommon symptom in patients who abuse cocaine. A small number also develop C acute myocardial infarction.1,2 Most, however, show electrocardiographic ST-segment or T-wave abnormalities as the only objective evidence of myocardial ischemia. Coronary artery spasm has been popularly invoked as the possible cause for chest pain.3*4 However, evidence for spasm is largely circumstantial at present. An alternative source of pain may be myocarditis,5 which has been demonstrated in some patients dying of cocaine abuse.6,7 The following investigations were carried out in 11 men, average age 27 years (range 18 to 35) presenting with prolonged chest pain at rest suggestive of acute myocardial ischemia I to 4 hours after useof cocaineby smoking or intravenous route, electrocardiographic STsegmentelevation or T-wave abnormalities and demonFrom the Sections of Cardiology and Critical Care Medicine, and Departments of Medicine and Pathology, Baylor College of Medicine, One Baylor Plaza, Room 513E, Houston, Texas 77030. Manuscript received September 15,1989; revised manuscript received and accepted November 9,1989.

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stration of cocaine or its metabolites in the urine. None had risk factors for coronary artery disease.After acute myocardial infarction was ruled out, informed consent was obtained and coronary arteriography was carried out (within 24 hours of admission) in multiple views using Judkins technique to exclude coronary artery disease.Coronary arteries werefound to be normal in all patients. None showedevidenceof spontaneouscoronary artery spasmor presenceof intraluminal thrombi. In 1 patient, catheter-induced spasmwasseenat the origin of right coronary artery without any symptoms or electrocardiographic changes.Coronary arteriography was repeated in 10patients after 0.4 mg of ergonovinemaleate was given intravenously in divided doses.No focal or diffuse vasoconstrictive responsewas seenon provocation by ergonovine.Ejection fraction calculatedfrom left ventricular angiography was mildly depressedwith an average of 45 f 5%. Only 3 patients had ejectionfractions >500%.Endomyocardial biopsy carried out in all patients failed to show evidenceof myocarditis. In 7 of 11 patients, however, intramyocardial small coronary