4uat
N 2 J Med (1979) 9, pp 4 4 4 8 ~
~
Atheromatous Coronary Artery Ectasia* D. W. Baron+, J. A. Branson- and J. J. Morgan**
From the Cardiovascular Unit, St
Vincent's
Hospital, Sydney
Summary: Atheromatous coronary artery ectasia. D. W. Baron, J. A. Branson and J. J. Morgan, Aust. N.Z.J . Med.. 1979, 9, pp. 44-48.
Of 431 consecutive patients who underwent coronary arteriography during the twelve month period ending December 1976, 23 (5%) had angiographically documented coronary artery ectasia. Of these only five had "pure" or isolated ectasia, whilst 18 had ectatic disease combined with coronary artery stenoses. Clinical findings that are significantly associated with ectasia are male predominance (96%), abnormal lipid patterns (64%), a positive family history of coronary artery disease (57%) and previous hypertension (50%). Anatomically, ectasia most often involved the right coronary artery (96%), then the circumflex artery (75%) and the left anterior descending artery (57%). Only seven (five with severe proximal stenoses) of the 28 patients had coronary artery bypass grafts. Care should be taken not to overdiagnose narrow segments between ectatic, dilated segments as being obstructions. Failure to appreciate this resulted in two patients with isolated coronary artery ectasia having bypass grafts performed with little relief of their symptoms.
Coronary angiography holds an important place in the evaluation of patients with the various syndromes of ischaemic heart disease, particularly in assessing prognosis' and suitability for coronary artery bypass Although much has been written about coronary artery disease it usually implies atheromatous o b ~ t r u c t i o n .l ~2 Indeed almost all the literature on the subject deals with obstructive or stenotic coronary artery disease. Very little has 'Based on a paper presented to the Cardiac Society. May 1977. +Registrar in Cardiology. Staff Radiologist. * * Staff Cardiologist. Correspondence: Dr J. J. Morgan, Cardiovascular Unit, St. Vincent's Hospital, Darlinghurst, NSW 2010 Accepted for publication: 24 August, 1978
been written about cctatic or saccular disease, a much less common form of athcromatous coronary disease, in which there is irregular dilatation of the coronary arteries up to four or five times thc diameter of major branch ~ e s s e l s . ' ~ This report reviews a group of23 patients with angiographically proven coronary artery ectasia (CAE) collected during the 12 months of 1976. The incidence of CAE, clinical features, arteriographic findings and results of trcatmcnt are presented. Patients, Materials and Methods Over the 17 month period ending December 1976, 431 patients were admitted to St. Vincent's Hospital. Sydney and undcrwcnt selective coronary arteriographq by the Sones technique. Urograffin 767, was used as contrast mcdium, with miiltiplc S-8 in1 hand injections into each coronary artery in multiple oblique projections. A Philips Danish Uarm with a 9 64 inch field was used. Records were obtained on niagnctic tape for immediate playback and on 35 mm CFA film (Kodak) at 25 rrames.sec. Films of all patients with evidcnce of CAE wcrc rcviewed by the three investigators. Of the 431 patients, 315 had typical obstructive coronary artcry diseasc, 93 had normal coronary arteries (often as part of'another investigation such as valvular disease) and 23 (5",J had CAb. In all 23 cascs, ectasia appeared to be due to atherosclerotic dilatation of the coronary arteries. TOthese were added another five cases recalled from previous years. Coronary arteriograms were classified as focal or diffuse according to tlie extent olectatic involvement of the right, left anterior descending and circumflex arteries. The classificatioii used by Markis's group (types I to IV)I3 was not used as thiq did not provide any additional worthwhile information. A prospectivc serics of paticnts with angiographically documcnted obstructive (hut non-ectatic) coronary artery disease collected during 1976 served as a control group. Age, sex, severity of symptoms. history of previous myocardial i n k c t i o n , coronary risk factors, electrocardiograms and lipoprotein patterns were compared.
Results
Of the 28 patients, 27 (96::,;)) were males with only one l'eniale (4%) compared with 8 1% and 19':d in the non-ectatic control group. The mean age of the two groups was identical at 52.0 years. The clinical presentation of those with ectasia comprised 23 patients with chronic stable angina (82. S),;, two ), with prinzmetal angina (7y.3, one
kI-BNJAKY
1979
41 HI ROMATOI,S CORONARY ARTFRY I CTASIA
FIGURE 1.
Angiograms showing normal right and left coronary arteries.
with left ventricular aneurysm ( 3 . 5 9 ; ) a young male with a recent infarct (3.5;;) and one patient with arrhythmias and syncope (3.57,J. The presentation of the non-ectatic control group was similar with chronic stable angina (8673, prinzinetal angina (7:;) and young males with recent infarcts (7:/3. Sixty-seven per cent ofthose with ectasia had a positive family history of ischaemic heart disease TABLE I Comparison of 28 paticnts with coronary artery ectasia (CAE) and a control group with obstructive coronary artery disease (OCAD) Patient profile
CAE . .
OCAD
.
Mcdn age (years) Males Clinical presentation: chronic angina unstable angina LV aneurysm recent infarct arrhythmias Positive family history Hypertension Previous infarction Electrocardiograms: infarction other abnormalities normal Abnormal lipids
* = Significant at
5"" level
45
52
52
96";
1 ( 3 S",,) 1 ( 3 S",,) 1 ( 3 Yo)
8 I I'
~,
~
7",,
16 2 1 (67",,) 14 (500,)) 17 (60",,)
40",)* 210,,* 50,
13 (46",,) 3 (lll)
N 2 J Med (1979) 9, pp 4 4 4 8 ~
~
Atheromatous Coronary Artery Ectasia* D. W. Baron+, J. A. Branson- and J. J. Morgan**
From the Cardiovascular Unit, St
Vincent's
Hospital, Sydney
Summary: Atheromatous coronary artery ectasia. D. W. Baron, J. A. Branson and J. J. Morgan, Aust. N.Z.J . Med.. 1979, 9, pp. 44-48.
Of 431 consecutive patients who underwent coronary arteriography during the twelve month period ending December 1976, 23 (5%) had angiographically documented coronary artery ectasia. Of these only five had "pure" or isolated ectasia, whilst 18 had ectatic disease combined with coronary artery stenoses. Clinical findings that are significantly associated with ectasia are male predominance (96%), abnormal lipid patterns (64%), a positive family history of coronary artery disease (57%) and previous hypertension (50%). Anatomically, ectasia most often involved the right coronary artery (96%), then the circumflex artery (75%) and the left anterior descending artery (57%). Only seven (five with severe proximal stenoses) of the 28 patients had coronary artery bypass grafts. Care should be taken not to overdiagnose narrow segments between ectatic, dilated segments as being obstructions. Failure to appreciate this resulted in two patients with isolated coronary artery ectasia having bypass grafts performed with little relief of their symptoms.
Coronary angiography holds an important place in the evaluation of patients with the various syndromes of ischaemic heart disease, particularly in assessing prognosis' and suitability for coronary artery bypass Although much has been written about coronary artery disease it usually implies atheromatous o b ~ t r u c t i o n .l ~2 Indeed almost all the literature on the subject deals with obstructive or stenotic coronary artery disease. Very little has 'Based on a paper presented to the Cardiac Society. May 1977. +Registrar in Cardiology. Staff Radiologist. * * Staff Cardiologist. Correspondence: Dr J. J. Morgan, Cardiovascular Unit, St. Vincent's Hospital, Darlinghurst, NSW 2010 Accepted for publication: 24 August, 1978
been written about cctatic or saccular disease, a much less common form of athcromatous coronary disease, in which there is irregular dilatation of the coronary arteries up to four or five times thc diameter of major branch ~ e s s e l s . ' ~ This report reviews a group of23 patients with angiographically proven coronary artery ectasia (CAE) collected during the 12 months of 1976. The incidence of CAE, clinical features, arteriographic findings and results of trcatmcnt are presented. Patients, Materials and Methods Over the 17 month period ending December 1976, 431 patients were admitted to St. Vincent's Hospital. Sydney and undcrwcnt selective coronary arteriographq by the Sones technique. Urograffin 767, was used as contrast mcdium, with miiltiplc S-8 in1 hand injections into each coronary artery in multiple oblique projections. A Philips Danish Uarm with a 9 64 inch field was used. Records were obtained on niagnctic tape for immediate playback and on 35 mm CFA film (Kodak) at 25 rrames.sec. Films of all patients with evidcnce of CAE wcrc rcviewed by the three investigators. Of the 431 patients, 315 had typical obstructive coronary artcry diseasc, 93 had normal coronary arteries (often as part of'another investigation such as valvular disease) and 23 (5",J had CAb. In all 23 cascs, ectasia appeared to be due to atherosclerotic dilatation of the coronary arteries. TOthese were added another five cases recalled from previous years. Coronary arteriograms were classified as focal or diffuse according to tlie extent olectatic involvement of the right, left anterior descending and circumflex arteries. The classificatioii used by Markis's group (types I to IV)I3 was not used as thiq did not provide any additional worthwhile information. A prospectivc serics of paticnts with angiographically documcnted obstructive (hut non-ectatic) coronary artery disease collected during 1976 served as a control group. Age, sex, severity of symptoms. history of previous myocardial i n k c t i o n , coronary risk factors, electrocardiograms and lipoprotein patterns were compared.
Results
Of the 28 patients, 27 (96::,;)) were males with only one l'eniale (4%) compared with 8 1% and 19':d in the non-ectatic control group. The mean age of the two groups was identical at 52.0 years. The clinical presentation of those with ectasia comprised 23 patients with chronic stable angina (82. S),;, two ), with prinzmetal angina (7y.3, one
kI-BNJAKY
1979
41 HI ROMATOI,S CORONARY ARTFRY I CTASIA
FIGURE 1.
Angiograms showing normal right and left coronary arteries.
with left ventricular aneurysm ( 3 . 5 9 ; ) a young male with a recent infarct (3.5;;) and one patient with arrhythmias and syncope (3.57,J. The presentation of the non-ectatic control group was similar with chronic stable angina (8673, prinzinetal angina (7:;) and young males with recent infarcts (7:/3. Sixty-seven per cent ofthose with ectasia had a positive family history of ischaemic heart disease TABLE I Comparison of 28 paticnts with coronary artery ectasia (CAE) and a control group with obstructive coronary artery disease (OCAD) Patient profile
CAE . .
OCAD
.
Mcdn age (years) Males Clinical presentation: chronic angina unstable angina LV aneurysm recent infarct arrhythmias Positive family history Hypertension Previous infarction Electrocardiograms: infarction other abnormalities normal Abnormal lipids
* = Significant at
5"" level
45
52
52
96";
1 ( 3 S",,) 1 ( 3 S",,) 1 ( 3 Yo)
8 I I'
~,
~
7",,
16 2 1 (67",,) 14 (500,)) 17 (60",,)
40",)* 210,,* 50,
13 (46",,) 3 (lll)
