Moosa Najmi

Devolutionary pattern of coronary atherosclerosis in patients with angina pectoris: Coronary arteriographic studies

Abstract The devolutionary pattern of coronary atherosclerosis in patients with angina pectoris was studied in 47 persons cinearteriographically. Two subsets of patients were identified at the initial examination. The first comprised 12 patients who did not have coronary atherosclerosis. In these 12, the cinearteriographic findings remained normal on repeated study 15 to 73 months later. The second subset included 35 patients with severe obstructive coronary atherosclerosis. When coronary visualization was repeated 15 months later, arterial disease remained stable in 11 patients (31.4 percent). Significant progression of the arterial disease was observed in the remaining 24 patients (68.5 percent). The frequency of hyperlipidemia, clinical diabetes, systolic and diastolic hypertension and a positive family history of coronary heart disease was not significantly different in those with stable and progressive disease. Furthermore, the distribution of the initial disease did not distinguish one group from the other. Since collateral channels were more prolific in patients who ultimately were classified as having stable arterial disease, it is possible that the initial severity of disease in this group was greater than in those with progressive disease. None in the latter group noted a reduction in the frequency or severity of angina pectoris. One third of those with stable disease did record such a reduction. However, paradoxically, two patients with stable coronary disease had a new myocardial infarction in the interval between examinations. Our findings suggest that the devolutionary pattern of coronary atherosclerosis in patients with angina pectoris as observed cinearteriographicaliy is unpredictable and apparently unrelated to commonly cited risk factors. They indicate that the severity of angina pectoris is the most precise guide to progressive coronary artery disease even though progressive disease can occur without affecting angina. The occurrence of myocardial infarction in patients with stable disease underscores the fact that many determinants influencing myocardial perfusion are not identified by cinearteriography.

Effects of Nitroglycerin on Hemodynamics During Rest and Exercise in Patients with Coronary Insufficiency

Twenty-three patients exhibiting coronary insufficiency on exercise have been studied at rest and at exercise prior to and following sublingual administration of nitroglycerin. The most consistent and marked effect of nitroglycerin was the reduction in pulmonary artery pressure, total pulmonary resistance, and right ventricular work at rest and during exercise. Our patients were grouped according to the degree of left ventricular failure as indicated by the abnormality of rise in pulmonary artery pressure during exercise. It became evident that nitroglycerin improved left ventricular function in terms of increased output and lessened pulmonary artery pressure in cases in which failure was most severe.

Clinical and hemodynamic evaluation of coronary collateral vessels in coronary artery disease.

Abstract To appraise the functional significance of coronary collateral vessels, 78 consecutive patients with angina pectoris and at least 75 per cent obstruction in a major coronary vessel were studied clinically, hemodynamically, and angiographically and by stress testing. Forty-eight of them (62 per cent) had coronary collateral vessels. When patients with collaterals were compared with those without, the severity of angina pectoris and the number of positive treadmill ECGs were not statistically different. The patients with collaterals had a greater incidence of past myocardial infarction, 3348 (68 per cent) vs. 830 (27 per cent) (P = 0.001); more extensive obstructive disease angiographically, 8.0 ± 0.4 vs. 6.3 ± 0.5 (P = 0.05); more abnormal pacing ventricular function curves, 2223 (96 per cent) vs. 915 (60 per cent) (P = 0.01); and a greater incidence of left ventricular contraction abnormalities, 4348 (90 per cent) vs. 1630 (53 per cent) (P = 0.025). Patients who have coronary artery disease and collateral vessels cannot be distinguished from their counterparts without collaterals on a clinical basis except for a greater incidence of myocardial infarction in the former. Present evidence implies that collateral vessels may protect the patient by delaying the onset of angina pectoris, but when angina occurs these patients have more extensive coronary artery disease and greater myocardial dysfunction. In addition, collaterals, although not preventing, may limit the extent of myocardial infarction and reduce immediate mortality. The prognosis from the onset of angina pectoris may be worse in those patients with collateral vessels, however, because of their more extensive disease.

Auscultatory and phonocardiographic findings in patients with prosthetic ball-valves

Abstract Phonocardiographic studies of single and multiple cardiac ball-valve prostheses were described. Slightly prolonged Q-M 1 intervals were correlated with slight gradients between the left atrium and ventricle. A relation between the preceding R-R interval and Q-M 1 interval, as well as the A 2 -opening click interval, was demonstrated. Increased diastolic ventricular pressure prolonged the A 2 -opening click of either the mitral or tricuspid ball-valve. This prolonged opening click has no relation to the surface area of the valve. Progressive shortening of the A 2 -opening click interval of the tricuspid or mitral ball-valve indicates improvement of cardiac status. The presence of ejection midsystolic murmurs with mitral as well as aortic valve prostheses was explained.

Results of aortocoronary artery saphenous vein bypass surgery for ischemic heart disease

Abstract The results of direct myocardial revascularization using aortocoronary artery saphenous vein bypass grafting in 100 consecutive patients with ischemic heart disease are evaluated. Twelve patients died at operation or early thereafter. Of 88 patients surviving, 72 had severe angina pectoris before operation, 15 had moderate angina and 1 mild angina. After operation, only 10 patients had severe angina, 6 had moderate angina and 72 were free of angina. Thirty-seven patients underwent an exercise stress test in the upright position using a bicycle ergometer 3 to 5 days before operation. Angina pectoris developed in 33 patients during exercise and was accompanied by significant S-T segment depression. The exercise study was terminated in four patients who experienced shortness of breath. Three to four months postoperatively, 20 of these 37 patients underwent exercise at similar and higher work load levels. No pain or S-T segment depression was noted in 18 of the 20 patients. Two of the 20 patients had positive exercise responses similar to their preoperative responses. Seventeen of the 37 patients did not undergo exercise testing after operation: Four died; eight showed clinical improvement but were not available for repeat exercise studies; the remaining five showed no clinical improvement and did not undergo repeat exercise studies. Left ventricular function was determined by measuring ejection fraction and mean velocity of circumferential fiber shortening per circumference in 51 patients. The preoperative ejection fraction of patients who manifested clinical improvement after operation was greater than that of patients whose condition did not improve; how-ever, there was considerable overlap of data. The success or failure to achieve a good clinical result correlated with flow through the bypass, measured at the time of operation. Flow through the saphenous bypass was directly related to the state of the distal coronary arterial system.

A Case Report of Arterial Emboli in a Male Secondary to Idiopathic Hypertrophic Subaortic Stenosis

Recently, many articles concerning arterial embolism have been described. The majority of arterial emboli arise from intracardiac mural thrombi. The left atrium may be the sit.e of thrombus formation. Mitral valve disease with atrial fibrillation, arteriosclerosis with atrial fibrillation, and myocardial infarction comprise the maj or sources of arterial embolus. We have been unable to find reports describing multiple arterial emboli from idiopathic hypertrophic subaortic stenosis (IHSS) in English medical literature to date.

Current Status of Aorto-Coronary Bypass Graft Surgery

The value of saphenous vein bypass surgery in the treatment of coronary artery disease will eventually be assessed through prospective randomized studies of homogeneous groups of patients undergoing either medical or surgical treatment. At present, there is insufficient evidence to demonstrate the beneficial effects of coronary bypass operations on prevention of myocardial infarction and prolongation of life. The improvement in the quality of life may be rewarding in patients with crippling angina pectoris in whom there is a major obstruction of the proximal coronary artery with good distal runoff and adequate ventricular function. This review summarizes our knowledge of the natural history of angina pectoris and examines the indications for a surgical approach in chronic, stable angina pectoris, in unstable angina, variant angina, main left coronary artery disease and acute myocardial infarction. Criteria for patient selection are tentatively defined.