Left ventricular systolic and diastolic function during acute coronary artery balloon occlusion in humans.

Left ventricular function during percutaneous transluminal coronary angioplasty was studied in 16 patients undergoing the procedure. All measurements were performed before and during the first episode of balloon coronary occlusion. In 16 patients (Group A), data were recorded before and 30 or 50 s after balloon inflation, and in 8 of these patients (Group B) data were also recorded 15 min after the complete procedure. Left ventriculograms indicated a marked dyskinesia of the anterior and apical wall in all patients. After balloon inflation, there was a marked depression in stroke index and ejection fraction and an increase in left ventricular end-diastolic pressure and the time constants of relaxation in all patients. Simultaneous recording of left ventricular pressure (Millar micromanometer) during cineangiography permitted the assessment of myocardial and chamber stiffness. Although there was a strong tendency for both myocardial and chamber stiffness to increase after 30 to 50 s of occlusion, these increases were statistically insignificant. In Group B, a third set of angiographic and pressure measurements obtained 15 min after completion of the coronary angioplasty procedure indicated no residual left ventricular dysfunction, and in this respect, the results are of added clinical importance.

[Reproducibility of the exercise test and coronary vasomotor tonus]. / Reproductibilité de l'épreuve d'effort et tonus vasomoteur coronaire.

The effect of coronary vasomotor tone on exercise test reproducibility was evaluated in two groups of patients. All had an apparently stable angina, a positive first exercise test and at least one significant stenosis at coronary arteriography. Group A patients (n = 30) had a positive ergonovine test (dynamic stenosis) whereas this test was negative (fixed stenosis) in group B patients (n = 29). Patients of both groups underwent two exercise tests without treatment, each of these tests being performed on a different day of the same week, at the same time and according to Bruce's procedure. The reproducibility of angina was poor in group A patients: 6/15 (40 p. 100) as against 18/20 (90 p. 100) in group B patients (p less than 0.05). Moreover, the initially positive exercise test subsequently become negative in 6 of the group A patients and in none of the group B patients (p less than 0.05). The time elapsed before ischaemia appeared was globally increased to the same extent in both groups, but individual variations were more pronounced in group A: a more than 1 minute variation was noted in 63 p. 100 of group A patients and in 18 p. 100 of group B patients (p less than 0.01). Similarly, the double product of ischaemia (-1 mm) varied by more than 20 p. 100 in 37 p. 100 of group A patients and in 14 p. 100 of group B patients. In contrast, the maximum stress parameters were increased to the same degree in both groups, including the double product duration.(ABSTRACT TRUNCATED AT 250 WORDS)

Enhanced efficacy of computerized exercise test by multivariate analysis for the diagnosis of coronary artery disease. A study of 558 men without previous myocardial infarction.

Multivariate analysis has been proposed to enhance diagnostic accuracy of the exercise test in coronary artery disease. To quantify the improvement given by multivariate analysis in comparison with ST segment depression alone during exercise test, 558 men without previous myocardial infarction were studied retrospectively. All the patients underwent a symptom-limited Bruce protocol with computer-averaged recordings in V5, aVF, V2. Coronary angiography was performed within the following 90 days. Prevalence of coronary artery disease (diameter narrowing of 50% or greater) was 0.56. Among 12 clinical and exercise parameters studied by stepwise multivariate analysis, five were found to reach the maximal accuracy: (1) exercise duration, (2) history of typical angina, (3) typical angina during the test, (4) age, (5) maximal heart rate. In comparison with ST depression, multivariate analysis significantly improves accuracy (74.6 vs. 66.8%, P less than 0.01) by increasing sensitivity (0.68 vs. 0.59, P less than 0.05) without affecting specificity (0.83 vs. 0.76, NS). Thus, in a group of men without infarction and a low prevalence of coronary artery disease, multivariate analysis with five easily collected variables is more accurate than ST segment depression alone during exercise. In addition, ST depression did not appear as discriminant as exercise duration for diagnostic purposes. This finding emphasises the importance of performing a symptom-limited exercise test.

Percutaneous transluminal coronary angioplasty in patients with spasm superimposed on atherosclerotic narrowing.

Of 552 patients undergoing percutaneous transluminal coronary angioplasty 102 had coronary artery spasm superimposed on atherosclerotic narrowing. Coronary angioplasty was successful in 97 (95%). The patients were discharged on a regimen of nifedipine (40-60 mg/day). Seventy six patients were symptom free 6-8 months after the procedure. Restenosis was detected in 35% of patients. Coronary artery spasm was provoked in 38 (44%) of the 87 patients who underwent an ergometrine maleate test. Twenty seven of the 34 patients with restenosis had a provocation test and coronary artery spasm was superimposed on restenosis in 22 (81.5%). Coronary angioplasty is feasible in patients with coronary artery spasm superimposed on atherosclerotic narrowing but the rate of restenosis is high and coronary artery spasm could have a role in the pathogenesis of restenosis.

[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.

[Prevention of myocardial ischemia during exercise 8 hours after use of transdermal nitrate derivatives]. / Prévention de l'ischémie myocardique d'effort 8 heures après l'application de dérivés nitrés transdermiques.

A controlled (placebo) double blind trial of a 20 cm2 transdermal system delivering 10 mg of Trinitrin per 24 hours, was carried out in 18 patients with stable angina and significant coronary artery disease. The exercise stress tests were performed at the same time of day using Bruce's protocol and computerised analysis (Case Marquette) after a 48 hour wash out period. All patients had two basal positive and reproducible exercise tests interrupted because of induced anginal pain and/or greater than or equal to 3.5 mm ST depression. There was no significant difference between the basal exercise stress tests and those performed after placebo. With the active drug the onset of ischaemia was delayed (ST less than -1 mm = 217 +/- 122 sec vs 150 +/- 70 sec with placebo, p less than 0.01); the duration of exercise was prolonged (419 +/- 119 sec vs 328 +/- 94 sec with placebo, p less than 0.01); for the same theoretical maximal heart rate, the ST depression was less (-1.6 +/- 0.9 mm vs -2.1 +/- 0.7 mm with placebo, p less than 0.01). On the other hand, the double rate pressure product was unchanged at rest and on effort. These results obtained after a 48 hour therapeutic window show statistically significant benefits with an increase in exercise tolerance and a decrease in myocardial ischaemia 8 hours after the application of transdermal Trinitrin system.

[Comparative study of short and medium-term results of angioplasty and bypass in severe or unstable angina pectoris caused by isolated stenosis of the anterior interventricular branch]. / Etude comparative des résultats à court et moyen terme de l'angioplastie et du pontage dans l'angor sévère ou instable par sténose isolée de l'IVA.

This retrospective non-randomized study deals with 146 patients subjected to revascularization procedures for severe or instable angina pectoris due to isolated stenosis of proximal or middle anterior interventricular artery, without myocardial infarction in the anamnesis. The patients were divided into two comparable groups: group A (74 patients) treated by an aorto-coronary bypass saphenous vein graft; group B (63 patients) subjected to transluminal coronary angioplasty. None of them presented an associated cardiopathy. The patients were controlled after 10.4 months (group A) and 9.1 months (group B); a physical stress-testing was performed according to the same protocol in the two groups, and control coronarography in group B. The evolution was characterized by one death in each group and a more frequent incidence of infarction (6.7%) in group A than in group B (2.7%, p = NS). The symptomatology in both groups was comparable: 12.1% in group A and 9.1% in group B was free of symptoms. Also the stress-testing yielded similar results: a negative and maximal in 43.6% in group A and 56.4% in group B. When positive at the control (in 27% of group A and 36% of group B) the threshold of appearance of ischemia was delayed only in group B. Thus even if the functional results are comparable in the two groups, the risk of infarction is less after angioplasty, in return, however, for 23% of recurrent stenoses.

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.

[Anti-Coxsackie antibodies and congestive cardiomyopathies]. / Anticorps anti-Coxsackies et cardiomyopathies congestives.

During a 4-years period 122 patients admitted to the cardiologic hospital in Lille presented a significative positivity of serological reaction against Coxsackievirus B. Among these patients 19 suffered from acute pericarditis, 4 from cardiac arrhythmias, 3 from Bornholm syndrome and 14 from apparently primary congestive cardiomyopathy. In most of these 14 patients representing 18.4% of congestive cardiomyopathies investigated at the same time, hemodynamic studies and heart scanning with radioactive gallium were performed. 7 of these patients had a chronic (group A) and 7 an acute evolution (group B). In group A the scans were negative 4 times out of 5, whereas in group B they were positive in 5 out of 5 examinations. The control group including 3247 patients coming from the Institut Pasteur exhibited serological positivity in 4.6% of cases. Comparison of this group with that of cardiomyopathies shows a significant difference (p less than 0.001). The authors draw the attention to the frequency of positive serodiagnosis in congestive cardiomyopathy and stress the importance of gallium scintiscanning.

Coronary arterial angiographic findings during transient myocardial ischemia.

Coronary arteriography remains the most precise clinical tool for diagnosis and therapeutical decision concerning patients with coronary artery disease; when performed during a short transient episode of myocardial ischemia, this investigation can afford interesting information. The first part of the paper describes the coronary arterial angiographic findings during ischemia related to increase in myocardial requirements. Thus, a vasoconstrictor reflex can decrease the area of narrowing during handgrip exercise. Other reports have described coronary arterial spasm during exercise in highly selected patients. Coronary arterial angiographic findings during transient decrease of coronary blood flow are described in the second part of this paper. They can rarely be detected spontaneously but most often are provoked. The results obtained with cold pressor, hyperventilation and ergonovine tests are discussed. In this latter provocative test, the incidence of spasm in a population of 2572 patients undergoing coronary angiography is described.

[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)