[Probability of coronary lesions evaluated by the discriminant analysis of clinical and ergometric parameters]. / Probabilité de lésion coronaire évaluée par l'analyse discriminante de paramètres cliniques et ergométriques.

It has been suggested that multivariate analysis can be used to improve the diagnostic value of the conventional exercise tests. In order to evaluate the usefulness of this method in clinical practice, we have conducted a retrospective study of 558 male subjects without history of infarction who had undergone an exercise test and, less than 90 days later, a coronary arteriography. All exercise tests were performed according to Bruce's procedure and with an equipment which provided continuous averaging of ST segment values on V5, V2 and VF leads. The prevalence of significant coronary lesions (more than 50% luminal narrowing) was 56%. The values of 12 clinical and electrocardiographic parameters at rest and during exercise were subjected to a step-by-step multivariate analysis. Compared with the quantitative analysis of ST alone, the multivariate analysis increased the sensitivity (68% vs 59%, p less than 0.05) and specificity (83% vs 76%, NS) of the tests and the percentage of well-classified subjects (74.6% vs 66.8%, p less than 0.01). The best combination was obtained with the first 5 parameters of the final classification, viz.: (i) duration of exercise; (ii) clinical history of angina; (iii) anginal pain during exercise; (iv) age, and (v) maximum heart rate. The validity of the method was demonstrated on a recent series of 200 consecutive patients where the prevalence of coronary lesions was 58%. The discriminant function score enabled 74% of these patients to be correctly classified and improved the sensitivity of their exercise test.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of the computerized analysis of ST segment depression during exercise without myocardial infarction. Apropos of 807 cases]. / Apport de l'analyse informatique du sous-décalage du segment ST à l'effort en dehors de l'infarctus du myocarde. A propos de 807 cas.

The diagnostic value of ST segment changes on exercise were reassessed by computerised analysis in 807 patients without myocardial infarction who underwent coronary angiography. All the stress tests were carried out according to Bruce's protocol with a system of continuous averaging of the ST segment in V5, V2 and VF. An abnormal response was defined by the association of the following three criteria: 1) ST depression less than or equal to 1 mm, 2) the algebraic sum of the depression + ST slope less than or equal to -1, 3) changes occurring during exercise or the first minute of recovery. A significant coronary lesion was defined as at least 50 per cent narrowing of the vessel lumen. In the study population the prevalence of lesions was 55 per cent in men and 18 per cent in women. The sensitivity of exercise stress testing was 69 per cent but the specificity was only 65 per cent. The positive predictive value was 70 per cent in men, 29 per cent in women; the negative predictive value was 90 per cent in women compared with 62 per cent in men. The predictive values depended on the interpretation of the amplitude, morphology and topography of the ST depression. The low sensitivity and specificity were independent of the coronary angiographic criteria and not related to the bias usually encountered in the correlation between stress testing and coronary angiography. These results show that the quantitative analysis of ST changes during computerised stress testing is not sufficiently accurate in itself to detect atherosclerotic coronary artery disease.

Comparative results of percutaneous transluminal coronary angioplasty in patients with dynamic versus fixed coronary stenosis.

This study compares the results of percutaneous transluminal coronary angioplasty in a group of 132 patients (group A) with fixed atherosclerotic narrowing (no spontaneous or ergonovine-provoked spasm) and in a group of 97 patients (group B) with dynamic coronary stenosis (spasm superimposed on the stenosis). All these patients underwent complete follow-up angiography. The rate of restenosis (defined as a loss of 50% of the initial gain) was significantly higher in patients in group B (dynamic coronary stenosis) than in group A (fixed narrowing) (35 versus 22%, p less than 0.05). Despite treatment with a calcium antagonist, coronary artery spasm persisted in 44% of the patients in group B and was detected for the first time in 15% of the patients in group A. Thus, in patients with dynamic coronary stenosis, the results of coronary angioplasty were less satisfactory than in patients with fixed narrowing, and in both groups coronary artery spasm was frequently (64%) superimposed on the restenosis.

[Transluminal coronary angioplasty: immediate and short-term results. Apropos of 302 dilated vessels]. / L'angioplastie transluminale coronaire: résultats immédiats et à court terme. A propos de 302 vaisseaux dilatés.

This study reports the experience of the Cardiac Hospital of Lille up to the 1st October 1984. Two hundred and sixty-nine patients with a mean age of 51 years underwent transluminal coronary angioplasty for one or more stenotic lesions. Three hundred and two vessels were dilated. The left anterior descending artery was dilated in 72.5% of cases, the right coronary in 17.6% and the left circumflex in 8.6% of cases. The immediate results may be summarised as follows: it was possible to cross the stenosis to be treated in 91.4% of cases; the primary success rate (a gain of more than 20% without complications) was 83%. The narrowing was significantly decreased from 72 +/- 7% to 25 +/- 17%, the average gain in lumen size was 53 +/- 16%. The emergency coronary artery bypass surgery rate was 4.3%, and 3.6% of all the patients developed myocardial infarction. Sixty four per cent of patients had negative maximal exercise stress tests on discharge from hospital. The patients who had positive tests had improved exercise tolerance compared to the stress test performed before angioplasty. Angiographic control at 6 months was performed in about half the patients and showed coronary stenosis in 27%. Sixty eight per cent of the patients were totally asymptomatic.

[Coronary vasomotor activity in man. Description of a method of quantification and normal values]. / La vasomotricité coronaire chez l'homme. Description d'une méthode de quantification et valeurs normales.

The role of vasomotor tone is important in coronary pathology but it has not yet been quantified. The aim of this study was to evaluate the normal maximal variation of diameter between vasoconstriction and vasodilation or the coronary vasomotor capacity: greater diameter-smallest diameter/smallest diameter %. This was performed by two successive pharmacological tests, ergometrine and isosorbide dinitrate (ISDN), the doses of which and modes of administration were defined in a group of 70 patients: Contrast medium: no variations were observed after 5 opacifications at a least 2 minute intervals in 6 patients. Ergometrine test: a single 0.4 mg dose (6 patients) gave a maximal response equal to that obtained with progressive increments 0.1, 0.2, 0.3, 0.4 mg (9 patients). Two opacifications at 3 and 5 minutes were adequate to assess the vasoconstriction with an underestimation of less than 3% compared with a 10 minute control. ISDN test: 3 mg was the maximal haemodynamically well tolerated dose in the majority of patients. This dose gave the same response whether administered by intracoronary (18 patients) or intravenous injection (10 patients). Maximal vasodilatation was obtained after 2 to 4 minutes. A single coronary opacification 2 minutes after injection of ISDN underestimated the vasomotor capacity by 9.3% compared to that calculated after 5 opacifications performed over a 10 minute period. We propose the following protocol: intravenous injection of 0.4 mg of ergometrine with 2 opacifications of the coronary arteries after 3 and 5 minutes respectively. This followed by intravenous or intracoronary injection of 3 mg of ISDN followed by opacification 2 minutes later.(ABSTRACT TRUNCATED AT 250 WORDS)

[Measurement of the diameter of coronary arteries and coronary stenoses. Presentation of 2 methods]. / Mesure du diamètre des artères coronaires et des sténoses coronaires. Présentation de deux méthodes.

This work consists of the presentation of two methods of quantitative coronary angiography: the first is simple to implement, cheap and offers a routine method for a more precise evaluation of stenoses than simple visual estimation. The second is more interesting if one wishes to measure the diameter of coronaries and attain a satisfactory degree of precision compared to semi-automatic methods using image digitalisation.

[Hemodynamic and coronarographic evaluation for identification of high risk patients following myocardial infarction]. / Bilan hémodynamique et coronarographique pour l'identification des patients à haut risque après un infarctus du myocarde.

The prognosis of patients surviving myocardial infarction is influenced by a high early mortality rate. The aim of this study was to assess the prognostic value of cardiac catheterisation and coronary angiography performed early after infarction to identify patients at high risk. Two hundred patients including 10 women with an average age of 49.1 +/- 8.6 years surviving (greater than 1 month) primary myocardial infarction underwent haemodynamic and coronary angiographic investigations on average 26 days after the onset of infarction (26 +/- 17 days, range 1 to 90 days). All patients were followed up for average period of 43.2 +/- 13.3 months. The overall mortality rate was 13.5% (27/200). The commonest cause of demise was sudden death: 52% (14/27). Most patients died within the first year of infarction (11/27). Indices of left ventricular function (left ventricular end diastolic pressure and ejection fraction) were significantly more pathological in the patients who died. Similarly, there were many more patients with multivessel (93%) and triple vessel disease (63%) in this sub group (p less than 0,001). Analysis of actuarial survival with respect to ejection fraction demonstrated the prognostic importance of this factor, especially during the first year: 38.5% mortality in patients with ejection fractions below 30%. Triple vessel disease was associated with 13% mortality in the first year. When these two factors were combined, the risk of death in the first year was 50%, so identifying a very high risk subgroup. On the other hand, no deaths were observed in patients with a single coronary lesion and normal left ventricular function (ejection fraction greater than 50%) during 72 months follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pulsus alternans: alternation of relaxation parameters]. / Pouls alternant: alternance des paramètres de la relaxation.

Pulsus alternans was observed during transluminal coronary angioplasty of the left anterior descending artery in a 48 year old man. Analysis of left ventricular pressures (Millar catheter) showed alternation of the parameters of relaxation. After the strong beats there was a lengthening of the relaxation constant T (78.8 +/- 3.9 ms compared to 72.9 +/- 4.4 ms, p less than 0.001), a widening of the negative deflection of dp/dt without a significant variation in amplitude and the point of minimal diastolic pressure was delayed. The first weak beat occurred after the longest constant of relaxation T and the lowest negative deflection of dp/dt. Regression of pulsus alternans was accompanied by a progressive decrease of T and an increase in amplitude and narrowing of the negative deflection of dp/dt. The increase in the constant of relaxation T and widening of the negative dp/dt, more apparent after the weak beats, could be signs of left ventricular asynchronism.

Apical hypertrophic cardiomyopathy: clinical and metabolic studies.

Among the hypertrophic non-obstructive cardiomyopathies, a particular group of patients with concentric apical hypertrophy can be described. We studied seven patients (five men and two women) who underwent heart catheterization because they had giant negative T waves in the precordial leads. M-mode and two-dimensional echocardiograms revealed no obstruction within the outflow tract of the ventricle. Coronary angiography was normal in all cases. None of these patients demonstrated any significant peak systolic pressure gradient in the outflow tract. A characteristic spade-like configuration (concentric apical hypertrophy) was observed in the right anterior oblique ventriculogram at end diastole. The apical thickness reached 17.2 +/- 0.85 mm and was significantly greater than mid-anterior wall thickness (9.8 +/- 2.14 mm). In five cases, atrial pacing with coronary arterial and venous lactate sampling revealed abnormalities in myocardial metabolism. With a mean follow up of 43 months, three patients remain asymptomatic and one had heart failure. ECG abnormalities were unchanged and echocardiograms showed an increase of the septal and posterior wall thickness, suggesting a transformation in concentric diffuse hypertrophic cardiomyopathy.

[Hemodynamic and coronary effects of methylergometrin]. / Effets hémodynamiques et coronaires de la méthylergométrine.

The methylergometrine test (ME) was performed during coronary angiography in 43 patients either by a single injection of 0,4 mg (34 cases) or by fractioned doses every 5 minutes of 0,1 mg, 0,2 mg, 0,3 mg, 0,4 mg (total 1 mg) (9 cases). Opacification of the coronary arteries was performed 1, 3 and 5 minutes after each injection; left ventricular pressures were recorded with a Millar catheter-tip transducer. The heart rate and first derivative of left ventricular pressure did not vary significantly after the 0,4 mg single dose ME. Left ventricular end systolic pressure rose by 11 p. 100 (p less than 0,001) and left ventricular end diastolic pressure from 18,3 to 23,1 mmHg (p less than 0,001). Myocardial oxygen consumption assessed by the TTI rose from 2873 +/- 896 to 3083 +/- 788 mmHg.s-1 .min (p less than 0,01), but myocardial contractility as assessed by the V max fell from 1,68 +/- 0,40 to 1,58 +/- 0,35 s-1 (p less than 0,001). The reduction in the calibre of the coronary lumen was identical after the single 0,4 mg dose and the 1 mg fractioned doses. In the later case, 50 p. 100 of the maximal response was observed after the first injection of 0,1 mg. After the single dose of 0,4 g ME the reduction in coronary lumen was very rapid over the first 3 minutes. Prolonged observation up to the 10th minute (7 patients) showed slight aggravation of the vasoconstriction between the 5th and 10th minutes, justifying an injection of a nitrate derivative before discontinuing surveillance. The vasoconstriction induced by ME seems to be within the physiological limits of vasoconstriction. The maximal overall decrease of the coronary diameter was 12,3 +/- 7,8 p. 100 and never exceeded 20 p. 100. There was a significant difference in the response of atheromatous patients in whom the vasoconstriction was greater in the presence of resting angina than in the absence of resting angina (16,4 +/- 8,7 p. 100 compared to 9,7 +/- 6,4 p. 100, p less than 0,01).

Detrimental effect of propranolol in patients with coronary arterial spasm countered by combination with diltiazem.

This study determines, with quantitative variables, if propranolol is detrimental in patients with documented coronary arterial spasm and if this drug can be used in combination with calcium antagonists. Eleven patients with documented coronary spasm were entered prospectively in a study with 4 phases of 2 days each: (1) control, (2) diltiazem or propranolol (mean 225 +/- 75 mg/day), (3) propranolol or diltiazem (360 mg/day), (4) propranolol and diltiazem. The effects of the drugs were assessed by the detection of ischemic electrocardiographic episodes (24-hour electrocardiographic monitoring) and provocative tests with ergonovine. During the period of treatment with propranolol, the number and the duration of attacks increased and provocative tests had positive results in all patients. Diltiazem completely abolished spontaneous episodes, but 6 of 11 patients remained sensitive to the administration of ergonovine. The association of the 2 drugs led to a disappearance of ischemic episodes. In conclusion, propranolol is ineffective in patients with coronary artery spasm. It can be used in combination with diltiazem, but without any advantage over diltiazem alone.

The provocation of coronary arterial spasm in patients with recent transmural myocardial infarction.

Provocative tests for coronary spasm were performed in a group of 131 patients (124 men and 7 women) with recent (less than 6 weeks) transmural myocardial infarction. Coronary arteriography was performed 27 +/- 9 days after the onset of the infarction. The provocative test was performed using a single IV bolus of 0.4 mg of ergometrine. Aortic pressure, ECG and arteriograms of the two coronary vessels were repeated 3 and 5 min later. Provoked spasm was observed in 27 (21%) of the patients. In 13 (48%) the coronary spasm occurred in a vessel presumed to be responsible for the myocardial infarction, while it was observed in coronary artery unrelated to the area of the infarct in 14 (52% of the cases with spasm). Thus, this study demonstrates a high degree of reactivity of the coronary tree of patients with recent transmural myocardial infarction suggesting the likelihood of a role for spasm in the infarction process and offering some explanation for subsequent recurrent ischemic events.

[Coronary artery spasm. Apropos of 165 cases]. / Le spasme artériel coronaire. A propos de 165 observations.

This study comprised 165 cases of coronary artery spasm (147 men and 18 women) with an average age of 49,2 years (range 27 to 73 years). Smoking was a particularly significant risk factor. Symptoms were usually of recent onset (80%) and dominated by attacks of angina pectoris either at rest alone or associated with angina of effort. 14% of cases of spasm were observed during acute myocardial infarction. Some cases presented with syncope due to cardiac arrhytmias. The basal electrocardiogramme was normal in 53% of cases. Exercise stress testing may be normal (30/65 cases) or positive (ST depression recorded in 26/65 cases). In 5 cases, ST elevation was observed. Left ventricular function was usually normal: 115 patients (70%) had organic atherosclerotic lesions, with 1, 2 and 3 vessel disease in 40%, 18% and 22% respectively. Spasm was spontaneous in 24,2% of cases but most commonly provoked by ergometrine. Criteria of spasm only applied to focal spasm and exclused catheter--induced spasm. The most common site of spasm was the right coronary artery (50,3% of cases), followed by the left anterior descending (31% of cases) and left circumflex (10,3% of cases). The outcome of these 165 cases depended on the therapeutic options (surgical treatment in 48 cases). The medium term results were generally good with a low mortality rate and follow up showed that the calcium antagonists provided effective prophylaxis against recurrence of spasm.

[Incidence of induced coronary artery spasm in recent acute transmural myocardial infarction]. / Fréquence du spasme artériel coronaire provoqué au cours de l'infarctus du myocarde aigu transmural récent.

A number of studies have suggested that coronary spasm may play a role in the genesis of myocardial infarction. We carried out a provocation test with 0,4 mg intravenous methylergometrine in 131 patients undergoing routine coronary angiography at least 6 weeks after transmural myocardial infarction. The 124 men and 7 women of equal mean age of 49,6 years underwent the investigation on average 27 +/- 9 days after the date of onset of myocardial infarction. Seventy four patients had anterior infarcts (antero septal, anterior, apical), 55 had inferior infarcts (inferior, diaphragmatic and true posterior) and 2 had lateral wall infarcts. Thirty two patients with anterior infarcts (45 p. cent) had a single vessel disease of the left anterior descending artery, 19 had double vessel disease (25 p. cent), 16 had triple vessel disease (21,6 p. cent). During the provocation test with methylergometrine, 13 patients (17,6 p. cent) developed a spasm, 6 on the left anterior descending, 6 on the right coronary and 1 on the left circumflex artery. The patients with insignificant coronary lesions (7 cases) did not develop focal spasm. Twenty seven patients with inferior infarcts (49 p. cent) had single vessel disease, 19 had double vessel disease (34,6 p. cent) and 9 patients had triple vessel disease (16,4 p. cent). The provocation test induced spasm in 14 of the 55 patients (25,5 p. cent). The spasm was localised on the right on the right coronary artery in 9 cases, on the left circumflex in 3 cases and the left anterior descending artery in 2 cases. Therefore, in the whole population studied, 27/131 patients (21 p. cent) developed focal spasm after methylergometrine. In 13 cases, the spasm was observed in the coronary artery presumed to be responsible for the infarct, and in 14 cases on a vessel which did not correspond to the infarcted territory. Resting angina preceded myocardial infarction in only 6 of these 27 patients. This study does not confirm that coronary spasm was the cause of myocardial infarction. It does show the presence of a certain degree of reactivity of the coronary vessels after recent myocardial infarction. Half of the cases of spasm occurred on the vessel presumed responsible for the infarct but the other cases occurred in another zone, which suggests the possibility of post-infarction angina or even a recurrent myocardial infarction. This would be an indication for prophylactic treatment with calcium antagonist drugs.

[Strategy of the treatment of vasospastic angina pectoris]. / Stratégie du traitement de l'angine de poitrine vasospastique.

The strategy of treatment in vasospastic angina is mainly based on the results of coronary angiography. In a series of 165 patients with coronary spasm documented by angiography, 51 patients (31 per cent) had angiographically normal arteries and 69 per cent had organic atherosclerotic lesions. Patients with fixed atherosclerotic lesions were divided in two subgroups depending on whether the lesions were operable. The first subgroup (47 cases) comprised patients with operable lesions and coronary spasm. They underwent aorto-coronary bypass associated with a procedure to prevent spasm (plexectomy) (40 cases). Depending on the site of the lesions, some patients with operable lesions may benefit from coronary angioplasty followed by treatment with calcium antagonist drugs. Patients in the second subgroup (67 cases) with inoperable fixed atherosclerotic lesions were treated with calcium antagonists. Betablockers, which may be considered in organic coronary artery disease, are theoretically contra-indicated because of the vasospastic factor. The remaining patients with "angiographically normal" vessels (51 cases) were treated with nitrate derivatives and calcium antagonists. Treatment should be directed to the suppression of the clinical symptoms and, above all, of ECG signs of ischemia as proved by repeated Holter monitoring. The clinical course may also be assessed by repeated provocation tests. Results may depend on the doses and their timing during the 24 hour period. Duration of treatment in patients with angiographically normal vessels has not yet been established. Isolated cardiac denervation may be indicated in these patients who fail to respond to medical treatment (8 cases).

What is the role of the coronary circulation in congestive heart failure?

Manifestations of congestive heart failure are frequently observed in patients with coronary disease. However, they may be predominant in patients who have sustained prior myocardial infarction, in whom left ventricular aneurysm or papillary muscle dysfunction may induce left ventricular dysfunction. A small group of patients can develop severe cardiac insufficiency and pump failure on the basis of diffuse occlusive coronary artery disease. Heart failure can also be induced by congenital coronary abnormalities and in congestive cardiomyopathy some previous studies have suggested a decrease of coronary blood flow per unit of myocardial mass. Moreover, coronary artery disease can be associated and worsened congestive heart failure can result from other causes (e.g. valvular disease). However, congestive heart failure per se can also disturb coronary circulation as a result of changes in subendocardial myocardial perfusion or metabolism.

Coronary hemodynamics following intravenous or intracoronary injection of diltiazem in man.

We measured coronary sinus blood flow by continuous thermodilution technique and aortic pressure after administration of diltiazem to 23 patients with coronary artery disease. In one group of patients (n = 12) the drug was infused at a rate of 0.15 mg/kg during 2 min followed by an infusion of 0.05 mg/kg during 8 min. Heart rate was unchanged except at 5 min when it decreased slightly. Aortic pressure was significantly (p less than 0.01) decreased, while coronary sinus flow increased slightly and transiently. A second group of patients (n = 5) received an intracoronary injection of 0.15 mg/kg of diltiazem into the left coronary artery. In a third group of patients (n = 7) 0.05 mg/kg of diltiazem was injected into the left coronary artery. In both these two groups the drug induced a marked increase of coronary sinus flow and a decrease of aortic pressure, while myocardial oxygen consumption was unchanged. This effect was dose related, since the rise in coronary flow was 47% with an injection of 0.15 mg/kg but only 23% with a dose of 0.05 mg-kg. These changes were short-lasting with values returning to normal within 10 min after the injection. We conclude that diltiazem is a potent dilator of coronary arteries.