Dennis G. Caralis

Smoking is a risk factor for coronary spasm in young women.

BackgroundRisk factors for pure coronary spasm are not known. Clinical observations have pointed to cigarette smoking, a known risk factor for obstructive coronary artery disease. Methods and ResultsWe conducted a case-neighborhood control study of premenopausal women, a population segment with the lowest prevalence of obstructive coronary artery disease. The cases were 21 premenopausal women (age range, 36–41 years) with angiographically proven coronary spasm. All coronary arteriograms were analyzed by two independent experienced cardiologists on two occasions. There were no differences between analyses; all cases had normal baseline coronary angiogram except for two, who had less than 20% coronary luminal stenosis in segments other than the site of the focal vasospasm. All cases had normal hemodynamics at rest, normal left ventricular function, and were in sinus rhythm. Ascertainment of the cases was done by angiographic demonstration of focal coronary spasm spontaneously or by ergonovine provocation. Six cases developed spontaneous coronary spasm before catheter engagement, and in 15, coronary spasm was induced by ergonovine provocation. Each case was asked to name as many as possible female neighborhood acquaintances of similar age and racial background who were willing to answer the same standardized questionnaire. The same standardized questionnaire was completed for each case and each control (n = 63). The standardized questionnaire was designed to obtain information on health characteristics, habits, socioeconomic status, and education. Only cigarette smoking was significantly more prevalent among coronary spasm cases. Cigarette smokers were 13 cases (62%) and 11 controls (17.5%) (p<0.001). The odds ratio was 7.7, with a 95% confidence interval of 2.6–23.1. ConclusionsThese findings suggest that there is a very strong association between cigarette smoking and pure coronary spasm in young women.

Prognostic value of dipyridamole thallium-201 imaging in elderly patients☆

The prognostic value of intravenous dipyridamole myocardial perfusion imaging has not been studied in a large series of elderly patients. Patients greater than or equal to 70 years of age with known or suspected coronary artery disease were evaluated to determine the predictive value of intravenous dipyridamole thallium-201 imaging for subsequent cardiac death or nonfatal myocardial infarction. Of the 348 patients, 207 were symptomatic and 141 were asymptomatic; 52% of the asymptomatic group had documented coronary artery disease. During 23 +/- 15 months of follow-up, there were 52 cardiac deaths, 24 nonfatal myocardial infarctions and 42 revascularization procedures (percutaneous transluminal coronary angioplasty in 20; coronary artery bypass surgery in 22). Clinical univariate predictors of a cardiac event included previous myocardial infarction, congestive heart failure symptoms, hypercholesterolemia and diabetes (all p less than 0.05). The presence of a fixed, reversible or combined thallium-201 defect was significantly associated with the occurrence of cardiac death or myocardial infarction during follow-up (p less than 0.05). Cardiac death or nonfatal myocardial infarction occurred in only 7 (5%) of 150 patients with a normal dipyridamole thallium-201 study (p less than 0.001). Stepwise logistic regression analysis of clinical and radionuclide variables revealed that an abnormal (reversible or fixed) dipyridamole thallium-201 study was the single best predictor of cardiac events (relative risk 7.2, p less than 0.001). As has been demonstrated in younger patients, previous myocardial infarction (relative risk 1.8, p less than 0.001) and symptoms of congestive heart failure at presentation (relative risk 1.6, p = 0.02) were also significant independent clinical predictors of cardiac death or myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal coronary angioplasty in patients with intracoronary thrombus

Abstract Percutaneous transluminal coronary angioplasty (PTCA) in the presence of intracoronary thrombus carries a risk of occlusive thromboembolism during or after the procedure. 1–3 The purpose of this study was to assess the incidence of and analyze the factors associated with coronary thromboembolic complications during PTCA in patients with intracoronary thrombus detected on the baseline angiogram.

Prognostic value of exercise thallium scintigraphy in patients with good exercise tolerance and a normal or abnormal exercise electrocardiogram and suspected or confirmed coronary artery disease.

Exercise thallium scintigraphy is widely used to assess prognosis in patients with suspected or proven coronary artery disease. The incremental prognostic value of this technique in patients who have good exercise tolerance has not been well studied. Two hundred ninety-nine patients with known or suspected coronary artery disease without prior myocardial infarction or revascularization procedure referred for exercise myocardial perfusion imaging and able to exercise to greater than or equal to stage III of the Bruce protocol were included. After a mean follow-up of 50 +/- 10 months, there were 15 cardiac events (5%). The incidence of cardiac events was 10 versus 3% (p less than 0.001) in patients with an abnormal versus normal thallium-201 scan, and 9 versus 3% (p = 0.03) for an abnormal versus normal exercise electrocardiogram. When the 185 patients with a normal exercise electrocardiogram were examined, the incidence of cardiac events was 3% (5 of 150) in patients with a normal scan versus 0% (0 of 35) in patients with an abnormal scan. In the 114 patients with an abnormal exercise electrocardiogram, an abnormal thallium-201 scan was predictive of cardiac events (18% [8 of 44] versus 3% [2 of 70]; p = 0.006). Stepwise logistic regression analysis selected an abnormal thallium-201 scan and abnormal exercise electrocardiogram, low peak exercise heart rate, and male gender as independent variables associated with a significant increased risk of cardiac events. Thus, in patients with known or suspected coronary artery disease and good exercise tolerance, the addition of thallium-201 imaging in patients with an abnormal exercise electrocardiogram provides useful prognostic information.(ABSTRACT TRUNCATED AT 250 WORDS)

Ergonovine-induced myocardial ischemia without epicardial coronary vasospasm: Evidence for ischemia produced by small-vessel vasoconstriction

Keprint requests: Morton J. Kern. MD, Director, d. Gerard Mudd Cardiac Catheterizat,ion Laboratory. St. Louis University Hospital, 3635 Vista Avenue at Grand. St. Louis, MO 63110. 4/4/2876X+ narrowing of epicardial vessels. Provocative ischemia is generally not attributed to small-vessel vasoconstriction.iv2 Although the incidence of ergonovine provocation of focal coronary spasm is generally low in North American patients with normal coronary arteries,2 many patients complain of chest discomfort or other symptoms without characteristic ischemic ECG changes or ST segment elevation during ergonovine administration. We observed a patient who experienced marked chest pain during testing with ergonovine, which reproduced his symptoms with ST segment depression but without focal coronary vasospasm. The ST segment depression was unrelieved by intracoronary nitroglycerin and other coronary vasodilators. This case demonstrates a unique response with persistent severe ergonovine-induced small-vessel vasoconstriction as a cause of myocardial ischemia in a patient who had angiographically normal epicardial vessels without focal largevessel spasm. The patient was a @-year-old white man who had recently experienced chest tightness and episodes of atria1 fibrillation. Chest pain did not typically occur with exertion. He also noted dyspnea on exertion without a previous history of cardiac disease. Medications at, the time of evaluation included digoxin (0.25 mg daily) and quinidine (325 mg orally, four times a day). The physical examination was unremarkable. Blood pressure was 140/80 mm Hg. ECG at rest (Fig. 1, A) showed normal sinus rhythm and nonspecific chagnes of ST segment alterations in leads Va to Ve.

Application of computerized exercise ECG digitization. Interpretation in large clinical trials.

The authors report on a semiautomated program that incorporates both visual identification of fiducial points and digital determination of the ST-segment at 60 ms and 80 ms from the J point, ST slope, changes in R wave, and baseline drift. The off-line program can enhance the accuracy of detecting electrocardiographic (ECG) changes, as well as reproducibility of the exercise and postexercise ECG, as a marker of myocardial ischemia. The analysis program is written in Microsoft QuickBASIC 2.0 for an IBM personal computer interfaced to a Summagraphics mm1201 microgrid II digitizer. The program consists of the following components: (1) alphanumeric data entry, (2) ECG wave form digitization, (2) calculation of test results, (4) physician overread, and (5) editor function for remeasurements. This computerized exercise ECG digitization-interpretation program is accurate and reproducible for the quantitative assessment of ST changes and requires minimal time allotment for physician overread. The program is suitable for analysis and interpretation of large volumes of exercise tests in multicenter clinical trials and is currently utilized in the TIMI II, TIMI III, and BARI studies sponsored by the National Institutes of Health.

An off-line digital system for reproducible interpretation of the exercise ECG

Exercise electrocardiograms of 20 patients were analyzed using a customized software exercise electrocardiographic program and compared to measurements made by two cardiologists performing independent interpretations. The computerized program requires identification of the PQ junction, J point, and tracing of the ST-segment in three consecutive beats. The proportion of variance for J point, and ST 80 measurements was 0.93 and 0.90, respectively, when the same electrocardiogram was processed twice and analyzed by two separate cardiologists. The same 20 exercise electrocardiograms were analyzed by two other experienced cardiologists without computerized measurements. The proportion of variance was less at 0.73 and 0.76 for the J point and ST 80 measurements, respectively. The average amount of time required for the cardiologist to over read the computerized measurements was 2.7 +/- 1.5 minutes per ECG as compared to 20.7 +/- 11 minutes for the cardiologists who did not have computer-assisted measurements (p less than 0.0001). Thus, off-line computerized exercise electrocardiographic interpretation is highly reproducible, accurate, time-sparing for cardiologist over read function, and suitable for use in large-scale clinical trials.

Preload or afterload reduction: Which is more beneficial for patients with ischemic heart disease?

SummaryWe studied the acute hemodynamic effects of molsidomine, a selective preload reducing agent, and nifedipine, a selective afterload reducing agent. Thirty-two patients with stable angina pectoris and angiographically significant coronary artery disease were randomized into two groups: group A patients received 4 mg of molsidomine, and group B patients received 20 mg of nifedipine orally. Molsidomine was associated with a significant reduction of the left ventricular end-diastolic pressure and an increase in Vcf. Nifedipine caused a significant reduction of the mean arterial pressure and an increase of the heart rate. Hemodynamic parameters associated with chronic exertional angina pectoris in patients with angiographically significant coronary artery disease improved more with a preload reducing agent, like molsidomine.

Acute Hemodynamic Effects of Molsidomine in Patients with Ischemic Cardiomyopathy

Molsidomine (N-ethoxycarbony l-3-morpholinosy dnonimine) is an antianginal agent that belongs to the class of sydononimines. Experimental [1] and human studies [2,3] suggest that molsidomine reduces preload by its direct action on the venous system, resulting in peripheral venous pooling, and thus in a decreased venous return. This effect leads to increased myocardial perfusion by reducing ventricular wall tension [4]. We studied 20 patients, 18 men and 2 women (age range 32-75, mean 50 years • 8), with symptoms and signs of congestive heart failure. All patients were in New York Heart Association functional classification III-IV, with severe coronary artery disease by coronary angiography (>75% luminal diameter narrowing in at least two major coronary branches). The onset of the heart failure ranged from 9 months to 11 years. Severe left ventricular dysfunction was present in all, with an angiographic ejection fraction of 0.18 mean (range 0.16-0.28). Eight patients had mitral insufficiency, which was angiographically mild to moderate. Informed consent to administer molsidomine and to carry out hemodynamic measurements was obtained from all