Asymptomatic coronary artery disease managed by myocardial revascularization: results at 5 years

Left ventricular function in patients with coronary heart disease in the presence or absence of angina pectoris during exercise radionuclide ventriculography

This study compares left ventricular (LV) performance during exercise in patients with angiographically documented coronary artery disease (CAD) based on the presence or absence of angina pectoris during the index exercise tests. The patients were divided into 2 groups: Group I included 31 patients who had angina pectoris during the test and Group II included 43 who did not. Multivessel CAD was present in 21 patients (68%) in Group I and 26 patients (60%) in Group II (difference not significant [NS]). There were no significant differences between the 2 groups in age, sex, history of diabetes mellitus, history of myocardial infarction and in the exercise duration, work load, heart rate and systolic blood pressure. Exercise-induced ST-segment depression was present in 48% of the patients in Group I and in 40% in Group II (NS). The mean LV ejection fraction at rest was 52 +/- 12% in Group I and 50 +/- 17% in Group II (NS). There were significant differences in the 2 groups in the change from rest to exercise in ejection fraction (-4.5 +/- 7.6% in Group I vs 1 +/- 9.4% in Group II, p less than 0.01), end-systolic volume (29 +/- 38 ml in Group I vs 9 +/- 23 ml in Group II, p less than 0.005), the change in systolic blood pressure-to-end-systolic volume ratio (-0.1 +/- 0.5 mm Hg/ml in Group I vs 0.3 +/- 1.1 mm Hg/ml in Group II, p less than 0.05), and wall motion score (-0.4 +/- 0.6 in Group I vs 0.09 +/- 0.7 in Group II, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Prognosis and treatment of asymptomatic coronary artery disease

Despite the large number of studies dealing with the natural history of angiographically defined coronary artery disease, there is still a paucity of data on the prognosis of totally asymptomatic persons. From the small number of reported studies, it appears that prognosis in selected asymptomatic patients may be better than that of symptomatic patients. However, the annual mortality rate in the subgroup of asymptomatic patients with triple vessel disease was as high as 4 to 5% in some studies that included patients with prior myocardial infarction or mild symptoms, or both. This has reinforced the views of those who advocate a more aggressive medical/surgical approach to asymptomatic patients with left main and triple vessel disease, especially if they have had a prior infarction. Although several small series of surgically treated patients have been reported to have excellent short-term survival rates, the absence of adequate control groups in nearly all of these studies has left the issue of prophylactic revascularization unresolved. Until there is more knowledge of prognosis in patients not operated on, it is likely to remain unresolved.

Prognosis of medically treated patients with coronary-artery disease with profound ST-segment depression during exercise testing

Reproducible and profound (greater than 2 mm) ST-segment depression during exercise testing in patients with coronary heart disease is associated with multivessel involvement. In these patients, coronary-artery bypass surgery has been recommended even when symptoms are absent. However, there are few long-term follow-up data regarding the prognosis when such patients are treated medically. Among 212 men with coronary-artery disease in whom profound ST-segment depression could be reproduced with exercise, 142 who had no other type of heart disease and were not receiving digitalis drugs had a mean ST-segment depression of 2.9 mm. Follow-up has lasted an average of 59 months: 11 patients have died (annual mortality, 1.4 per cent), and nine have had bypass operations (1.3 per cent per year). Survival correlated with exercise tolerance but not with degree of ST depression, peak heart rate, or peak blood pressure during exercise. We conclude that such ST-segment depression is not associated with a poor prognosis. There is rarely a need to resort to cardiac surgery; medical management is highly successful and associated with a low mortality.

Coronary angiography post first myocardial infarction in the asymptomatic or mildly symptomatic patient: clinical, angiographic, and prospective observations

The role of coronary arteriography in the asymptomatic or mildly symptomatic post first myocardial infarction patient is controversial. Thirty-one class 0-1 patients (Canadian Heart Association Grading System) underwent coronary arteriography within six months (mean 67 days) of their first myocardial infarction. Coronary arteriography revealed three-vessel disease in nine (29%), two-vessel disease in ten (32%), single-vessel disease in ten (32%), and normal coronary arteries in two (6%). No patient had left main disease, and two (6%) had left main equivalent disease. In 12 patients with single-vessel disease or normal coronary arteries there were no morbid events over a mean follow-up period of 26 months. In the 19 with multivessel disease, eight (40)% developed a cardiac event during a mean follow-up period of 11.4 months. These included one who elected to undergo immediate aortocoronary bypass surgery, two with unstable angina, three acute myocardial infarctions, and two deaths. Based on these data and review of the literature, a scheme is proposed for the subsequent evaluation and treatment of this patient group.

Coronary revascularization surgery: feasibility after myocardial infarction

Since coronary revascularization improves prognosis in some patients with multivessel disease, can the potential benefits be extended to "prophylaxis" in selected postinfarction patients as well? These investigators sought the answer on the basis of patient characteristics, types of surgery, survival data, and mode of death in the postinfarction population of 129 patients who had early angiography.

Selection of angina-free patients with severe left ventricular dysfunction for myocardial revascularization

Stress thallium-201 myocardial imaging was used in two angina-free patients with severe congestive heart failure to identify clinically silent areas of ischemic myocardium and to distinguish between scar and reversibly ischemic myocardium as a cause for akinesia of left ventricular wall segments. Subsequent myocardial revascularization in these patients led to considerable improvement in their clinical state and findings in postoperative nuclear scans. Thus, stress myocardial imaging may be useful in selecting patients with severe left ventricular failure but no angina pectoris for myocardial revascularization.