Richard S. Ross

Unstable angina pectoris: National cooperative study group to compare surgical and medical therapy: II. In-Hospital experience and initial follow-up results in patients with one, two and three vessel disease

Abstract A prospective randomized study comparing intensive medical therapy with urgent coronary bypass surgery for the acute management of patients with unstable angina pectoris was carried out by nine cooperating medical centers under the auspices of the National Heart, Lung, and Blood Institute. Between 1972 and 1976, a total of 288 patients were entered into the study. All patients had transient S-T or T wave changes, or both, in the electrocardiogram during pain; 90 percent had pain at rest in the hospital, and 76 percent had multivessel coronary disease. The medically and surgically treated patients were comparable with respect to clinical, electrocardiographic and angiographic characteristics and left ventricular function. During the total study period, the hospital mortality rate was 5 percent in the surgical group and 3 percent in the medical group (difference not significant). The rate of in-hospital myocardial infarction was 17 and 8 percent in the respective groups (P In the 1st year after hospital discharge class III or IV angina (New York Heart Association criteria) was more common in medically than in surgically treated patients with one vessel disease (22 percent versus 3 percent, P The results indicate that patients with unstable angina pectoris can be managed acutely with intensive medical therapy, including the administration of propranolol and long-acting nitrates in pharmacologic doses, with adequate control of pain in most patients and no increase in early mortality or myocardial infarction rates. Later, elective surgery can be performed with a low risk and good clinical results if the patients angina fails to respond to intensive medical therapy.

Multiple-lead exercise electrocardiography. Experience in 107 normal subjects and 67 patients with angina pectoris, and comparison with coronary cinearteriography in 84 patients.

A system of multiple-lead exercise electrocardiography has been applied to the study of 107 normal subjects and 67 patients with angina pectoris. The results of this test are compared to those of coronary cinearteriography in 84 patients. In-exercise ECGs gave useful additional information in 59% of the angina patients but were essential for interpretation in 9%. It added considerably to the safety of the test. The value of each individual lead and of the multiple lead system was assessed. Lead V6 was the most often positive, but each made a contribution in some cases. Test-retest reproducibility survey indicated that five of 65 tests on 25 subjects failed to conform. Evidence has been presented that 1.0 mm of ischemic S-T segment shift was the best criterion for a positive test in the subjects studied. The test was positive in 84% of 67 patients with angina pectoris and 3.7% of 107 normal subjects (excluding vasoregulatory hyperreactors). The double two-step test given to the first 41 of the same angina patients for comparison was found to give 61% positive reactions despite the use of multiple leads and in-exercise recording. The test was administered to 84 subjects who were studied concurrently by selective coronary cinearteriograms and these two parameters were compared with the clinical diagnosis of angina in each patient. Since each of these parameters represents a different facet of coronary arterial disease, the agreement among them is very instructive.

Natural History of Ischemic Heart Disease in Relation to Arteriographic Findings A Twelve Year Study of 224 Patients

The severity of the atherosclerotic disease of the coronary arteries is demonstrated to be an important predictor of survival in a group of 224 patients followed from 5 to 12 years after coronary arteriography. The group consisted of young patients (average age 41.8 years) without hypertension or congestive heart failure, who were studied during the stable phase of their disease. The current status of 218 or 97% of this group of patients is known.

Unstable angina pectoris: Morbidity and mortality in 57 consecutive patients evaluated angiographically

Fifty-seven consecutive patients presenting with unstable angina pectoris or so-called pre-infarction angina were prospectively evaluated by clinical and angiographic studies. One patient died during angiography and another died of acute myocardial infarction 11/2 hours after cardiac catheterization. Forty-five patients had significant obstruction in two or three coronary arteries. The average left ventricular ejection fraction was 59 percent. Of 15 patients treated medically, 10 were potential candidates for surgery. One of these 10 died during hospitalization and 9 survived. The nine survivors were followed up for an average of 10 months; six reported symptomatic improvement, and one had an uncomplicated myocardial infarction 6 months after study. Aortocoronary saphenous vein bypass was performed in 40 patients, of whom 9 died during hospitalization and 31 survived operation. Of the 31 survivors, 1 had an uncomplicated myocardial infarction 9 months postoperatively; there were no late deaths in this group during a follow-up period averaging 16.7 months. Thirty of the 31 survivors reported marked symptomatic improvement, and 21 of these survivors were pain-free.

Myocardial-Infarct Extension Detected by Precordial ST-Segment Mapping

Abstract Daily precordial ST-segment mapping was performed with the millimeter sum of ST-segment deviation (ΣST) in a 48-lead system (1 mv = 20 mm) to evaluate 26 normal subjects and 19 patients with acute myocardial infarction. At the time of admission, ΣST (± S.D.)for transmural infarction (men + 140 ± 84.8, and women + 95.7 ± 8.8) and nontransmural infarction (-67 ± 32) was significantly different (p<0.001) from controls (men + 30.1 ± 18.1, and women + 17 ± 11.7). ΣST approached normal values by 10.6 and 13 hospital days, respectively. Twelve of 14 patients (86 per cent) with transmural infarction had re-elevation of ΣST ( + 76 ± 49.7) 5.8 days (mean) after admission. This finding was associated with abnormal creatine phosphokinase in eight (57 per cent), suggesting infarct extension. Standard six precordial leads did not reflect re-elevation of ΣST in four of the 12 patients with infarct extension. The 86 per cent incidence of infarct extension indicates that measures designed to decrease myocardial i...

Unstable angina pectoris: National cooperative study group to compare medical and surgical therapy

A preliminary report is presented of a prospective randomized trial conducted by eight cooperative institutions under the auspices of the National Heart and Lung Institute to compare the effectiveness of medical and surgical therapy in the management of the acute stages of unstable angina pectoris. To date 150 patients have been included in the randomized trial, 80 assigned to medical and 70 to surgical therapy; the clinical presentation, coronary arterial anatomy and left ventricular function in the two groups are similar. Some physicians have been reluctant to prescribe medical or surgical therapy by a random process, and the eithical basis of the trial has been questioned. Since there are no hard data regarding the natural history and outcome of therapy for unstable angina pectoris, randomization appears to provide a rational way of selecting therapy. Furthermore, subsets of patients at high risk may emerge during the process of randomization. The design of this randomized trial is compared with that of another reported trial. Thus far, the study has shown that it is possible to conduct a randomized trial in patients with unstable angina pectoris, and that the medical and surgical groups have been similar in relation to the variables examined. The group as a whole presented with severe angina pectoris, either as a crescendo pattern or as new onset of angina at rest, and 84 percent had recurrence of pain while in the coronary care unit and receiving vigorous medical therapy. It is anticipated that sufficient patients will have been entered into the trial within the next 12 months to determine whether medical or surgical therapy is superior in the acute stages of unstable angina pectoris.Abstract A preliminary report is presented of a prospective randomized trial conducted by eight cooperative institutions under the auspices of the National Heart and Lung Institute to compare the effectiveness of medical and surgical therapy in the management of the acute stages of unstable angina pectoris. To date 150 patients have been included in the randomized trial, 80 assigned to medical and 70 to surgical therapy; the clinical presentation, coronary arterial anatomy and left ventricular function in the two groups are similar. Some physicians have been reluctant to prescribe medical or surgical therapy by a random process, and the ethical basis of the trial has been questioned. Since there are no hard data regarding the natural history and outcome of therapy for unstable angina pectoris, randomization appears to provide a rational way of selecting therapy. Furthermore, subsets of patients at high risk may emerge during the process of randomization. The design of this randomized trial is compared with that of another reported trial. Thus far, the study has shown that it is possible to conduct a randomized trial in patients with unstable angina pectoris, and that the medical and surgical groups have been similar in relation to the variables examined. The group as a whole presented with severe angina pectoris, either as a crescendo pattern or as new onset of angina at rest, and 84 percent had recurrence of pain while in the coronary care unit and receiving vigorous medical therapy. It is anticipated that sufficient patients will have been entered into the trial within the next 12 months to determine whether medical or surgical therapy is superior in the acute stages of unstable angina pectoris.

Use of Phentolamine in Acute Myocardial Infarction Associated with Hypertension and Left Ventricular Failure

In 11 patients with hypertension associated with acute myocardial infarction intravenous phentolamine decreased the elevated left ventricular filling pressure. Cardiac index increased with a small decrease in arterial pressure, and therefore the same or increased stroke work was achieved at a lower filling pressure. In patients with acute hypertension myocardial oxygen demand was decreased and this may tend to increase infarct size. The potentially beneficial effects were less great in patients with chronic hypertension antedating the myocardial infarction.

Changes in Intrinsic Coronary Circulation and Segmental Ventricular Motion after Saphenous-Vein Coronary Bypass Graft Surgery

Abstract Occlusive changes in the intrinsic coronary arterial circulation were found in 50 of 71 patients 6.1 ± 0.8(± S.E.M.) after saphenous-vein bypass surgery. A new total arterial occlusion was found in 57 (30 per cent) of 188 major coronary arteries. These occlusions occurred in 29 per cent (20 of 68) of intrinsic coronary arteries with a patent graft, in 62 per cent (24 of 39) of those with an occluded graft, and in 16 per cent (13 of 81) of arteries not bypassed. A comparable reduction in segmental left ventricular motion was noted. Eighty-six per cent of the 71 patients had symptomatic improvement of angina; 60 per cent were asymptomatic. Thus, change in the intrinsic coronary circulation after bypass procedures is not inconsistent with relief of angina and must be considered in the evaluation of this operation.

Unstable angina pectoris: National cooperative study group to compare medical and surgical therapy. I. Report of protocol and patient population

A preliminary report is presented of a prospective randomized trial conducted by eight cooperative institutions under the auspices of the National Heart and Lung Institute to compare the effectiveness of medical and surgical therapy in the management of the acute stages of unstable angina pectoris. To date 150 patients have been included in the randomized trial, 80 assigned to medical and 70 to surgical therapy; the clinical presentation, coronary arterial anatomy and left ventricular function in the two groups are similar. Some physicians have been reluctant to prescribe medical or surgical therapy by a random process, and the eithical basis of the trial has been questioned. Since there are no hard data regarding the natural history and outcome of therapy for unstable angina pectoris, randomization appears to provide a rational way of selecting therapy. Furthermore, subsets of patients at high risk may emerge during the process of randomization. The design of this randomized trial is compared with that of another reported trial. Thus far, the study has shown that it is possible to conduct a randomized trial in patients with unstable angina pectoris, and that the medical and surgical groups have been similar in relation to the variables examined. The group as a whole presented with severe angina pectoris, either as a crescendo pattern or as new onset of angina at rest, and 84 percent had recurrence of pain while in the coronary care unit and receiving vigorous medical therapy. It is anticipated that sufficient patients will have been entered into the trial within the next 12 months to determine whether medical or surgical therapy is superior in the acute stages of unstable angina pectoris.Abstract A preliminary report is presented of a prospective randomized trial conducted by eight cooperative institutions under the auspices of the National Heart and Lung Institute to compare the effectiveness of medical and surgical therapy in the management of the acute stages of unstable angina pectoris. To date 150 patients have been included in the randomized trial, 80 assigned to medical and 70 to surgical therapy; the clinical presentation, coronary arterial anatomy and left ventricular function in the two groups are similar. Some physicians have been reluctant to prescribe medical or surgical therapy by a random process, and the ethical basis of the trial has been questioned. Since there are no hard data regarding the natural history and outcome of therapy for unstable angina pectoris, randomization appears to provide a rational way of selecting therapy. Furthermore, subsets of patients at high risk may emerge during the process of randomization. The design of this randomized trial is compared with that of another reported trial. Thus far, the study has shown that it is possible to conduct a randomized trial in patients with unstable angina pectoris, and that the medical and surgical groups have been similar in relation to the variables examined. The group as a whole presented with severe angina pectoris, either as a crescendo pattern or as new onset of angina at rest, and 84 percent had recurrence of pain while in the coronary care unit and receiving vigorous medical therapy. It is anticipated that sufficient patients will have been entered into the trial within the next 12 months to determine whether medical or surgical therapy is superior in the acute stages of unstable angina pectoris.

Identification of high risk subsets of acute myocardial infarction

To Identify the patient at high risk after acute myocardial Infarction data on 400 patients obtained from the Myocardial Infarction Research Units Cooperative Data Bank were examined. Patients were grouped according to clinical findings as follows: uncomplicated (class 1, 81 patients); mild to moderate failure (class II, 150 patients); severe failure with pulmonary edema (class III, 17 patients); and severe failure with shock (class IV, 152 patients). Hemodynamic data Including pulmonary capillary wedge pressure and cardiac output were available In all patients. High risk subsets within clinical classes I, II and IV were Identifiable. In class I, nonsurvivors had significantly (P <0.05) higher values for pulmonary capillary wedge pressure (16 mm Hg) and heart rate (96 beats/min); nonsurvivors In class II also had a significant (P <0.01) elevation In pulmonary capillary wedge pressure (23 mm Hg); and In class IV the high risk subset was characterized (P <0.01) by pulmonary capillary wedge pressure (21 mm Hg), heart rate (100 beats/min), cardiac Index (1.6 liters/min per m2), stroke index (14 cc/m2) and stroke work index (12 g-m/m2). Discrimlnant function analysis using pulmonary capillary wedge pressure and heart rate predicted mortality In classes I to III with 72 percent accuracy; a similar equation representing stroke work index, pulmonary capillary wedge pressure and cardiac Index had an 83 percent rate of accuracy in class IV patients. interclass comparison of the last three measurements indicated that the data differed significantly among classes, thus signifying a spectrum of ventricular impairment after Infarction that was commensurate with the clinical presentation. However, in individual patients the clinical examination did not consistently reflect the degree of ventricular dysfunction. Thus, careful bedside examination together with hemodynamic monitoring of wedge pressure, cardiac output and heart rate serve to identify the high risk patient after acute myocardial infarction.