Norma E. Hill

One-year psychosocial follow-up of patients with chest pain and angiographically normal coronary arteries

As many as 30% of patients with chest pain symptoms who are referred for arteriography are found to have normal coronary arteries. Research has shown that patients with anginal symptoms and normal coronary arteries score higher on neuroticism measurements (anxiety, depression and somatic concerns) at the time of catheterization than patients with anginal symptoms who have coronary artery disease. Research examining the cardiac course of chest pain patients with normal coronary arteries indicates that this is a nonprogressive disorder. Although follow-up studies of these patients report continued chest pain and diminished physical activity, these studies have ignored the psychologic status of the patients. Thus, it is not known whether their higher neuroticism scores at the time of catheterization persist following angiography or whether such elevated indexes of neuroticism are transient phenomena associated with precatheterization anticipatory stress. The present study examined 48 Veterans Administration Medical Center patients: 24 with anginal symptoms and normal coronary arteries and 24 with documented coronary artery disease. The patients completed a structured clinical interview and a set of psychologic inventories on the day before catheterization and 1 year later. The findings established continued high neuroticism scores among patients with anginal symptoms only and supported the findings of other investigators regarding continuing chest pain and restricted physical activity. The knowledge alone of benign coronary artery status resulted in virtually no change in the psychosocial status of these patients. Alternative treatment methods are discussed.

Electrocardiographic criteria for the diagnosis of combined inferior myocardial infarction and left anterior hemiblock

New electrocardiographic (ECG) criteria for diagnosing the combination of inferior myocardial infarction and left anterior hemiblock are proposed. The proposed criteria are based upon the relations between portions of the vectorcardiographic QRS loop in the frontal plane and the corresponding portions of the QRS complexes recorded by the limb leads. The application of the proposed criteria requires that the tracings be obtained with 3-channel ECG machines. The proposed criteria for the diagnosis of inferior myocardial infarction and left anterior hemiblock are as follows: (1) leads aVR and aVL both end in R waves, with the peak of the terminal R wave in lead aVR occurring later than the peak of the terminal R wave in lead aVL, and (2) a Q wave of any magnitude is present in lead II. The performance of the proposed criteria was superior to that of 10 combinations of traditional ECG criteria for inferior myocardial infarction and left anterior hemiblock.

Electrocardiographs criteria for the diagnosis of anterior myocardial infarction: Importance of the duration of precordial R waves

A systematic evaluation of a large number of electrocardiographic (ECG) variables that might be useful for diagnosing anterior myocardial infarction (MI) is reported. Previous anterior MI was shown to be present or absent by cardiac catheterization in 199 patients. The best discriminator between cases and noncases of anterior MI in most patients is the presence of a Q wave of any magnitude or an initial R wave less than 20 ms in lead V2. In patients with ECG evidence of associated left ventricular or type C right ventricular enlargement, the more stringent criterion of a Q wave of any magnitude in lead V2 yielded the optimal combination of sensitivity and specificity for diagnosing anterior MI. The diagnostic performance of the proposed criteria for anterior MI is superior to that of more traditional criteria that use measurements of the absolute and relative amplitudes of precordial R waves.

Improved electrocardiographic criteria for the diagnosis of left anterior hemiblock

New electrocardiographic (ECG) criteria for the diagnosis of left anterior hemiblock are proposed. The proposed criteria are based upon the relation between portions of the vectorcardiographic (VCG) QRS loop in the frontal plane and the corresponding portions of the ECG QRS complexes recorded by the limb leads. The application of the proposed criteria requires that the tracings be obtained with 3-channel ECG machines so that the temporal relation between the QRS complexes in simultaneously recorded limb leads can be inspected. This type of analysis of the electrocardiogram permits prediction of features of the VCG QRS loop that are important for the diagnosis of left anterior hemiblock. The proposed ECG criteria for the diagnosis of left anterior hemiblock are (1) the QRS complexes in leads aVR and aVL each end in an R wave (terminal R wave), and (2) the peak of the terminal R wave in lead aVR occurs later than the peak of the terminal R wave in lead aVL. The sensitivity and specificity of the proposed criteria were empirically evaluated using series of electrocardiograms obtained under clinical circumstances during which the occurrence of left anterior hemiblock was, respectively, likely and unlikely. The performance of the proposed criteria was statistically superior to that of 2 sets of frontal plane QRS axis criteria.

Comparison of optimal scalar electrocardiographic, orthogonal electrocardiographic and vectorcardiographic criteria for diagnosing inferior and anterior myocardial infarction

A scalar electrocardiogram (ECG), orthogonal ECG and vectorcardiogram (VCG) were recorded in 46 normal persons, 38 patients with inferior myocardial infarction (MI) and 22 patients with anterior MI proved at cardiac catheterization. The diagnostic information provided by the scalar ECG, orthogonal ECG and VCG was quantitatively analyzed and the optimal criteria for diagnosing inferior and anterior MI exhibited by each method were identified. The optimal scalar electrocardiographic, orthogonal electrocardiographic and vectorcardiographic criteria, respectively, are: For inferior MI: initial superior duration in lead aVF greater than 30 ms (sensitivity 63%, specificity 100%), superior/inferior amplitude ratio in lead Y greater than or equal to 0.2 (sensitivity 63%, specificity 96%), initial superior duration greater than 29 ms or initial superior distance greater than 0.4 mV in the frontal plane loop (sensitivity 68%, specificity 100%). For anterior MI: initial anterior duration in lead V2 less than 20 ms or initial anterior duration in lead V3 less than 25 ms (sensitivity 91%, specificity 100%), anterior/posterior duration ratio in lead Z less than 0.3 (sensitivity 73%, specificity 98%), initial anterior duration less than 15 ms in the transverse plane loop (sensitivity 64%, specificity 98%). There were no significant differences among the performances of the optimal scalar ECG, orthogonal ECG and the VCG for diagnosing inferior MI. However, the performance of the optimal scalar ECG was superior to that of the optimal orthogonal ECG and the optimal VCG for diagnosing anterior MI (chi-square = 5.20, p less than 0.02 and chi-square = 7.14, p greater than 0.01, respectively).

Lack of relationship between plasma insulin and glucagon levels and angiographically-documented coronary atherosclerosis☆

In 120 consecutive patients undergoing diagnostic coronary arteriography, fasting blood glucose, plasma insulin, glucagon, serum cholesterol and triglyceride concentrations were measured. The insulin-glucose ratio and insulin-glucagon ratio were calculated. Forty-five patients had normal coronary arteries, 19 had single vessel coronary artery disease and 56 patients had multiple vessel disease. Fasting blood glucose was greater than 120 mg/100 ml in 37 patients (group A) and included 9 of the 10 known diabetics, 3 of whom were being treated with insulin. Seventy-seven patients included in group B had fasting blood glucose concentration less than 120 mg/100 ml. Patients with multiple vessel coronary disease in either group had higher blood glucose and cholesterol concentrations than those with normal coronary arteries or the ones with single vessel disease, but they did not have higher plasma insulin or glucagon levels nor increased insulin-glucose or insulin-glucagon ratios. With comparable extent of coronary artery disease patients in group A had higher plasma insulin levels and insulin-glucagon ratios than those in group B, but no correlation exists between the presence or extent of coronary atherosclerosis and these variables in either group. Thus, neither fasting plasma insulin level nor insulin-glucagon ratio predicts the status of underlying coronary atherosclerosis in either diabetics or nondiabetics.

Differentiating anginal patients with coronary artery disease from those with normal coronary arteries using psychological measures.

Abstract Up to 30% of patients with chest pain who undergo coronary catheterization have angiographically normal coronary arteries. 1 Several recent prospective studies have shown that patients who are found to have normal coronary arteries score consistently higher than patients with coronary artery disease (CAD) on measures of the personality dimension of neuroticism when measured at catheterization 2–4 or 1 year after. 5 These findings are based on a diverse set of psychological tests, including the Minnesota Multiphasic Personality Inventory, Beck Depression Inventory, Spielberger State-Trait Anxiety Inventory, Eysenck Personality Questionnaire, Cornell Medical Index, and the Millon Behavioral Health Inventory, attesting to the reliability and validity of the association between normal coronary arteries and neuroticism. Anticipating these findings linking neuroticism and chest pain with minimal, if any, intimal irregularities of the coronary arteries, Costa 6 raised the possibility that psychometric information might be helpful to physicians in evaluating candidates for angiography. If a sensitive and specific psychometric scale could be developed to determine that the patient is likely to have normal coronary arteries, then less invasive alternatives to catheterization might be recommended. As a first step, we initiated this prospective study to evaluate the usefulness of an inventory that was developed for use in medical settings to differentiate chest pain patients.

Usefulness of abnormalities of repolarization in the electrocardiographic diagnosis of healed myocardial infarction

The authors evaluated the ability of criteria involving abnormalities of repolarization to diagnose healed myocardial infarction (MI). They studied the Q, R, S, and T waves and the ST-segments of the electrocardiograms (ECGs) of 60 angiographic-normal patients, 63 patients with angiographic evidence of healed inferior MI, and 33 patients with angiographic evidence of anterior MI. The best individual criteria involving repolarization were T wave amplitude less than or equal to 0.4 mm in lead II for inferior MI (specificity, 93%: sensitivity, 67%) and T wave amplitude greater than 2.4 mm for anterior MI (specificity, 100%: sensitivity, 27%). These T wave criteria enhanced the diagnostic performances of otherwise marginal QRS criteria for both inferior and anterior MI. The authors conclude that ECG criteria that involve abnormalities of the T waves are useful for diagnosing healed MI.

Importance of the terminal portion of the QRS in the electrocardiographic diagnosis of inferior myocardial infarction

The scalar electrocardiograms of 64 patients with inferior wall myocardial infarction (MI) and 87 normal subjects were quantitatively analyzed to determine the respective contributions of the initial and terminal portions of the QRS to the diagnosis of inferior MI. Of the 10 best individual electrocardiographic criteria for inferior MI, 7 were Q-wave criteria and 3 were criteria that consisted of delayed termination of the QRS in leads II or III. Combining the best terminal QRS criterion (the QRS in lead III ending at least 20 ms later than the QRS in lead I) with the 7 best Q-wave criteria and the best Q-wave criterion (Q wave 40 ms or longer in lead aVF) with the 3 best terminal QRS criteria, resulted in criteria with better sensitivities and overall diagnostic performances than those of the individual criteria. Analyzing the vectorcardiograms that were also available in 26 of the patients with inferior MI and 34 of the normal subjects showed that the delayed inscription of the end of the QRS in leads II and III in patients with inferior MI is due to redirection of the terminal forces of ventricular depolarization. The terminal portions of the QRS complexes in the limb leads, considered both alone and in conjunction with traditional measurements of Q waves, contain information that is useful for diagnosing inferior MI.

Optimized electrocardiographic criteria for prior inferior and anterior myocardial infarction

BACKGROUND AND PURPOSE The first purpose of the study was to optimize empirically the detection of prior inferior myocardial infarction (IMI) and prior anterior myocardial infarction (AMI) by electrocardiogram (ECG). The second purpose was to compare the diagnostic performances of the new criteria with those of 3 widely used commercial diagnostic ECG algorithms. MATERIALS AND METHODS We analyzed the digital ECG data from 1138 subjects with suspected coronary artery disease in whom the presence or absence of prior IMI or AMI was documented by coronary angiography and left ventriculography. We used receiver operating characteristic curves to develop the new criteria for prior IMI and AMI using a training set of 562 subjects and then tested their diagnostic performances using a separate test set of 576 subjects. In both the training and test sets, we used χ(2) test to compare the performances of the new criteria with those of 3 commercial computerized diagnostic algorithms. RESULTS The best criterion for prior IMI was the algebraic sum of the Q and T amplitudes in leads III and aVF. Its sensitivities/specificities were 71%/98% and 74%/98% in the training and test sets, respectively. The best criterion for prior AMI was the algebraic sum of the Q, R, and T amplitudes minus the Q duration in leads V(2), V(3), and V(4). Its sensitivities/specificities were 68%/98% and 65%/98% in the training and test sets, respectively. In both the training and test sets, these diagnostic performances were generally superior to those of the 3 commercial algorithms. CONCLUSIONS Using digital ECG data, we developed and tested new criteria for prior IMI and AMI whose diagnostic performances are generally superior to each of 3 widely used commercial ECG diagnostic algorithms.