Earl K. Shirey

Selective Cine Coronary Arteriography Correlation with Clinical Findings in 1,000 Patients

The clinical records of 1,000 patients who had adequate selective cine coronary arteriography were reviewed. The clinical diagnoses were made by a physician who had no knowledge of the arteriographic findings. Correlation of the clinical diagnoses with the arteriographic findings was made subsequently.Symptomatic coronary disease was accompanied by arteriographic evidence of significant obstruction of major coronary arteries in most instances. A close correlation existed between the clinical diagnosis of angina pectoris without rest pain and significant arterial obstruction (95%). A similar correlation was found between QRS evidence of myocardial infarction and severe arterial obstruction (99%). The demonstrated arterial obstruction in patients who had angina pectoris almost always was severe and usually almost total or total in one or more major vessels. In myocardial infarction the demonstrated obstruction was always severe and generally almost total or total.The correlation between clinical and arteriographic findings was moderately close in patients who had angina with symptoms at rest. The correlation between the arteriographic findings and less characteristic clinical syndromes (rest pain only, 79%, coronary failure, 78%, and especially atypical angina pectoris, 65%) was not so close. In congestive failure secondary to coronary disease, arterial obstruction was extensive unless ventricular aneurysm, mitral insufficiency, arrhythmia, arterial hypotension, or some other complication was present. Most patients thought to have noncoronary symptoms had no significant obstructive lesions.In 37% of the entire group of patients, almost all of whom had been suspected of having coronary disease by some physicians, no significant arteriographic obstruction was demonstrated; in 27% the arteriograms were normal.Diagnoses, based on appraisal of the clinical records without knowledge of the arteriographic findings, yielded 83% correlation with abnormal arteriographic findings in 700 patients thought to have coronary disease.

Ergonovine maleate provocative test for coronary arterial spasm

Ergonovine maleate was evaluated as a provocative agent for inducing coronary spasm during coronary arteriography. The study group consisted of 98 patients with either mild fixed obstructions of coronary luminal diameter (less than 50 percent) or normal coronary arteriograms. The test was considered positive if the drug precipitated severe coronary spasm. A positive ergonovine test occurred in 10 of 11 patients with Prinzmetals variant angina (P < 0.02). Two of these patients had a transmural myocardial infarction in the distribution of the spastic artery. Ergonovine tests were negative in (1) the 15 control patients with no clinically suspected coronary artery disease (P < 0.001), (2) 63 of 66 patients with angina-like chest pain (P < 0.001), and (3) all 6 patients with myocardial infarction and no history of Prinzmetals variant angina (P < 0.05). No major complications occurred as a result of this test. Thus, ergonovine maleate test is a safe, sensitive and specific method for reproducing coronary spasm in patients with Prinzmetals variant angina and no major coronary obstructions. The results suggest that coronary spasm can be implicated as a cause of myocardial infarction in patients with normal coronary arteriograms who also have Prinzmetals variant angina. Coronary spasm was not demonstrated in patients who had normal coronary arteriograms and a history of myocardial infarction as an isolated clinical event. Also, coronary spasm could not be demonstrated in the majority of patients who had angina-like chest pain and no major coronary obstruction.

Chloroquine neuromyotoxicity. Clinical and pathologic perspective.

Six cases of toxic myopathy and/or neuropathy with chloroquine and/or hydroxychloroquine therapy are described. Two patients had unique clinical and pathologic evidence of cardiomyopathy secondary to chloroquine or hydroxychloroquine therapy. One patient had polyneuropathy secondary to chloroquine toxicity. This may be the first documentation of several features of chloroquine/hydroxychloroquine toxicity: morphologic changes in human peripheral nerve in chloroquine toxicity; chloroquine/hydroxychloroquine cardiomyopathy diagnosed by endomyocardial biopsy; and hydroxychloroquine myotoxicity. Chloroquine is a neuromyotoxin that affects nerves and cardiac and skeletal muscles. Discontinuation of chloroquine and hydroxychloroquine resulted in marked improvement in most cases. The reversibility of the symptoms emphasizes the importance of recognizing potential signs of nerve, muscle, and cardiac toxicity in patients being treated with chloroquine or hydroxychloroquine.

Distribution of Arterial Lesions Demonstrated by Selective Cinecoronary Arteriography

The distribution of obstructions exceeding 30% of the normal diameter of the lumen of one or more major coronary arteries was studied in 627 of 1,000 patients who had selective cinecoronary arteriograms. An additional 99 patients had lesser degrees of narrowing, and in the arteriograms of 274 patients, normal arteries were demonstrated. An average of 2.0 lesions resulting in at least 50% luminal narrowing of major arteries was found per patient. The anterior descending coronary artery was involved slightly more frequently than were other vessels. More than 75% of the symptomatic patients had 90% or more obstruction of at least one vessel, and more than 50% had total occlusions of one or more vessels. A single major artery was the site of obstruction exceeding 30% of the luminal diameter in 131 patients (20.9% of the 627 patients), and in 43 of these (6.9%) the other arteries appeared to be entirely normal. Severe involvement of single arteries was most frequent in patients who had myocardial infarction without angina pectoris or in those who had rest pain only. No pattern of arterial involvement was pathognomonic of a clinical syndrome.

Diagnosis of chloroquine cardiomyopathy by endomyocardial biopsy.

CHLOROQUINE and hydroxychloroquine are antimalarial agents that are often used in the treatment of collagen vascular diseases. However, both drugs can cause a toxic skeletal-muscle myopathy, the hi...

Primary myocardial disease. Correlation with clinical findings, angiographic and biopsy diagnosis: Follow-up of 139 patients

The purpose of this study was determination of the prognostic value of clinical and tissue (biopsy) findings of 139 patients with cardiomyopathy. The types of cardiomyopathy were congestive (113 patients) and hypertrophic or constrictive (26 patients). The mean follow-up period of all patients was 4.3 years. Follow-up of the survivors was between 13 months and 11.9 years, mean 5.4 years. Of the 47 cardiac deaths (33.8%), the minimum and maximum follow-up was two weeks and 7.5 years, respectively (mean 2.1 years). Patients with congestive heart failure had the highest five year cardiac mortality rate (51.8%). Coexisting cardiac arrhythmia had no influence on prognosis and an arrhythmia only was benign in most patients. Myocardial hypertrophy or fibrosis or both and myocardium with no pathologic diagnosis had prognostic value. Small-vessel disease was infrequent and not associated with specific clinical manifestations.

Cinecoronary Arteriography in Young Men

Of a group of 723 men less than 40 years old who underwent cinecoronary arteriography primarily for evaluation of chest pain, 357 (49%) were found to have at least 50% narrowing of one or more coronary arteries. The youngest person was 17 years old.The distribution of lesions in the young men was similar to that found earlier in a study of persons not selected by age. The anterior descending coronary artery was most frequently affected; the right coronary artery was most often totally occluded. No total occlusions of the left main coronary artery were seen.Electrocardiographic evidence of myocardial infarction, found in 109 patients, was less common with disease of the circumflex or right coronary arteries than with disease of the anterior descending coronary artery. This observation was confirmed by examination of left ventriculograms for areas of decreased contractility. Six patients had no significant arterial narrowing.The extent of arterial involvement seemed to be related to the duration of symptoms in patients who had angina pectoris or myocardial infarctions.Clinical diagnoses correlated well with the angiographic findings, particularly in those men considered to be normal and those with typical angina pectoris. Addition of atypical features or prolonged pain decreased the degree of correlation.Only 20% of those with cholesterol levels less than 200 mg/100 ml had significant lesions, whereas 81% with levels more than 275 mg/100 ml had such findings.

Certain Clinical Characteristics Correlated with Extent of Obstructive Lesions Demonstrated by Selective Cine-Coronary Arteriography

The duration of the history of angina pectoris, the distribution of the pain, the factors precipitating the pain, and serum cholesterol levels in the men less than the age of 40 years were studied in a group of 337 patients who had angina pectoris. Also the number of obstructed coronary arteries in 588 patients with severe obstruction in a larger study group of which the 337 patients were a part was compared with the number in men less than 40 years of age with severe lesions. The distribution of coronary arterial obstructions shown by selective cine-coronary arteriography was determined in relation to the clinical characteristics mentioned, and they were found to be of little predictive value. In most patients who had congestive heart failure occurring in the absence of recognized complications, multiple severe arterial obstructions were found. Division of patients who have anginal syndrome into groups on the basis of duration of history cannot clarify the natural history of symptomatic obstructive coronary arterial disease.

Percutaneous Myocardial Biopsy of the Left Ventricle Experience in 198 Patients

A thin-walled Silverman needle has been used for 254 percutaneous punch biopsies of the left ventricle in 198 patients with closed chests at the Cleveland Clinic. The technic is described. The biopsy specimens were adequate for diagnosis in 192 patients. In all but three patients (who had lupus erythematosus, scleroderma, and chronic glomerulonephritis with congestive heart failure) cardiac catheterization and selective cardioangiographic studies were performed. There was angiographic evidence of primary myocardial disease, coronary atherosclerosis, or both, or rheumatic valvular disease in 175 patients. Cardiac catheterization and angiographic studies demonstrated no evidence of organic heart disease in 20 patients.Cardiac tamponade was a complication of myocardial biopsy in eight patients. Post-pericardiotomy syndrome occurred in four patients and ventricular fibrillation in one patient.Myocardium with no pathologic diagnosis and interstitial fibrosis or myocardial hypertrophy or both were the light microscopic findings in 165 patients. Representative sections of the biopsy in 27 patients demonstrated small-vessel disease, basophilic degeneration, focal interstitial myocarditis, amyloidosis, Aschoffs nodules, or vacuolar degeneration. The current experience suggests that myocardial biopsy combined with selective cardioangiography is of experimental value, improves the accuracy of diagnosis, and plays a role in the management of some patients.

Comparison of stress digital ventriculography stress thallium scintigraphy and digital fluoroscopy in the diagnosis of coronary artery disease in subjects without prior myocardial infarction

Exercise thallium scintigraphy is often used for the diagnosis of coronary artery disease (CAD). Exercise digital subtraction ventriculography and digital subtraction fluoroscopy are new diagnostic procedures with roles that have not been determined. To compare the relative accuracies of the digital techniques with thallium scintigraphy, 97 consecutive patients without myocardial infarction underwent all 3 tests on the day before their scheduled coronary angiograms. Forty-two patients had CAD (more than 50% diameter narrowing of 1 major artery). A fixed or reversible perfusion defect defined an abnormal thallium test response and a segmental wall motion abnormality at rest or with exercise defined an abnormal digital ventriculographic response. Any visualized coronary calcific deposit defined an abnormal digital fluorographic response. The sensitivities of digital fluoroscopy (86%) and digital ventriculography (79%) were significantly higher than the sensitivity of thallium (62%) (p less than 0.05). The specificity of thallium (82%) was not significantly higher than that of either digital ventriculography (72%) or fluoroscopy (67%). The diagnostic accuracies of digital fluoroscopy, digital ventriculography, and thallium were 75%, 75% and 73%, respectively. A logistic regression model showed that thallium and digital fluoroscopy were more accurate in younger patients, whereas digital ventriculography was more sensitive in hypertensive persons and in those not taking beta-blocking drugs. The choice of test depends on disease prevalence, clinical variables (such as age and hypertension) and the importance of functional information obtained from stress testing.