Coronary arteriography

Value of galectin-3 in the diagnosis of acute coronary syndrome and the assessment of coronary artery lesions

Aim: To investigate the value of galectin-3 in the diagnosis of acute coronary syndrome (ACS) and the assessment of coronary artery lesions. Methodology: This study recruited 157 patients with coronary artery disease where 102 and 55 of them were subsequently grouped as ACS and non-ACS, respectively. The severity of coronary artery lesions was evaluated by Gensini score and the number of vessels involved. Results: Receiver operator characteristics analyses of galectin-3 yielded an area under the curve of 0.679 in diagnosing ACS. The galectin-3 levels were correlated with Gensini score and the number of vessels involved. Conclusion: Our study demonstrated that galectin-3 is an effective auxiliary biomarker for the diagnosis of ACS and assessment of coronary artery lesions.

Coronary thromboembolism with fatal outcome following coronary angiography

A case of fatal thromboembolic occlusion of the left coronary artery at selective coronary arteriography is described. The course of events and the findings at autopsy suggest that thrombotic material was deposited on one intravascular catheter and transferred to a second catheter inserted over the same guide wire. Contrast injection through the second catheter into the left coronary ostium resulted in immediate and fatal occlusion of the two major branches of the left coronary artery.

Correlation between myocardial enzyme serum levels and markers of inflammation with severity of coronary artery disease and Gensini score: a hospital-based, prospective study in Greek patients

BACKGROUND

Our objective was to associate serum levels of myocardial enzymes and inflammatory biomarkers with severity of coronary artery disease (CAD).

PATIENTS AND METHODS

123 patients participated in our study, including 65 cases of acute myocardial infarction (MI), 27 cases of newly diagnosed CAD--without MI--and 31 controls. In all subjects, myocardial serum enzyme levels (creatine phosphokinase, aspartate aminotransferase, lactate dehydrogenase) and inflammatory indices (C-reactive protein, fibrinogen, white blood cells, and erythrocyte sedimentation rate) were measured. Patients were all submitted to coronary angiography and CAD severity was evaluated by Gensini score.

RESULTS

Significant differences concerning enzyme serum levels and inflammatory indices were found to exist between the three study groups, being highest among patients with acute MI (p < 0.001). A significant association was demonstrated between Gensini score and serum enzyme levels as well as inflammatory biomarkers.

CONCLUSIONS

Our findings suggest that serum levels of myocardial enzymes and inflammatory indices correlate with CAD severity in Greek patients.

Angiographic assessment of coronary stenoses: a review of the techniques

This article reviews the fundamental techniques to quantify the physiological severity of (coronary) stenoses. Although a wide survey of different techniques and applications is provided, the focus of this review is on: 1) the assessment of the immediate effect of the stenoses on blood flow (i.e., the hemodynamic severity), and not on the assessment of the pathology of the vessel itself; 2) the flow reserve methods to defining the physiological severity of stenoses; and 3) the determination of blood flow and tissue perfusion by X-ray angiography (a short survey of other imaging modalities is provided as well). Although the practical implementation of the techniques is illustrated by applying them to coronary stenoses, most of the issues involved are of interest in other application areas (using other imaging modalities) as well. This review consists of four parts. The first part deals with the definition of stenoses severity; the second part with tracer kinetic theory necessary to determine flows by imaging; the third part focusses on (cardiac) imaging modalities, with an emphasis on X-ray angiography; and the last part illustrates the practical implementation of the techniques in cardiology.

Effects of nonionic versus ionic contrast media on complications of percutaneous transluminal coronary angioplasty

To evaluate the effect of contrast agents on percutaneous transluminal coronary angioplasty (PTCA) complications, 913 patients undergoing 1,058 separate PTCA procedures were prospectively randomized to receive either nonionic iopamidol (Isovue-370) [n = 507 PTCA procedures] or ionic contrast media, meglumine sodium diatrizoate (Renografin-76) [n = 551 PTCA procedures]. Angioplasty operators, technicians, nurses and patients were blinded to the agent used. All patients were pretreated with 0.6 mg of atropine sulfate intravenously before any contrast injections. Hypotension (mean arterial pressure less than 65 mm Hg associated with contrast injections) occurred during 8.5% of PTCA procedures in which the patients were receiving iopamidol and during 9.5% of the procedures in which the patients were given diatrizoate (difference not significant). Bradycardia (heart rate of less than 40 beats/min associated with contrast injections) developed during 5.7% of procedures when patients were given iopamidol and during 5.1% of procedures when patients were given diatrizoate (difference not significant). The need for additional atropine or temporary pacing during the procedure was similar for patients given iopamidol and diatrizoate. The overall incidence of ventricular tachycardia or fibrillation, or both, during the procedure occurred less frequently when iopamidol was used compared with diatrizoate (1 vs 2.5%, p = 0.045). These serious ventricular arrhythmias were attributable to contrast injections in 0.6% of the PTCA procedures when iopamidol was given and in 2.0% of the cases in which diatrizoate was the contrast agent (p = 0.09). Only 1 patient had an allergic reaction to the contrast agent, and this was in a patient who received iopamidol.(ABSTRACT TRUNCATED AT 250 WORDS)

Dual purpose computer aided program for cardiac catheterization laboratory data management

This communication describes the design criteria used in the early systems analysis activity of the cardiac laboratory. This analysis activity required an understanding of the cardiology laboratory environment, the establishment of needs to be answered by the program, and the goals of the entire system. The rationale for inclusion of various cardiologic, demographic, quality assurance, and personnel safety parameters is discussed. The input forms used, the database structure created, and the information provided by an applications system are described. Since the system is built around a general-purpose computer (the IBM PC or compatible) and widely available powerful general purpose software, the entire system may be used for many other cardiology laboratory data management tasks.

Automated analysis of coronary arterial morphology in cineangiograms: geometric and physiologic validation in humans

A method of coronary border identification is discussed that is based on graph searching principles and is applicable to the broad spectrum of angiographic image quality observed clinically. Cine frames from clinical coronary angiograms were optically magnified, digitized, and graded for image quality. Minimal lumen diameters, referenced to catheter size, were derived from automatically identified coronary borders and compared to those defined using quantitative coronary arteriography and to observer-traced borders. computer-derived minimal lumen diameters were also compared to intracoronary measurements of coronary vasodilator reserve, a measure of the functional significance of a coronary obstruction. To test the robustness of the present border detection method, computer-derived coronary borders were compared to independent standards separately for good and poor angiographic images. The accuracy of computer-identified borders was similar in the two cases.

Assessment of hemodynamic significance of isolated stenoses of the left anterior descending coronary artery using thallium-201 myocardial scintigraphy

This study tests the hypothesis that the results of stress thallium-201 myocardial perfusion scans (TI-201) are related to the mean transstenotic pressure gradient of coronary stenoses independent of the percent luminal diameter narrowing seen at angiography. The 22 study patients (20 men, 2 women, mean age 47 years, range 30 to 62) had no previous myocardial infarction. Each underwent a symptom-limited, erect bicycle TI-201 test off antianginal therapy, shortly before percutaneous transluminal coronary angioplasty for isolated left anterior descending coronary artery stenosis. The percent narrowing, mean gradient at percutaneous transluminal coronary angioplasty and presence of a visually apparent TI-201 defect were independently evaluated and results compared. All 4 patients with 90% or greater diameter narrowing had positive TI-201 responses, and the mean gradient was 72 +/- 11 mm Hg. Among the 18 patients with less than 90% diameter narrowing, the mean gradient was higher (p less than 0.001) in the 11 with a positive TI-201 (63 +/- 15 mm Hg) than in the 7 with a negative TI-201 (33 +/- 20 mm Hg), but their percent narrowing did not differ significantly (72 +/- 14% vs 66 +/- 19%). Multiple regression analysis showed that the presence of a TI-201 defect was a strong (p = 0.003) and percent narrowing (p = 0.048) a weak independent predictor for gradient. When the mean gradient was normalized for the prestenotic pressure, both percent narrowing (p = 0.003) and TI-201 defects (p = 0.006) were significant independent predictors.(ABSTRACT TRUNCATED AT 250 WORDS)

Does visual interpretation of the coronary arteriogram predict the physiologic importance of a coronary stenosis?

To assess visual interpretation of the coronary arteriogram as a means of predicting the physiologic effects of coronary obstructions in human beings, we compared caliper measurements of the degree of coronary stenosis with the reactive hyperemic response of coronary flow velocity studied with a Doppler technique at operation, after 20 seconds of coronary arterial occlusion. In 39 patients (44 vessels) with isolated, discrete coronary lesions varying in severity from 10 to 95 per cent stenosis, measurement of the percentage of stenosis from coronary angiograms was not significantly correlated (r = -0.25) with the reactive hyperemic response. Results were the same for obstructions in the left anterior descending, diagonal, and right coronary arteries. Underestimation of lesion severity occurred in 95 per cent of vessels with greater than 60 per cent stenosis of the diameter by arteriography. Both overestimation and underestimation of lesions with less than 60 per cent stenosis were common. These results, together with the high interobserver and intraobserver variability of standard visual analysis of angiograms, suggest that the physiologic effects of the majority of coronary obstructions cannot be determined accurately by conventional angiographic approaches. The need for improved analytical methods for the physiologic assessment of angiographically detected coronary obstructions is apparent.

Digital angiography in assessment of ventricular function and wall motion during pacing in patients with coronary artery disease

Using digital subtraction angiography, left ventriculograms were obtained with 10 ml of iodinated contrast material in 21 patients both at rest and during atrial pacing. In 15 patients with significant coronary artery lesions (CAD) (greater than 50% diameter narrowing in at least 1 major artery), ejection fraction decreased during atrial pacing from a mean of 62 +/- 14% to 51 +/- 15% (p less than 0.001). In 14 (93%) of 15 patients, ejection fraction decreased or was unchanged during pacing. In 6 patients with chest pain but normal coronary arteries, ejection fraction increased from a mean of 66 +/- 9% at rest to 72 +/- 6% during atrial pacing (p less than 0.01). Ejection fraction increased by greater than or equal to 5% during pacing in 5 of 6 patients with normal coronary arteries. Patients with CAD also had an abnormal response in end-systolic volume during atrial pacing (50 +/- 31 ml at rest versus 47 +/- 24 ml during pacing) compared with patients with normal coronary arteries (46 +/- 16 ml at rest versus 26 +/- 9 ml during pacing; p less than 0.01). The digital ventriculograms demonstrated new or increased wall motion abnormalities during atrial pacing in 4 of 5 patients with CAD who had wall motion abnormalities at rest and in 8 of 10 patients with CAD who had normal wall motion at rest. Moreover, these wall motion abnormalities occurred in myocardial wall segments that were supplied by coronary arteries with significant lesions. Thus, because digital subtraction angiography allows multiple left ventriculograms to be obtained during routine cardiac catheterization, intervention studies such as atrial pacing can be used to obtain a functional assessment of the severity of coronary arterial lesions.

The minimum error in estimating coronary luminal cross-sectional area from cineangiographic diameter measurements

A formal analysis of the error associated with the use of radiographic diameter measurements in estimating the luminal area of an elliptically-shaped coronary cross-section was performed. When two views are available, the maximum potential error was found to decrease rapidly as the angle between the views increased to 90 degrees, but this error was small (less than 25%) for orthogonal views only for mild degrees of ellipticity (major/minor axis ratio less than 2). Since, for each successive doubling of the number of radiographic views, a stepwise reduction in the potential error by an approximate factor of only one-half was found, a large number of views is required to eliminate the potential error associated with diameter assessment of highly elliptical lumena.

Effect of selective coronary arteriography on left ventricular volumes and ejection fraction in man

This study was performed to assess the influence of selective coronary arteriography on left ventricular volumes and ejection fraction in man. In 30 patients with assorted cardiac diseases, left ventricular end-diastolic and end-systolic volumes and ejection fraction were quantitated immediately before and after selective coronary arteriography. In 19 patients (Group A), contrast left ventriculography was performed immediately before and after selective coronary arteriography. In the remaining 11 patients (Group B), multigated equilibrium blood pool imaging was performed just before and after coronary arteriography. In both groups, mean systemic arterial pressure and heart rate did not change from just before the first to immediately before the second assessment of left ventricular volumes and ejection fraction, but left ventricular end-diastolic pressure increased. End-diastolic and end-systolic volume indexes, and ejection fraction did not change from just before to immediately after selective coronary arteriography. Therefore, selective coronary arteriography (1) consistently causes an increase in left ventricular end-diastolic pressure but (2) exerts no effect on left ventricular volumes and ejection fraction, even in patients with severely compromised left ventricular function.

Cough-facilitated conversion of ventricular tachycardia

Coughing has been shown to be helpful in altering the bradycardia and hypotension that may occur after intracoronary injections of contrast medium and can enable a patient to maintain consciousness during episodes of ventricular fibrillation and asystole. This report describes a patient with ischemic heart disease in whom 33 episodes of drug-refractory ventricular tachycardia were converted to normal sinus rhythm after abrupt forceful coughs were performed on command. When the patient was unable to cough as directed, external electric countershock was necessary to terminate the arrhythmia. These findings suggest that the cough may in isolated cases be effective in the conversion of potentially fatal ventricular tachyarrhythmias.

Relationship between extent of coronary artery disease and correlative risk factors

An analysis was made of correlative factors which might be related to the angiographically measured extent of coronary artery disease in 140 patients. All patients presented with clinically important chest pain. Thirty-three had a normal coronary arteriogram. The extent of the atheromatous process was measured precisely at angiography by three different techniques. A coronary score, based on the percentage of luminal narrowing, was found to be best suited for the analysis. The most important contributory factors to the severity of atherosclerosis was duration of clinical history, number of previous myocardial infarctions, and male sex, but more specifically elevation of serum cholesterol and diabetes mellitus. Cigarette smoking, obesity, hypertension, a family history of atherosclerosis, and elevated serum triglycerides had a positive influence but this was not statistically significant.

Percutaneous preformed single catheter coronary arteriography and its complications--10,000 cases

The single preformed catheter has offered an alternative to the conventional approaches to study of the coronary circulation and ventriculography. It has the advantages of being introduced percutaneouly without multiple changes for routine study or for provocative drug testing such as for spasm with Ergonovine maleate or muscular bridges with nitroglycerine. It requires no arteriotomy and has been associated with a low complication rate.

Stress and disease: the missing link. A vasospastic theory. III. Stress, vasospasm and general disease

The potential importance of vasospasm, with or without consequent thrombosis, as a mechanism in general disease is discussed and the evidence examined in one organ, namely the brain. It is concluded that vasospasm might be important in a number of neurological disorders, including migraine, epilepsy, and even some of the schizophrenia-like illnesses. Repeated ischaemic cell damage from vasospasm is also discussed as a possible factor initiating autoimmune disease and cancer. The similarities between viral transformation and neoplasia have led to the proposition that much cancer might be explained if as a species we have evolved by the gradual build-up of viruses.

Stress and disease: the missing link. A vasospastic theory. II. The nature of degenerative arterial disease

An analysis of the evidence indicates that the initiation and progress of atherosclerosis might well be explained by repeated bouts of arterial constriction in relation to life stresses, through increased blood flow velocity and turbulence at points of constriction, and consequent endothelial damage, plasma insudation into the wall, and intimal smooth muscle cell - connective tissue proliferation.

Stress and disease: the missing link. A vasospastic theory. I. Acute myocardial infarction - a potentially reversible event?

A review of the evidence in acute myocardial infarction indicates that it might well be initiated by coronary artery spasm, and that coronary thrombosis, although important in tipping the balance between severe damage and death of heart muscle, may merely be secondary to the spasm-induced reduction in coronary blood flow.