Angioplasty of a coronary artery via the translumbar approach in a patient with severe peripheral vascular disease.

We report on a woman with severe peripheral vascular disease with unstable angina, in which access to the central circulation was not possible from a peripheral route. The translumbar approach was used for coronary angiography and a successful angioplasty of the left circumflex artery.

Double cardiomyopathy: coexistent cardiac amyloidosis and hypertrophic obstructive cardiomyopathy.

A combination of hypertrophic obstructive cardiomyopathy (HOCM) and cardiac amyloidosis in the same patient is very rare. Clinical diagnosis could be extremely difficult and may require myocardial biopsy. We are reporting a patient with this combination who was referred to our institution because of features of HOCM based on clinical, echocardiographic and Doppler criteria. Cardiac amyloidosis was only recognized after myocardial biopsy that failed to reveal evidence of HOCM. Only after the patient expired from severe, intractable heart failure did the autopsy findings confirm the association of HOCM. We believe that the combination of the two cardiomyopathic processes is very rare and makes treatment extremely difficult.

Relation of extent of extracranial carotid artery atherosclerosis as measured by B-mode ultrasound to the extent of coronary atherosclerosis.

The extent of carotid artery atherosclerosis as measured by B-mode ultrasound has been shown to be strongly and independently correlated with the presence or absence of coronary atherosclerotic disease (CAD), but no studies to date have used carotid B-mode ultrasound to compare the extent of atherosclerotic disease in the two arterial circulations. We used data from a registry of patients undergoing cardiac catheterization and B-mode ultrasound of the carotid arteries to compare the extent of CAD (number of major coronary vessels with 50% or greater stenosis as judged by a consensus interpretation) with the extent of extracranial carotid atherosclerosis. Four hundred thirty-four patients (234 men, 200 women) greater than 40 years of age were stratified by gender and then divided into quartiles on the basis of a B-mode score that was derived by summing arterial wall thickness at nine sites in the left and nine sites in the right carotid arteries. Evaluation of extent of CAD for the four B-mode quartiles showed that men in the lowest B-mode quartile were over six times more likely to have normal coronary arteries than three- to four-vessel CAD, while men in the highest B-mode quartile were over 10 times more likely to have three- to four-vessel CAD than normal coronary arteries. The findings were similar for women but not as dramatic. Gender-specific discriminant function models using traditional risk factors alone or in combination with B-mode score were developed to predict the extent of CAD.(ABSTRACT TRUNCATED AT 250 WORDS)

Reevaluation of transient ischemic attacks as a risk factor for early mortality.

The prevailing belief that transient ischemic attack is a risk factor for cardiovascular morbidity and mortality is based primarily on comparisons of survival of patients after transient ischemic attacks to that of an age-, race-, and sex-adjusted general population. Concomitant conditions that carry a high risk of premature mortality or morbidity, such as ischemic heart disease, hypertension, and diabetes, are very prevalent among patients with transient ischemic attacks. Hence, the poor prognosis of such patients may be attributable to these factors rather than their transient ischemic attack per se, which may only serve to bring patients into the medical system. We compared the survival of 336 patients after transient ischemic attack to that of a control group with a similar risk factor profile consisting of 6,710 patients evaluated for cardiac catheterization. Survival estimates, both unadjusted and adjusted for risk factors, did not differ between the two groups. Three-year survival estimates, after adjustment to the mean value of covariates, were 94% for the patients with transient ischemic attacks and 91% for the controls. These results suggest that the transient ischemic attack may not be an independent risk factor for mortality, although it may identify patients already at increased risk from coexisting conditions.

Central adipose distribution is related to coronary atherosclerosis.

A "male" distribution of adipose tissue in women (excess of fat in the abdomen compared with that in the hips; i.e., elevated waist/hip ratio) has been related to symptomatic cardiovascular disease. An elevated waist/hip ratio has also been related to symptomatic cardiovascular and cerebrovascular diseases in men, as well as to risk factors for these diseases and various metabolic conditions. To determine whether adipose distribution was related to coronary atherosclerosis, we performed a case-control study in patients with angiographically documented coronary atherosclerosis (cases) and in angiographically normal hospital and neighborhood controls. The data show that distribution of adiposity as assessed by waist/hip ratio is significantly related to coronary atherosclerosis in both females and males. Waist/hip ratio is significantly greater in female cases compared with either control group; in males, waist/hip ratio is significantly greater in cases compared with asymptomatic neighborhood controls but not compared with patients with normal coronary arteries. These results persist after control for age, plasma concentrations of lipids and lipoproteins, body mass index, history of hypertension, history of diabetes, and smoking status. The connection between the male adipose distribution in females and coronary atherosclerosis partly explains the greater likelihood of symptomatic cardiovascular disease in them. Males with excess deposition of fat in the abdominal region are also likely to experience increased risk.

Comparison of hospital and neighborhood controls in a study of coronary artery disease.

Case-control studies of risk factors for coronary artery disease (CAD) have almost invariably employed hospital controls, with minimal or no coronary artery stenosis. Although there is an important advantage in knowing the CAD status of controls, such groups are subject to bias related to hospitalization. To evaluate the generalizability of results obtained from studies using hospital controls, we compared risk factors in 342 hospital controls free of angiographic evidence for CAD, 168 neighborhood controls without symptoms of CAD, and 450 CAD patients. Coronary artery disease in cases and hospital controls was established arteriographically. No significant differences were found between the male control groups for total and low density lipoprotein (LDL) cholesterol, LDL apo-B, pack-years of smoking, body mass index, proportion with hypertension, diabetes and family history of coronary heart disease. Compared with neighborhood controls, male hospital controls had significantly lower high density lipoprotein (HDL) cholesterol, higher triglycerides and uric acid and scored higher on the Framingham Type A behavior pattern scale. Among women, the hospital control group had significantly lower LDL cholesterol and fewer pack-years of smoking, and a greater prevalence of hypertension than the neighborhood group. A greater proportion of both male and female hospital controls had left ventricular hypertrophy, and there were more current smokers among the neighborhood controls in both sexes. Age adjustment did not change these comparisons. While very few neighborhood controls were treated with beta-blockers, 32.7% of male and 41.4% of female hospital controls were so medicated. Control for beta-blocker use eliminated the difference in HDL cholesterol and triglycerides between the two male control groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of the associations between carotid artery atherosclerosis and coronary artery stenosis. A case-control study.

To evaluate the consistency, strength, and independence of the relation of carotid atherosclerosis to coronary atherosclerosis, we quantified coronary artery disease risk factors and extent of carotid atherosclerosis (B-mode score) in 343 coronary artery disease patients and 167 disease-free control patients. In univariable analyses, there was a strong association between coronary status and extent of carotid artery disease in men and women older than and younger than 50 years (p less than 0.001 for men and women greater than 50 years, p less than 0.001 for women less than or equal to 50 years, p = 0.045 for men less than or equal to 50). The relation remained strong after control for age in men and women older than 50 years and in women younger than 50 (p less than 0.001 for men and women greater than 50 years, p = 0.003 for women less than or equal to 50) but did not persist after control for age in men younger than 50. Logistic models that included coronary disease risk factors, with or without B-mode score, as independent variables and presence or absence of coronary disease as the outcome variable indicated that the extent of carotid atherosclerosis was a strong, statistically significant independent variable in models for men and women older than 50 years of age. Next, we examined the usefulness of B-mode score as an aid in screening for coronary artery disease in men and women older than 50 years. Classification rules, both including and excluding B-mode score, were developed based on logistic regression and, for comparison, recursive partitioning (decision trees). The performance of these rules and the bias of their performance statistics were estimated. The improved classification of the study sample when B-mode score was incorporated in the rule was statistically significant only for men (p = 0.015). However, the addition of B-mode score was found to 1) increase the median discrimination score for both sex groups based on the logistic model, and 2) yield better sensitivities and specificities for rules based on recursive partitioning. Thus B-mode score is strongly, consistently, and independently associated with coronary artery disease in patients older than 50 and is at least as useful as well-known risk factors for identifying patients with coronary artery disease.

Changes in pharmacologic treatment of hyperlipidemia.

We evaluated the changes in frequency of pharmacologic treatment of hyperlipidemia in 345 hyperlipidemic patients with symptomatic cardiovascular disease requiring cardiac catheterization between 1982 and 1987. The frequency of pharmacologic treatment increased from 13% (1982) to 59% (1987), with the major increase occurring in 1984. Increases in the frequency of treatment were paralleled by increases in prescriptions for lipid-lowering drugs nationwide. During this period the percentage of hyperlipidemic patients we evaluated who were treated with various agents changed, and at the end of the study the use of gemfibrozil, bile acid-binding resins, and nicotinic acid had increased, whereas clofibrate and probucol use decreased. Although the data showed an increase in prevalence of treatment, almost half the patients remained untreated, and of those treated over half remained hypercholesterolemic despite treatment. The results suggest increasing but incomplete physician awareness of hyperlipidemia as a cardiovascular disease risk factor and the need for further physician education in the pharmacologic management of hyperlipidemia.

Can coronary angiography predict the site of a subsequent myocardial infarction in patients with mild-to-moderate coronary artery disease?

To help determine if coronary angiography can predict the site of a future coronary occlusion that will produce a myocardial infarction, the coronary angiograms of 42 consecutive patients who had undergone coronary angiography both before and up to a month after suffering an acute myocardial infarction were evaluated. Twenty-nine patients had a newly occluded coronary artery. Twenty-five of these 29 patients had at least one artery with a greater than 50% stenosis on the initial angiogram. However, in 19 of 29 (66%) patients, the artery that subsequently occluded had less than a 50% stenosis on the first angiogram, and in 28 of 29 (97%), the stenosis was less than 70%. In every patient, at least some irregularity of the coronary wall was present on the first angiogram at the site of the subsequent coronary obstruction. In only 10 of the 29 (34%) did the infarction occur due to occlusion of the artery that previously contained the most severe stenosis. Furthermore, no correlation existed between the severity of the initial coronary stenosis and the time from the first catheterization until the infarction (r2 = 0.0005, p = NS). These data suggest that assessment of the angiographic severity of coronary stenosis may be inadequate to accurately predict the time or location of a subsequent coronary occlusion that will produce a myocardial infarction.

Individual variation in susceptibility to extracranial carotid atherosclerosis.

Risk factors for coronary disease were assessed and noninvasive methods were used to quantitate the extent of extracranial carotid atherosclerosis in 382 patients free of cerebrovascular symptoms. The ages of the participants ranged from 27 to 80 years. There were 183 men and 199 women, 30 black and 352 white persons. All patients had heart disease symptoms and were hospitalized for coronary angiography. Correlation of risk factors with extent of extracranial carotid atherosclerosis in this series of patients undergoing coronary angiography uncovered individual variability in relationships between risk factors and carotid atherosclerosis that depended on coronary status. Risk factors for carotid atherosclerosis in patients with and without coronary disease differed. Age and hypertension were independently related to carotid atherosclerosis in patients with, as well as those without, coronary disease. However, other risk factors were related to carotid atherosclerosis in only one group or the other. Risk factors correlated strongly with carotid atherosclerosis in patients with coronary disease (r2 = 0.41) but poorly in those with no coronary disease (r2 = 0.21). Certain risk factors (age, pack years of smoking, left ventricular hypertrophy) related differently to the extent of carotid atherosclerosis in patients with, than in those without, coronary disease. Clarification of the role of coronary status in the carotid atherosclerosis response to risk factors may partly explain the results of certain population-based studies that have related race, gender, and other risk factors to carotid atherosclerosis.(ABSTRACT TRUNCATED AT 250 WORDS)

A microcomputer based automated, quantitative coronary angiographic analysis system.

Rapid and accurate assessment of coronary artery stenotic severity is important in therapy and understanding of coronary artery disease. Since automated systems minimize prejudice and variations in analysis, we developed an automated, quantitative coronary analysis system utilizing an IBM PC-XT computer. Film images (35 mm) were cine-to-video converted and subsequently digitized by an IBM PC-XT computer. Given an approximate center line, the computer automatically detected edges, corrected for X-ray magnification, and calculated arterial dimensions. On objects of known dimensional sizes, the correlation coefficient between actual and calculated dimensions was 0.996 (p less than 0.01) with a standard error of estimate of 0.07 mm and +/- 3.0% reproducibility. For objects less than 1 mm in diameter, the standard error of estimate was 0.05 mm with +/- 4.1% reproducibility. However, with minimal contrast material (25%), the standard error of estimate increased to 0.20 mm with +/- 7.2% reproducibility. The results indicate that automated, quantitative coronary angiography can be achieved using an inexpensive IBM PC-XT based system, provided that the vessels are adequately opacified.

Risk factors for extracranial carotid artery atherosclerosis.

We related risk factors, cardiovascular symptoms, and coronary status to the extent of extracranial carotid atherosclerosis as measured by B-mode ultrasonography in 376 volunteers hospitalized for elective coronary angiography. In a first analysis, we correlated risk factors and cardiovascular symptoms with carotid atherosclerosis. Univariate analysis showed that relations between many continuous risk factors and carotid atherosclerosis were graded and consistent for men and women. Multivariate analysis identified 6 significant variables (age, hypertension, pack-years smoked, and inversely, plasma concentrations of high density lipoprotein cholesterol and uric acid, and Framingham Type A score) that together accounted for 35% of the variability in extent of carotid atherosclerosis. In a second multivariate analysis, addition of coronary status (presence or absence of coronary stenosis as evaluated by coronary angiography) to the roster of candidate independent variables produced a new equation that accounted for an additional 5% of the variability in carotid atherosclerosis extent. Although much of the variability in extent of carotid atherosclerosis remains unexplained, these data define an association between coronary and carotid atherosclerosis that depends partly on shared exposure of both arteries to the same risk factors. They are also consistent with the concept that as yet undiscovered risk factors and/or genetic (e.g., arterial wall) factors common to both arterial beds also contribute to the relation between coronary and carotid atherosclerosis in human beings.

Evaluation of a scoring system for extracranial carotid atherosclerosis extent with B-mode ultrasound.

We have developed a scoring system to quantify extent of extracranial carotid artery atherosclerosis using real-time ultrasound (B-mode). To evaluate repeatability of this scoring system we correlated repeat scores obtained within a short interval of one another (6 months) in 52 individuals. We compared repeatability of extent measurements with repeatability of a measure of severity (single most severe lesion). Correlations between first and second studies for severity were weak (r2 = 0.20) but significant (p less than 0.001). Extent scores correlated much better (r2 = 0.77, p less than 0.001). In another group of 22 patients we found that the extent of atherosclerosis decreased following endarterectomy. We used this method to determine changes in extent of carotid atherosclerosis with age in two sets of individuals. One consisted of a cohort of 22 patients who underwent repeat B-mode studies separated by 1 1/2-3 years. This cohort demonstrated an increase in carotid score with age (p less than 0.05). In a second group of volunteers undergoing cardiac catheterization and B-mode evaluation of the carotid system, carotid scores could be compared in individuals with age differences that averaged 15 years. Extent of carotid atherosclerosis was significantly greater in older individuals (p less than 0.01) and differences in extent with age were exaggerated in patients with coronary disease compared to coronary disease free controls.

Studies of low density lipoprotein molecular weight in human beings with coronary artery disease.

Low density lipoprotein molecular weight (LDL MW) correlates positively with coronary artery disease in cholesterol-fed nonhuman primates. To evaluate this in human beings with coronary artery disease (CAD) we measured LDL MW in 93 volunteers undergoing coronary angiography (47 controls and 46 CAD patients). LDL MW of CAD patients was less than that of controls (patients, 2.79 +/- 0.17 g/mumol; controls, 2.93 +/- 0.19 g/mumol; P less than 0.001). However, LDL MW decreased as plasma triglyceride increased and concentrations of triglyceride were greater in CAD patients than in controls. Since decreased LDL MW is likely to result, in part, from increased plasma triglyceride concentrations, we attempted to determine the effect of triglyceride on the relation of LDL MW to CAD in this study. After covariance adjustment for triglyceride, there was no LDL MW difference between CAD patients and controls. Because LDL heterogeneity has been identified in other studies and was apparent on inspection of agarose column profiles of LDL of these volunteers, we sought differences in the profiles that might distinguish coronary disease cases from controls. No differences could be found. In addition, we used density gradient ultracentrifugation to characterize LDL in more detail in a subset of volunteers who had a wide range of plasma triglyceride concentrations (50 mg/dl to 900 mg/dl). LDL mean hydrated density was inversely related to LDL MW and increased as triglyceride increased. The increase in peak density was reflected in an increase in percent of total protein in LDL found to have d greater than 1.045 g/ml and a decrease in protein in LDL of d 1.035-1.040 g/ml. These interrelationships were not apparently influenced by coronary artery status.

Spasm of the aortocoronary venous graft.

Two cases of spasm of the coronary artery bypass graft are reported, and the angiographic and clinical findings are discussed. Few previous reports of this entity were found in a search of the literature. The therapeutic implications are also presented.

Randomized withdrawal from nifedipine: placebo-controlled study in patients with coronary artery spasm.

A multicenter randomized double-blind withdrawal study was conducted to compare the efficacy of nifedipine to that of placebo in vasospastic angina. Following a 2-week single-blind nifedipine baseline period, during which nifedipine was maintained at prestudy levels, 38 patients, 19 taking placebo and 19 continuing nifedipine therapy, either completed a 4-week randomized phase or were prematurely withdrawn because of therapeutic failure. During the randomized phase, an increase in median anginal frequency (2.8 attacks/wk, p less than 0.003) and nitroglycerin usage (0.5 tablets/wk, p less than 0.03) occurred only in the placebo group. The randomized phase was prematurely terminated because of anginal exacerbation in 7 of 19 placebo patients (37%) (only 1 patient receiving nifedipine [p = 0.02] experienced anginal exacerbation). Double-blind therapy was judged effective in 16 patients (84%) receiving nifedipine and in 3 patients (16%) receiving placebo (p less than 0.001). Nifedipine was well tolerated. This study establishes the efficacy of nifedipine in the treatment of variant and validates previous clinical experience.