Clinical, haemodynamic, and coronary angiographic correlates of angina pectoris in patients with severe aortic valve disease

Angina in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

INTRODUCTION AND OBJECTIVES

To evaluate the prevalence, clinical characteristics, and outcomes of patients with angina undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis.

METHODS

A total of 1687 consecutive patients with severe aortic stenosis undergoing TAVR at our center were included and classified according to patient-reported angina symptoms prior to the TAVR procedure. Baseline, procedural and follow-up data were collected in a dedicated database.

RESULTS

A total of 497 patients (29%) had angina prior to the TAVR procedure. Patients with angina at baseline showed a worse New York Heart Association (NYHA) functional class (NYHA class> II: 69% vs 63%; P=.017), a higher rate of coronary artery disease (74% vs 56%; P <.001), and a lower rate of complete revascularization (70% vs 79%; P <.001). Angina at baseline had no impact on all-cause mortality (HR, 1.02; 95%CI, 0.71-1.48; P=.898) and cardiovascular mortality (HR, 1.2; 95%CI, 0.69-2.11; P=.517) at 1 year. However, persistent angina at 30 days post-TAVR was associated with increased all-cause mortality (HR, 4.86; 95%CI, 1.71-13.8; P=.003) and cardiovascular mortality (HR, 20.7; 95%CI, 3.50-122.6; P=.001) at 1-year follow-up.

CONCLUSIONS

More than one-fourth of patients with severe aortic stenosis undergoing TAVR had angina prior to the procedure. Angina at baseline did not appear to be a sign of a more advanced valvular disease and had no prognostic impact; however, persistent angina at 30 days post-TAVR was associated with worse clinical outcomes.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Pathophysiological coronary and microcirculatory flow alterations in aortic stenosis

Regulation of coronary blood flow is maintained through a delicate balance of ventriculoarterial and neurohumoral mechanisms. The aortic valve is integral to the functions of these systems, and disease states that compromise aortic valve integrity have the potential to seriously disrupt coronary blood flow. Aortic stenosis (AS) is the most common cause of valvular heart disease requiring medical intervention, and the prevalence and associated socio-economic burden of AS are set to increase with population ageing. Valvular stenosis precipitates a cascade of structural, microcirculatory, and neurohumoral changes, which all lead to impairment of coronary flow reserve and myocardial ischaemia even in the absence of notable coronary stenosis. Coronary physiology can potentially be normalized through interventions that relieve severe AS, but normality is often not immediately achievable and probably requires continued adaptation. Finally, the physiological assessment of coronary artery disease in patients with AS represents an ongoing challenge, as the invasive physiological measures used in current cardiology practice are yet to be validated in this population. This Review discusses the key concepts of coronary pathophysiology in patients with AS through presentation of contemporary basic science and data from animal and human studies.

Role of short-acting nitroglycerin in the management of ischemic heart disease

Nitroglycerin is the oldest and most commonly prescribed short-acting anti-anginal agent; however, despite its long history of therapeutic usage, patient and health care provider education regarding the clinical benefits of the short-acting formulations in patients with angina remains under-appreciated. Nitrates predominantly induce vasodilation in large capacitance blood vessels, increase epicardial coronary arterial diameter and coronary collateral blood flow, and impair platelet aggregation. The potential for the prophylactic effect of short-acting nitrates remains an under-appreciated part of optimal medical therapy to reduce angina and decrease myocardial ischemia, thereby enhancing the quality of life. Short-acting nitroglycerin, administered either as a sublingual tablet or spray, can complement anti-anginal therapy as part of optimal medical therapy in patients with refractory and recurrent angina either with or without myocardial revascularization, and is most commonly used to provide rapid therapeutic relief of acute recurrent angina attacks. When administered prophylactically, both formulations increase angina-free walking time on treadmill testing, abolish or delay ST segment depression, and increase exercise tolerance. The sublingual spray formulation provides several clinical advantages compared to tablet formulations, including a lower incidence of headache and superiority to the sublingual tablet in terms of therapeutic action and time to onset, while the magnitude and duration of vasodilatory action appears to be comparable. Furthermore, the sublingual spray formulation may be advantageous to tablet preparations in patients with dry mouth. This review discusses the efficacy and utility of short-acting nitroglycerin (sublingual spray and tablet) therapy for both preventing and aborting an acute angina attack, thereby leading to an improved quality of life.

Detection of coronary artery disease by means of exercise ECG in patients with aortic stenosis

In a preoperative evaluation, 35 consecutive patients with aortic stenosis were examined by means of exercise ECG, Doppler and direct manometric measurements of the pressure difference over the aortic valve (delta P) and angiocardiography. Coronary artery disease (CAD) was found in 43% of the patients. Those with CAD had a lower mean maximum physical performance expressed as a percentage of the normal value (Wmax%), larger ST depressions and a higher effort angina (EA) score at the exercise test than the non-CAD group. Mean delta P was equal in the two groups. A myocardial coronary obstruction score covariated positively with a coronary insufficiency index (CT index = 100 X STdepr/Wmax%) and the EA score. There was no correlation between delta P and the EA score or the CI index. A CI index less than 3 and an EA score less than 2 were found in 49% of the patients and excluded the presence of CAD with a predictive accuracy of 88%, a better diagnostic complement to coronary arteriography than a history of EA.

Angina pectoris in aortic valvular disease and its relation to coronary pathology

Angina pectoris is a common symptom in aortic valvular disease. In our study of 100 consecutive patients it was found more commonly in patients with aortic stenosis than in those with aortic insufficiency. Only 21 of 80 patients with angina pectoris had significant narrowing (more that 75%) of one or several coronary arteries. Angina pectoris in aortic valvular disease thus seems to be most often functional due to disproportion between myocardial oxygen supply and demand. On the other hand, 5 of 20 patients without angina pectoris had significant coronary artery stenosis. As coronary artery involvement may jeopardize the results of aortic valve replacement in these patients, coronary angiography should always be carried out in patients evaluated for surgery of aortic vavlular disease. Coronary bypass surgery should be carried out during the same operation if the stenosis is severe and bypass is technically feasible.

Resting heart rate: a modifiable prognostic indicator of cardiovascular risk and outcomes?

A growing body of evidence from clinical trials and epidemiological studies has identified elevated resting heart rate as a predictor of clinical events. Proof of direct cause and effect is limited, because current drugs that lower heart rate (eg, beta-blockers) have multiple mechanisms of action. A new class of drug, selective I(f) inhibitors, is under investigation as a 'pure' heart rate-reducing medication and will help confirm if there is a causal link between elevated heart rate and cardiovascular outcomes. The present paper reviews the evidence for elevated heart rate as a cardiovascular risk factor and some of the current clinical trials testing this hypothesis.

Approach to the patient with chest pain and nonobstructive coronary artery disease

Patients with chest pain and nonobstructive coronary artery disease (NOCAD) utilize a significant part of our health care resources. Their diagnosis and treatment can often be difficult and time consuming. A simple classification system and stepwise diagnostic approach may help to reduce unnecessary testing. Also, utilization of a chest pain clinic may be beneficial for these patients.

Angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis

BACKGROUND

Angina pectoris has long been recognised as one of the principal symptoms of severe aortic valve stenosis (AS), even in patients without significant coronary artery disease (CAD). However, controversy exists concerning the prevalence of angina pectoris and associated CAD in such patients.

OBJECTIVE

To determine the prevalence of CAD detectable by angiography and its relation to angina pectoris and coronary risk factors in patients with severe AS.

PATIENTS AND METHODS

All patients with symptomatic AS who had undergone aortic valve replacement and preoperative cardiac catheterisation at the Austin and Repatriation Medical Centre between 1 January 1986 and 31 May 1996 were retrospectively analysed. Those patients with multiple valve disease, aortic regurgitation of grade 2 or more in severity, or who had had prior coronary artery or valve surgery were excluded from this analysis.

RESULTS

A total of 328 consecutive patients with severe AS (242 men and 86 women; mean age 72 years, range 39-84 years) were studied. Significant CAD (reduction in luminal diameter > or = 50%) was found in 162 patients (49.4%). Typical angina was present in 74.7% of these 162 patients but it was also found in 44.6% of the 166 patients without obstructive CAD. Of the patients without angina (n = 133), 30.8% had significant CAD. By multivariate logistic regression, we have identified seven significant predictors for CAD among severe AS patients. Five factors increased risk. Expressed as odds ratio with 95% confidence interval, these included: (i) age in years (1.07; 1.04-1.11, P = 0.001); (ii) male gender (2.09; 1.14-3.80, P = 0.016); (iii) angina pectoris (3.19; 1.89-5.37, P < 0.001); (iv) history of myocardial infarction (2.87; 1.38-5.97, P = 0.005); and (v) peripheral vascular disease (2.28; 1.28-4.05, P = 0.005). Factors associated with decreased likelihood of CAD were serum high density lipoprotein (HDL) cholesterol (0.58; 0.34-0.71, P = 0.002) and peak systolic gradient across the aortic valve (0.97; 0.95-0.99, P = 0.0113).

CONCLUSION

Coronary arteriography can probably be omitted for a patient with severe AS if that patient has no symptoms of angina and has no risk factors known to increase its incidence.

Angina pectoris in patients with aortic stenosis and normal coronary arteries. Mechanisms and pathophysiological concepts

BACKGROUND

The incidence of angina pectoris (AP) in patients with severe aortic stenosis (AS) and normal coronary arteries has been reported to be 30% to 40%. The exact pathophysiological mechanism, however, is not known. The purpose of this work was to evaluate the various hemodynamic and angiographic determinants of myocardial perfusion in 61 patients with severe AS.

METHODS AND RESULTS

In a retrospective analysis, 61 patients with severe AS and without significant coronary artery disease were studied. Thirty-three patients with atypical chest pain and angiographically normal arteries served as control subjects. Patients were divided into two groups: 32 with AP and 29 without AP. Quantitative coronary angiography was performed in 59 patients and 22 control subjects. Coronary flow reserve was determined in 29 patients and 7 control subjects by use of coronary sinus thermodilution technique. Patients with AP had a lower left ventricular (LV) muscle mass, an increased LV peak systolic pressure, and increased wall stress than those without AP. Vessels of the left coronary artery were smaller and coronary flow reserve was lower in patients with AP than in those without. Inadequate L V hypertrophy with an increased wall stress was found in patients with AP but not in patients without AP.

CONCLUSIONS

Myocardial ischemia in patients with severe AS can occur in the absence of coronary artery disease and appears to be due to inadequate LV hypertrophy with high systolic and diastolic wall stresses and a reduced coronary flow reserve. The cause of inadequate LV hypertrophy, however, remains unclear.

Profiles of coronary blood flow velocity in patients with aortic stenosis and the effect of valve replacement: a transthoracic echocardiographic study

OBJECTIVE

To report the first non-invasive assessment by transthoracic Doppler echocardiography of coronary blood flow in patients with aortic stenosis and of the effects of valve replacement.

DESIGN

High frequency transthoracic Doppler echocardiography was used to examine resting phasic flow in the left anterior descending coronary artery before and after replacement of the aortic valve in awake, unsedated patients with pure aortic stenosis and normal coronary arteries.

SETTING

A tertiary referral cardiothoracic centre.

METHODS

Eleven patients with pure aortic stenosis and normal coronary arteries (six men, five women, mean (range) age 69 (50-82) years), were studied the day before and 1 week after replacement of the aortic valve. These patients were selected from a cohort of 15 due to ease of imaging of the left anterior descending coronary artery. Seven had a history of angina. Haemodynamics, peak transvalvar aortic gradient, left ventricular mass index, ventricular dimensions, and profiles of coronary flow velocity were measured. Profiles of coronary flow velocity were also measured in a control population of 10 normal subjects (five men, five women, mean (range) age 58 (34-66) years).

RESULTS

The control population showed forward flow throughout systole, but reversed early systolic flow (mean velocity 20.6 (3.6) cm/s) was seen in six patients with aortic stenosis. Only three of these patients had a clinical history of angina. Peak and mean systolic and diastolic forward flow velocities were not significantly different in the control group and in patients with aortic stenosis. The time from the start of systole to the onset of forward systolic flow was significantly longer in patients with aortic stenosis than in the control population (185 (8.5) v 85 (10) ms, p < 0.01). The time from the onset of diastolic flow to peak diastolic velocity was also significantly longer in the aortic stenosis group (146 (16) v 74 (13) ms, p < 0.01). These abnormalities in profiles of coronary flow were reversed by replacement of the aortic valve. There was no correlation between changes in flow profiles in patients with aortic stenosis and preoperative clinical history, transvalvar gradient, left ventricular mass index, or ventricular dimensions.

CONCLUSIONS

Coronary flow profiles in patients with aortic stenosis were characterised by reversed early systolic flow and delayed forward systolic flow and attainment of peak diastolic velocity. Reversal of these abnormalities by replacement of the aortic valve may reflect altered left ventricular and aortic haemodynamics and contribute to the relief of angina when left ventricular hypertrophy persists. Further studies may correlate abnormalities of coronary flow with preoperative clinical and haemodynamic state.

Angina and coronary artery disease in patients with aortic valve disease

The significance of angina pectoris in patients with aortic valve disease (AVD) and the need for coronary arteriography before valve replacement are controversial. The history of chest pain and coronary arteriographic findings were reviewed in 333 patients > or = forty years old, with AVD: 142 with aortic stenosis, 87 with mixed AVD and 104 with aortic regurgitation. The prevalence of coronary artery disease (CAD) was similar among different types of AVD. Angina pectoris was more frequent in patients with aortic stenosis (56%) and mixed AVD (53%) than in patients with aortic regurgitation (24%) (p < 0.0001). Similar results were found in patients with and without CAD. Twenty-six of 95 (27%) patients with CAD had no chest pain at all. The absence of any chest pain in CAD patients was more frequent in those > or = sixty years old than in those < sixty (p < 0.05). Thus, since a significant number of patients had CAD in the absence of any chest pain, the authors recommend coronary arteriography for all patients > or = forty years of age before aortic valve replacement.

Aortic valve regurgitation and the congenitally bicuspid aortic valve: a clinico-pathological correlation

OBJECTIVE

To investigate the morphology of congenitally bicuspid aortic valves causing pure valve regurgitation.

DESIGN

A case series collected over five years.

SETTING

An academic hospital.

PATIENTS AND METHODS

One hundred and forty eight excised congenitally bicuspid aortic valves. The morphological findings were correlated with sex, age, clinical history, and data on haemodynamic function before operation. Pure valve regurgitation was defined as grade 3-4/4 with a gradient less than 30 mm Hg. Aortic root dilatation was evaluated angiographically or echocardiographically or both.

RESULTS

Three types were recognised: valves that were purely bicuspid (23%), bicuspid valves with a raphe (34%), and valves with an additional indentation of the free edge of the conjoined cusp (43%). In 14 cases pure valve regurgitation was present. Dilatation of the aortic root was present in 47 cases. The relative risk for regurgitation when the aortic root was dilated (compared with no dilatation) was 3.99. The relative risk for valve regurgitation when there was indentation of the conjoined cusp (compared with no indentation) was 4.95. The mean age at operation in patients with pure regurgitation was 56 years, which is significantly younger (p = 0.0008) than that of patients with a congenitally bicuspid valve with combined valve stenosis and regurgitation (64.7 years).

CONCLUSIONS

Congenitally bicuspid aortic valves with a central indentation of the free edge of the conjoined cusp seem particularly likely to develop pure aortic valve regurgitation.

Patch aortotomy for aortic valve replacement after previous coronary artery bypass grafting

Exposure for aortic valve operations after previous coronary artery bypass grafting may be technically difficult owing to the presence of patent vein grafts on the proximal aorta. A patch or "island" aortotomy technique that allows excellent exposure of the aortic valve is presented here. In select patients this approach may facilitate cardioplegia administration.

William Heberden and Myron Prinzmetal: angina pectoris

The most significant accounts of angina pectoris appeared in the medical literature separated by nearly two centuries. They were Heberden's initial description of classic angina and Prinzmetal's report of the variant form. Angina pectoris represents a transient myocardial oxygen deficiency. It is usually related to atherosclerotic coronary artery disease, but there are a number of less common etiologies, most notably aortic stenosis. Stable and unstable forms exist, with stable angina being further subclassified as being of one of four patterns: classic, variant, atypical, and angina equivalent.

Decision analysis in clinical cardiology: when is coronary angiography required in aortic stenosis?

Decision analysis offers a reproducible, explicit approach to complex clinical decisions. It consists of developing a model, typically a decision tree, that separates choices from chances and that specifies and assigns relative values to outcomes. Sensitivity analysis allows exploration of alternative assumptions. Cost-effectiveness analysis shows the relation between dollars spent and improved health outcomes achieved. In a tutorial format, this approach is applied to the decision whether to perform coronary angiography in a patient who requires aortic valve replacement for critical aortic stenosis.

Stable angina pectoris: 1. Clinical patterns

The symptoms of angina pectoris reflect transient inadequacy of myocardial oxygen supply as a consequence of decreased myocardial blood flow, increased myocardial oxygen demand, or both. The prognosis for patients with angina depends on the extent and severity of coronary artery disease, on left ventricular systolic function, and on the presence and severity of ischemia on exercise testing. The characteristics of angina may be variable, but certain clinical patterns are consistent and are helpful for diagnosis. Angina must be distinguished from various noncardiovascular and cardiovascular conditions; in most cases, the differences can be established by careful clinical assessment.

Aortic valve replacement with combined myocardial revascularisation

Early and late outcome was studied in 630 patients who underwent aortic valve replacement between 1974 and 1982. Group 1 (506 patients) did not have important coronary artery disease, group 2 (69 patients) had coronary artery disease and underwent coronary artery bypass grafting, and group 3 (55 patients) had coronary artery disease but did not undergo myocardial revascularisation. Early mortality (within 30 days of operation) was significantly lower for group 1 (6%) than for group 2 (13%) and for group 3 (16%). Operative mortality in all three groups was lower in patients operated on more recently. The three year survival of patients in group 1 (83%) was significantly higher than that of patients in group 3 (62%) but not than that of patients in group 2 (76%). The findings of this study suggest that the presence of coronary artery disease increases the risk of aortic valve replacement whether or not coronary artery grafting is performed. Myocardial revascularisation, however, seems to return patients with aortic valve and coronary artery disease to a survival curve similar to that of patients with isolated aortic valve disease.

Effect of electrical stimulus parameters on the development and propagation of action potentials in short excitable fibres

Intracellular action potentials (IAPs) produced by short fibres in response to their electrical stimulation were analysed. IAPs were calculated on the basis of the Hodgkin-Huxley (1952) model by the method described by Joyner et al. (1978). Principal differences were found in processes of activation of short (semilength L less than 5 lambda) and long fibres under near-threshold stimulation. The shorter the fibre, the lower was the threshold value (Ithr). Dependence of the latency on the stimulus strength (Ist) was substantially non-linear and was affected by the fibre length. Both fibre length and stimulus strength influenced the IAP amplitude, the instantaneous propagation velocity (IPV) and the site of the first origin of the IAP (and, consequently, excitability of the short fibre membrane). With L less than or equal to 2 lambda and Ithr less than or equal to Ist less than or equal to 1.1Ithr, IPV could reach either very high values (so that all the fibre membrane fired practically simultaneously) or even negative values. The latter corresponded to the first origin of the propagated IAP, not at the site of stimulation but at the fibre termination or at a midpoint. The characters of all the above dependencies were unchanged irrespective of the manner of approaching threshold (variation of stimulus duration or its strength). Reasons for differences in processes of activation of short and long fibres are discussed in terms of electrical load and latency. Applications of the results to explain an increased jitter, velocity recovery function and velocity-diameter relationship are also discussed.

Patent ductus arteriosus in the elderly

Patent ductus arteriosus presenting in an elderly patient is unusual. This report describes the oldest patient (72 years) to undergo successful surgical interruption of a patent ductus arteriosus with a unique clinical presentation of typical angina pectoris with normal coronary anatomy. A possible pathophysiologic mechanism for this previously unreported presenting symptom is proposed. The natural history of patent ductus arteriosus and the role of surgery in the elderly patient are discussed.

Phasic coronary artery flow velocity determined by Doppler flowmeter catheter in aortic stenosis and aortic regurgitation

Phasic coronary artery flow velocity was recorded in 14 patients with aortic regurgitation (AR), 4 with aortic stenosis, 61 with other heart diseases and in 2 normal subjects by means of a bidirectional Doppler flowmeter catheter. The normal pattern of the phasic coronary artery flow velocity was characterized by a small forward flow during systole (S wave) and a large forward flow during diastole (D wave). The phasic coronary artery flow velocity in patients with AR showed increased S wave and decreased D wave. The area under the S-wave curve divided by the area under the D-wave curve (S/D ratio) in patients with AR increased (left coronary artery flow velocity 0.66 +/- 0.39, p less than 0.05; right coronary flow velocity 0.79 +/- 0.36, p less than 0.01) as compared with the S/D ratio in patients with other heart diseases (left coronary flow velocity 0.32 +/- 0.12; right coronary artery flow velocity 0.38 +/- 0.17). There was a tendency toward a relative positive correlation between S/D ratio values and AR cineangiographic grades. Decreased S/D ratios were observed in 4 patients with aortic stenosis. It is believed that no reports exist on phasic coronary flow velocity recorded in conscious patients who had aortic valve disease.

Frequency of angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis

A consecutive series of 192 patients (121 men and 71 women, mean age 59 years, range 28 to 82) with isolated, severe valvular aortic stenosis was with isolated, severe valvular aortic stenosis was analyzed retrospectively to determine the relation of angina pectoris and coronary risk factors to angiographically significant coronary artery disease (CAD). Significant CAD (diameter reduction greater than or equal to 50%) was found in 47 patients (24%). Angina was present in 83% of them, but it was also found in 61% of the non-CAD patients. This symptom had as a result a low positive predictive value (31%). Of the patients without angina (n = 65) 12% had significant CAD. The negative predictive value of angina alone was thus 88%. By using multivariate logistic regression, a risk score could be calculated based on angina, age and sex, which increased the negative predictive value to 95%. It was concluded that coronary arteriography can only be omitted in severe aortic valvular stenosis, when patients have no angina and when they are less than 40 years of age for men and less than 50 years for women. For all other cases, coronary arteriography should be recommended.

Angina pectoris and coronary artery disease in severe aortic regurgitation

A consecutive series of 198 patients (148 men and 50 women, mean age 51 years, range 18 to 76) with pure, isolated, severe aortic regurgitation was retrospectively studied to determine the prevalence of angiographically significant coronary artery disease (CAD) and its relation to angina pectoris and coronary risk factors. Significant CAD (coronary diameter stenoses greater than 50%) was found in 28 patients (14%). Typical angina was present in 18% and atypical chest pain in 16%. Angina alone had a sensitivity of 57% to detect significant CAD. The predictive accuracy of a positive history of angina was 46% and that of a negative test 93%. By using multivariate logistic regression, a risk score could be calculated that increased the sensitivity to 74% at equal specificity. Almost 40% of the total population had a risk score of less than -2.9 (only 1 patient in this group had CAD). It is concluded that coronary arteriography can safely be omitted in many patients with severe aortic regurgitation if they have no symptoms of myocardial ischemia or risk factors known to increase its incidence.

Angina pectoris and coronary artery disease in isolated, severe aortic regurgitation

Seventy-eight patients with isolated, severe aortic regurgitation (AR) were studied retrospectively to determine the prevalence of angiographically significant coronary artery disease (CAD) and its relation to angina pectoris (AP). Angiographically, significant CAD was present in 29 of 78 patients (37%), and 36 patients (46%) had AP. Twenty-one of 36 patients (58%) with AP and 8 of 42 patients (19%) without AP had angiographically significant CAD. AP as a predictor of significant CAD had a sensitivity of 73%, specificity of 69% and a risk ratio of 3:1. The predictive accuracy of detecting CAD in the absence of AP was 81%. The benefit from concomitant coronary artery bypass grafting at the time of aortic valve replacement for AR has not been clearly demonstrated; therefore, routine coronary angiography is still recommended for all AR patients older than 40 years undergoing aortic valve replacement.

Relation of angina pectoris to coronary artery disease in aortic valve stenosis

One hundred three patients with isolated, severe aortic stenosis (AS) were retrospectively analyzed to determine the relation of angina pectoris to angiographically significant coronary artery disease (CAD). All patients underwent coronary angiography regardless of the presence or absence of angina. Angina was significantly associated with CAD (p less than 0.002), with a sensitivity of 78% and a specificity of 53%. However, 25% of the patients without angina had angiographically significant CAD, and in these patients there was a 70% prevalence of 1-vessel disease. Patients with isolated, severe AS should undergo coronary angiography to identify coexistent CAD accurately. The absence of angina does not reliably exclude angiographically significant CAD.

Detection of coronary artery disease in aortic stenosis by exercise gated nuclear angiography

Because the clinical diagnosis of coronary artery disease (CAD) in the presence of aortic stenosis (AS) is difficult, the value of exercise gated nuclear angiography in detecting CAD in 33 patients with AS was assessed. Exercise left ventricular (LV) ejection fraction (EF) and wall motion analysis were evaluated after symptom-limited supine cycle ergometer exercise. Sixteen patients had severe AS (valve area 0.8 cm2 or less). Thirteen had significant associated CAD (50% or greater reduction in luminal diameter of 1 major coronary artery). Twenty patients had normal coronary arteriograms. All 10 patients with mild to moderate AS and normal coronary arteries had normal nuclear studies. Patients with CAD, regardless of the severity of AS, had a decrease in LVEF during exercise (12 of 13 patients) and regional wall motion abnormalities (11 of 13 patients). Abnormal exercise gated nuclear ventriculographic studies occurred in the absence of CAD in 10 of 20 patients, and all had severe AS (mean aortic valve area 0.8 cm2 or less, range 0.4 to 0.8). Ten had an abnormal LVEF response to exercise and 7 had exercise-induced abnormal wall motion. These findings suggest that the presence of an abnormal LVEF, whether in conjunction with an abnormal wall motion analysis, is indicative of further invasive evaluation; conversely, in those patients with a normal response of LVEF and normal wall motion during exertion, invasive studies may be safely deferred.

Prevalence of coronary artery disease in patients with isolated aortic valve stenosis

The prevalence of significant coronary artery disease (reduction in luminal diameter by more than 50%) among 88 consecutive patients with aortic stenosis requiring aortic valve replacement at Hammersmith Hospital was examined. Twenty two (34%) patients had significant coronary disease. Nineteen of 42 (45%) patients with typical angina had coronary disease; three of 20 (15%) patients with atypical chest pain had coronary disease, while none of 26 patients free of chest pain had significant coronary disease. Risk factors for coronary disease were equally distributed among patients with and without significant luminal obstruction. Because of the small, but definite, hazard of coronary arteriography and in the interest of cost containment it is suggested that patients with aortic stenosis who are free of chest pain do not require routine coronary arteriography. This applies particularly to patients requiring urgent aortic valve replacement.

Amounts of coronary arterial narrowing by atherosclerotic plaques in clinically isolated, chronic, pure aortic regurgitation: analysis of 37 necropsy patients older than 30 years

The degree of cross-sectional area (XSA) narrowing by atherosclerotic plaque in each of the 4 major epicardial coronary arteries (right, left main, left anterior descending and left circumflex) was determined at necropsy in 37 patients (30 men and 7 women) aged 34 to 77 years (mean 54) with severe, isolated, chronic, pure aortic regurgitation (AR). In 7 patients (19%), greater than or equal to 1 major coronary artery was narrowed 76 to 100% in XSA at some point. Of the 148 major coronary arteries examined in the 37 patients, 12 arteries (8%) were narrowed at some point 76 to 100% in XSA. Each of the 148 major coronary arteries were divided into 5-mm-long segments (average 53 per patient) and a histologic section from each segment was examined. Of the 1,977 segments, 1,087 were narrowed 0 to 25%, 669 (34%) 26 to 50%, 170 (9%) 51 to 75%, 48 (2%) 76 to 95% and 3 (0.001%) 96 to 100%. The average amount of XSA narrowing by atherosclerotic plaque per segment was about 28%. Of the 37 patients, 9 had had angina pectoris, 2 of whom had significant (greater than 75% XSA reduction) coronary narrowing; 2 other patients had had acute myocardial infarction clinically, 1 of whom had significant coronary narrowing at necropsy. Thus, in general, the amount of coronary narrowing in our 37 adults with severe, pure, isolated, chronic AR was relatively mild.

Coronary artery disease in aortic stenosis: importance of coronary arteriography and surgical implications

In our report, the presence or absence of angina pectoris did not predict the presence of coronary artery disease. A significant number of patients with aortic stenosis and angina pectoris have coronary artery disease but coronary artery disease also exists in asymptomatic form in a significant number of patients with severe aortic stenosis that could not be detected clinically and therefore suggests that the routine use of selective coronary arteriography is indicated in patients over 40 years undergoing cardiac catheterization because of aortic stenosis. This is very important in the preoperative evaluation and in planning the technique of operation to employ during extracorporeal circulation and in determining the necessity of combining aortic valve replacement and myocardial revascularization.

Noninvasive assessment of valvular heart disease: surgery without catheterization

Forty-one patients underwent valve surgery at our institution based solely on clinical, M-mode echocardiographic, phonocardiographic, and external pulse recording findings without preoperative cardiac catheterization. Patients with clinical evidence of coronary artery disease were excluded from the study. Preoperatively, 83% of the patients were New York Heart Association functional class III or IV. In all patients, the noninvasive evaluation was considered sufficiently diagnostic of the nature and severity of valvular heart disease to allow surgery without preoperative catheterization. In 23 of 41 cases (group 1), cardiac catheterization was not performed due to the patients' unstable hemodynamic condition at the time surgery was being considered. In the remaining 18 patients (group 2), the probability of obtaining data at catheterization that would significantly affect management decisions was thought to be low, thus not justifying the cost and potential morbidity of this procedure. In all cases, the noninvasive diagnosis was corroborated at operation; there were no unexpected findings nor deaths related to incomplete or incorrect diagnoses. Over a followup period of 4.5 +/- 1.4 years, no patient experienced signs or symptoms of ischemic heart disease. In selected patients without anginal chest pain syndromes, appropriate and successful valve surgery may be performed on the basis of combined clinical and noninvasive evaluation without the need for cardiac catheterization.

Myocardial oxygen supply/demand ratio in aortic stenosis: hemodynamic and echocardiographic evaluation of patients with and without angina pectoris

Angina pectoris is a common symptom in patients with aortic stenosis without coronary artery disease. To investigate the correlates of angina pectoris, echocardiographic and hemodynamic data from 44 patients with aortic stenosis and no coronary artery disease (mean age 56 +/- 10 years) were analyzed. Twenty-three patients had no angina pectoris and 21 patients had angina pectoris. The ratio of the diastolic pressure-time index (area between the aortic and left ventricular pressure curves during diastole) to the systolic pressure-time index (area under the left ventricular pressure curve during systole), an index of the oxygen supply/demand ratio, was not different in patients with or without angina pectoris. There were no differences between patients with and without angina pectoris in echocardiographically determined wall thickness, chamber size, systolic and diastolic wall stress and left ventricular mass; in electrocardiographically defined voltage; and in hemodynamically defined aortic valve area, transaortic gradient and stroke work index. Thus, echocardiographic and hemodynamic measurements at rest are not significantly different in the presence or absence of angina pectoris in patients with aortic stenosis. Dynamic data appear to be essential for evaluation of the mechanisms of angina pectoris in patients with aortic stenosis.

Association of coronary artery disease and valvular heart disease in Chile

This study analyzes the prevalence of coronary artery disease (CAD) among patients with rheumatic valvular heart disease (VHD) in Chile. Coronary angiography was performed in all patients referred to cardiac catheterization with VHD who were over age 50 years and who had angina or ECG signs of ischemia. A total of 100 patients entered the study. Significant CAD (greater than 50% obstruction) was found in 14% of the cases: 7% in patients with mitral valve disease (MVD), 18% in aortic valve disease (AVD), and 21% in combined mitral and aortic valve disease (MAVD). Angina was present in 14% of the patients with MVD, 63% with AVD, and 53% with MAVD. Only 57% of patients with CAD had angina pectoris; 20% with angina had CAD. Hemodynamic parameters and left ventricular ejection fraction were not correlated with the presence or absence of CAD. We conclude that in patients with valvular heart disease, the incidence of CAD is lower in Chile than previously reported in the English literature. We confirmed the fact that angina is often not associated with CAD, and that CAD is often present in the absence of angina.

Coronary arteriography in isolated aortic and mitral valve disease

Coronary arteriographic findings in 200 patients with isolated aortic and mitral valve disease were reviewed to examine the relationship between obstructive (greater than 50% diameter stenosis) coronary artery disease (CAD) and angina pectoris (AP). Of 100 patients with aortic valve disease, 30 had CAD of whom 20 gave a history of AP. Thirty-two of 52 patients (61%) with AP did not have CAD and 10 of 48 (21%) had CAD without AP. CAD was evenly distributed among patients with aortic stenosis, incompetence and mixed aortic valve disease. CAD was found in 23 of 100 patients with mitral valve disease. Sixteen of 32 patients with mitral incompetence had CAD of whom four had AP. Seven of 68 patients with mitral stenosis or mixed mitral valve disease had CAD. AP was noted by four of these seven patients but by none of the 61 with normal coronary arteriograms (p less than 0.0001). Asymptomatic CAD was more common among patients with mitral incompetence (12/28 vs 3/64 p less than 0.005). AP was an unreliable marker for CAD in aortic valve disease or mitral incompetence. Conversely, CAD was uncommon without AP in mitral stenosis or mixed mitral valve disease. Coronary arteriography seems indicated in the pre-operative assessment of patients aged greater than or equal to 40 years with aortic valve disease or mitral incompetence. Its value is limited in patients with mitral stenosis or mixed mitral valve disease without AP.