F. Mason Sones

Progress Study of 590 Consecutive Nonsurgical Cases of Coronary Disease Followed 5-9 Years: I. Arterographic Correlations

The clinical progress was studied in a series of 590 patients documented to have significant obstructive disease by coronary arteriography. Ventriculographic findings, age, history, cigarette smoking, hypertension, serum cholesterol, and diabetes were correlated with prognosis. In categories separated on the basis of left ventricular angiogram the 5-year cardiac mortality rates ranged from 25% among patients with normal left ventricles to 69% among patients with dilated and generally poorly contracting left ventricles. Combining the results of coronary and left ventricular angiography yielded a better prediction than either method separately. Most of the other parameters studied were related to a certain extent to mortality, but their predictive power was limited and could partly or entirely be explained by the associated obstructions of the coronary arteries or the condition of the left ventricle. The most significant clinical determinants were the history, the electrocardiogram, and the presence of diabetes mellitus. Particularly high mortality was found in patients with congestive heart failure or electrocardiographic conduction disturbances.

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.

Clinical significance of isolated coronary bridges: Benign and frequent condition involving the left anterior descending artery

Review of 658 normal cineangiograms performed in the cardiac laboratory of the Cleveland Clinic during 1974 revealed myocardial bridging in 81 patients (12 % ). Maximal systolic compression was measured and compared to diastolic dimension above and below the obstruction by means of a programmable digital caliper. Systolic bridging involved the left anterior descending coronary artery in all cases and was mild in 26 patients, moderate in 55 patients, and severe in 11 patients. Seventy per cent of the patients were men and 30% were women. The majority had atypical symptoms although 15 patients were thought to have angina pectoris. Fiveyear survival rate was 97.5 % . No survivor had acute myocardial infarction during this follow-up period of 5 years. In the patient with normal coronary arteries and normal left ventricular function, myocardial bridging is benign. Myocardial bridging of coronary arteries was recognized and described by Black’ in 1796. If specifically sought at autopsy, such bridges are found in 5 % to 86% of hearts examined.2-4 These bridges also can be recognized arteriographically as a systolic compression of the vessel involved. A prevalence of 0.5% to 1.6% has been reported.5p6 It has been suggested that myocardial bridges, by reducing myocardial blood flow in systole, are responsible for cardiac ischemia,5*7 acute myocardial infarction (AMI),7-g ventricular fibrillation,‘O and sudden death.” Furthermore, it has been implied that myocardial bridging may have the same significant clinical morbidity and mortality as coronary atherosclerosis.12

Progress study of 590 consecutive nonsurgical cases of coronary disease followed 5-9 years. II. Ventriculographic and other correlations.

The clinical progress was studied in a series of 590 consecutive nonsurgical patients with coronary disease documented by selective coronary arteriography. All had 50% or more obstruction in at least one major artery. Patients who were operated on within 5 years were excluded. Observations of the survivors ranged from 5 to 9 years. During the total observation period 263 patients died; only 19 deaths were not due to coronary disease. The 5-year cardiac mortality rate was 34.4% for the entire population, 14.6% for patients with one-vessel involvement, 37.8% for patients with two-vessel involvement, 53.8% for patients with three-vessel involvement, and 56.8% for those with at least 50% narrowing of the left main coronary artery. In patients with single-vessel disease the presence or absence of additional lesions causing less than 50% narrowing was of significant prognostic influence.

Natural history of obstructive coronary artery disease: Ten-year study of 601 nonsurgical cases

The most important factors in the prognosis of coronary artery disease are the number of arteries severly obstructed, significant involvement of the left main coronary artery, and generalized impairment of left ventricular function or ventricular aneurysm. Other prognostic influences at least partially independent of these factors are the severity of functional impairment imposed by angina pectoris, electrocardiographic evidence of left ventricular hypertrophy or conduction defects, hypertension, and diabetes. Candidates for bypass operation have a better prognosis than noncandidates, but difference in left ventricular function is responsible. Refinement of prognostic precision will depend largely on future improvement in measurement of obstructive disease and left ventricular function serially and better knowledge of the cause or causes of coronary artery disease.

Left Main Coronary Arterial Obstruction: Long-Term Follow-Up of 141 Nonsurgical Cases

The prognosis of 141 patients with obstructive left main coronary artery disease was studied. The patients were followed up for 5 to 10 years from the date of coronary arteriography. The 5 year cardiac mortality rate was 51 percent. During the first 3 years after diagnosis, the mortality rate was especially high, 21.9, 34.7 and 43 percent, respectively. Among patients who died in the 1st year after diagnosis, evidence of left ventricular hypertrophy or conduction delay in the electrocardiogram and multiple vessel involvement indicated poor prognosis. Severe angina pectoris, evidence of congestive heart failure and generalized decrease in left ventricular contractility increased the 5 year mortality rate. More than 97 percent of the total patient population had additional lesions elsewhere in the coronary arteries.

Acute coronary insufficiency (impending myocardial infarction and myocardial infarction): Surgical treatment by the saphenous vein graft technique

Abstract The development of direct coronary artery surgery by the saphenous vein graft technique for the first time provides a method that immediately increases the supply of oxygen to the myocardium. As a result, the area of myocardial infarction no longer depends only upon oxygen consumption. Emergency surgery was performed on 29 patients from April 1968 to May 1971; 18 operations were performed upon patients with impending myocardial infarction and 11 upon patients with acute myocardial infarction. Nineteen patients underwent coronary cineangiography before the acute episode; 9 were studied during an acute episode. Patients with impending myocardial infarction were operated upon within 24 hours of the acute episode. Nine patients with acute infarction were operated upon within 4 to 5 hours, 1 within 8 hours, and 1 within 10 hours. Three patients died after the operation; 2 in the group with impending myocardial infarction and 1 in the group with acute infarction. Twelve patients underwent repeat cineangiographic evaluation. All grafts but 1 were open. In the group with impending myocardial infarction, postoperative left ventriculography showed good function of the left ventricle. In the group with acute myocardial infarction, 4 patients showed good function of the left ventricle. In 1 the ventricle was unchanged, and in 2 impaired contraction was demonstrated. Although the present clinical experience is limited, certain conclusions can be made: (1) Emergency coronary cineangiography can be performed with minimal risk. (2) Patients with impending myocardial infarction can undergo operation with a low mortality rate and minimal complications. These patients are ideal candidates. The operation can prevent myocardial infarction. (3) When operations are performed within 6 hours of an acute myocardial infarction, most of the heart muscle can be preserved. (4) In patients with acute myocardial infarction and cardiogenic shock, assisted mechanical circulation is mandatory as the first step. The increase of well oxygenated blood supply should improve myocardial perfusion.

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.

Vein Graft Surgery for Coronary Artery Disease: Survival and Angiographic Results in 1,000 Patients

One thousand patients were operated upon with vein graft techniques for severe coronary artery obstructions between May 1967 and July 1970, with a hospital mortality rate of 4% and a 5.6% incidence of angiographically confirmed in-hospital myocardial infarctions. Postoperative angiograms, performed in 619 of the survivors, revealed patency of one or more vein grafts in 84.2% of patients, and 82.5% of all grafts were patent in studies performed 1 to 49 months after surgery.The hospital survivors were followed for 22 to 60 months; only three patients were lost to follow-up. The survival curve for this group of patients was compared with that of another group of 469 patients who also had severe coronary artery disease and were potential surgical candidates, but were studied in an earlier period and did not have surgical treatment. The annual rate of attrition for each of the four years of follow-up in the surgical group averaged 4.8% per year (2.5% per year excluding hospital mortality), and 9.3% per year in the nonsurgical group. Remission of symptoms correlated closely with the completeness of revascularization.Myocardial revascularization with vein graft techniques can be accomplished successfully and with low risk in the majority of properly selected patients, resulting in a significant improvement in symptoms, as well as in long-term survival.

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.