Clinical communications
Clinical correlates of coronary cineangiography in young males with myocardial infarction S t e p h e n V. Savran, M.D. A. Laird Bryson, M.D. T h o m a s G. Welch, M.D., F.A.C.C. B a r r y L. Zaret, M.D., F.A.C.C. R o n a l d L. M c G o w a n , M.D., F.A.C.C., M.D. F l a m m , Jr., M.D., F.A.C.C. Travis AFB, Calif.
Before the a d v e n t of c o r o n a r y a n g i o g r a p h y , the presence of m y o c a r d i a l infarction was generally accepted as a m a n i f e s t a t i o n of severe diffuse coronary a r t e r y disease. M o r e recent studies, however, h a v e d e m o n s t r a t e d t h a t o b s t r u c t i v e coronary a r t e r y disease in p o s t - m y o c a r d i a l infarction p a t i e n t s can be localized to only one or two m a j o r c o r o n a r y arteries. 1' ~ T h e i m p o r t a n c e of this fact has been d e m o n s t r a t e d b y studies based on d a t a f r o m selective c o r o n a r y angiogr a p h y which h a v e shown t h a t the l o n g - t e r m survival of patients with c o r o n a r y a r t e r y disease varies inversely with the n u m b e r of significantly diseased m a j o r vessels. 3-~ It would seem p a r t i c u larly i m p o r t a n t to k n o w the e x t e n t of c o r o n a r y a r t e r y disease present in y o u n g people in order to b e t t e r advise t h e m of their f u t u r e a c t i v i t y a n d prognosis. I t would f u r t h e r be quite helpful if these r e c o m m e n d a t i o n s could be m a d e on t h e basis of noninvasive studies r a t h e r t h a n c o r o n a r y angiography. We wish to r e p o r t the results of our evaluation of 38 patients, all of w h o m h a d t r a n s m u r a l m y o c a r d i a l infarctions before age 40, a n d c o m p a r e their noninvasive d a t a with their c m e a n giographic findings.
From the D e p a r t m e n t of Medicine. Cardiology Section. David G r a n t USAF Medical Center, Travis AFB. Calif. Opinions expressed are those of the a u t h o r a n d do n o t represent official Air Force policy. Received for publication M a r c h 13. 1975. Reprint requests: Stephen V. Savran. Major. USAF. MC, D e p a r t m e n t of Cardiology, U S A F Medical Center_ S c o t t AFB, Ill. 62225.
May, 1976, Vol. 91, No. 5, pp. 551-555
Materials and methods
All patients were a c t i v e - d u t y m i l i t a r y personnel when studied, with the exception of one recently retired 38-year-old Air Force s e r g e a n t who incurred an inferior wall m y o c a r d i a l infarction while on active duty. Prerequisites for entrance into the s t u d y were: age u n d e r 40 at t h e time of m y o c a r d i a l infarction, p e r f o r m a n c e of selective c o r o n a r y a r t e r i o g r a p h y a t the t i m e of clinical evaluation, and referral to our i n s t i t u t i o n for reasons o t h e r t h a n i n c a p a c i t a t i n g a n g i n a pectoris, congestive h e a r t failure, or r e c e n t myocardial infarction. All p a t i e n t s were N e w York H e a r t Association f u n c t i o n a l Class I or I I and were referred to our i n s t i t u t i o n for e v a l u a t i o n of their c o r o n a r y a r t e r y disease as it applied to their future military or civilian careers. T h e patients were studied for f r o m 2 m o n t h s to 2 y e a r s after their a c u t e t r a n s m u r a l m y o c a r d i a l infarction. T r a n s m u r a l m y o c a r d i a l infarction was defined as loss of R wave a n d / o r a p p e a r a n c e of new Q waves of at least 0.04 second in d u r a t i o n and 0.1 mV. in depth along with clinical a n d enzymatic evidence of m y o c a r d i a l infarction. All patients were e v a l u a t e d by a t least one s t a f f cardiologist for historical a n d physical d a t a prior to coronary angiography. Blood pressures were averaged t h r o u g h o u t the hospital stay. H e i g h t and weight were recorded on all p a t i e n t s at t h e time of admission to the hospital. Obesity was defined as a weight 15 per cent or m o r e a b o v e t h a t considered ideal by Air Force s t a n d a r d s for a given height. Chest x-ray a n d e l e c t r o c a r d i o g r a m
American Heart Journal
551
S a v r a n et al.
Table I. History and physical parameters
Age H i s t o r y of hypertension + F H of infarction ~ Smokers Obesity A n g i n a pectoris
Group I
I GroupII
I
p
34 + 2.5 3/21
35 _+ 1.2 1/17
12/21
8/17
NS
19/21 13/21 3/21
15/17 8/17 10/17
NS NS < 0.01
NSt NS
÷ FH Positive family history. ÷NS Not significant. =
=
tability or reproduction of chest pain was considered further confirmatory data but such tests were not considered positive in the absence of ischemic ST-segment changes. Selective coronary arteriography by either the Judkins or Sones technique was performed by 35 mm. cineangiography at 60 frames per second with a General Electric Fluorocon II Image Intensifier System. Left ventriculograms were obtained in the 30 degrees RAO-60 degrees LAO biplane positions. Ventricular volumes were calculated from the single-frame 30 degrees RAO left ventriculograms by the method of Sandler and Dodge. Patients were divided into two groups on the basis of their cineangiographic findings. Group I consisted of 21 patients. Eighteen of these had a high-degree (greater than 75 per cent) obstructive lesion in the major coronary artery felt to be responsible for the prior myocardial infarction, but no other significant obstructive lesions. Three patients with normal coronary arteriograms were placed in Group I. These three patients, all under age 31 at the time of their infarction, had unequivocal enzyme and ECG evidence of transmural myocardial infarction and in the two patients in whom left ventriculography was able to be performed, abnormal myocardial contractility in the area of the previous myocardial infarction was present. Group II, consisting of 17 patients, had similar high-degree obstructions felt to be responsible for the prior myocardial infarction, as well as at least one 75 per cent or greater lesion in a major vessel anatomically removed from the area of infarction. All parameters studied utilized comparison between these two groups. Statistical analysis was performed with Student's t test and Fisher's test. TM
Table II. Laboratory parameters
I GroupI Cholesterol (mg. p e r 100 ml.} Triglycerides (mg. p e r 100 m l . ) Lipids (mg. per 100 ml, ) F B S * ( m g . p e r 100 ml.) 2 hr. PPBSt (mg. p e r 100 m l . ) Uric acid (mg. per 100 ml. )
264 z
I
P
232 _-- 15
NS
246 _~ 153
156 m 28
NS
8 2 4 _~ 107
744 m 72
NS
97 z
52
Group II
17
115 _~ 23 6.8 z
0.4
99 _
7
NS
116 m 19
NS
5.8 _
0.5
< 0.001
*FBS = Fasting blood sugar. t2 hr. PPBS = 2 hour postprandial blood sugar.
(ECG) were performed by standard methods. Serum cholesterol, triglycerides, and total lipids were measured as previously described. 6-~ Fasting and 2 hour postprandial blood sugars were performed by the standard direct O-toludine method on the Auto Analyzer. Uric acid was also determined by the standard AutoAnalyzer method. Treadmill exercise tolerance testing was performed by the method of Bruce and Hornsten ~ to at least 90 per cent of predicted maximum heart rate in all patients with negative tests, or the occurrence of angina a n d / o r positive ST-segment changes in those patients with positive tests. The diagnosis of an ischemic response to exercise was made when 1 mm. or greater ST-segment depression, horizontal or downsloping for a~ least 0.08 second after the J point, was noted on three consecutive beats during a n d / o r after exercise. The presence of exercise-induced ventricular irri-
552
Results History and physical. No significant differences were noted between the two groups with regard to age, systolic blood pressure, obesity, family history of coronary artery disease, or tobacco use (Table I). Very few of the patients in Group I (3/ 21), or in Group II (1/17) had a history of hypertension. Twelve of 21 patients in Group I and eight of 17 patients in Group II had a history of myocardial infarction in their immediate family. Thirteen of the 21 patients in Group I and 10 of the 17 patients in Group II were obese. T h e mean weights in both Groups I and II were 15 per cent above ideal. Approximately 90 per c e n t of
May, 1976, Vol. 91, No. 5
Coronary cineangiography and myocardial infarction both groups smoked at least one pack of cigarettes per day at the time of their myocardial infarction. In contrast to the above, the presence of angina pectoris was significantly more common in Group II than in Group I. T e n of the 17 patients comprising Group II had angina pectoris, but only three in Group I (p
Clinical correlates of coronary cineangiography in young males with myocardial infarction S t e p h e n V. Savran, M.D. A. Laird Bryson, M.D. T h o m a s G. Welch, M.D., F.A.C.C. B a r r y L. Zaret, M.D., F.A.C.C. R o n a l d L. M c G o w a n , M.D., F.A.C.C., M.D. F l a m m , Jr., M.D., F.A.C.C. Travis AFB, Calif.
Before the a d v e n t of c o r o n a r y a n g i o g r a p h y , the presence of m y o c a r d i a l infarction was generally accepted as a m a n i f e s t a t i o n of severe diffuse coronary a r t e r y disease. M o r e recent studies, however, h a v e d e m o n s t r a t e d t h a t o b s t r u c t i v e coronary a r t e r y disease in p o s t - m y o c a r d i a l infarction p a t i e n t s can be localized to only one or two m a j o r c o r o n a r y arteries. 1' ~ T h e i m p o r t a n c e of this fact has been d e m o n s t r a t e d b y studies based on d a t a f r o m selective c o r o n a r y angiogr a p h y which h a v e shown t h a t the l o n g - t e r m survival of patients with c o r o n a r y a r t e r y disease varies inversely with the n u m b e r of significantly diseased m a j o r vessels. 3-~ It would seem p a r t i c u larly i m p o r t a n t to k n o w the e x t e n t of c o r o n a r y a r t e r y disease present in y o u n g people in order to b e t t e r advise t h e m of their f u t u r e a c t i v i t y a n d prognosis. I t would f u r t h e r be quite helpful if these r e c o m m e n d a t i o n s could be m a d e on t h e basis of noninvasive studies r a t h e r t h a n c o r o n a r y angiography. We wish to r e p o r t the results of our evaluation of 38 patients, all of w h o m h a d t r a n s m u r a l m y o c a r d i a l infarctions before age 40, a n d c o m p a r e their noninvasive d a t a with their c m e a n giographic findings.
From the D e p a r t m e n t of Medicine. Cardiology Section. David G r a n t USAF Medical Center, Travis AFB. Calif. Opinions expressed are those of the a u t h o r a n d do n o t represent official Air Force policy. Received for publication M a r c h 13. 1975. Reprint requests: Stephen V. Savran. Major. USAF. MC, D e p a r t m e n t of Cardiology, U S A F Medical Center_ S c o t t AFB, Ill. 62225.
May, 1976, Vol. 91, No. 5, pp. 551-555
Materials and methods
All patients were a c t i v e - d u t y m i l i t a r y personnel when studied, with the exception of one recently retired 38-year-old Air Force s e r g e a n t who incurred an inferior wall m y o c a r d i a l infarction while on active duty. Prerequisites for entrance into the s t u d y were: age u n d e r 40 at t h e time of m y o c a r d i a l infarction, p e r f o r m a n c e of selective c o r o n a r y a r t e r i o g r a p h y a t the t i m e of clinical evaluation, and referral to our i n s t i t u t i o n for reasons o t h e r t h a n i n c a p a c i t a t i n g a n g i n a pectoris, congestive h e a r t failure, or r e c e n t myocardial infarction. All p a t i e n t s were N e w York H e a r t Association f u n c t i o n a l Class I or I I and were referred to our i n s t i t u t i o n for e v a l u a t i o n of their c o r o n a r y a r t e r y disease as it applied to their future military or civilian careers. T h e patients were studied for f r o m 2 m o n t h s to 2 y e a r s after their a c u t e t r a n s m u r a l m y o c a r d i a l infarction. T r a n s m u r a l m y o c a r d i a l infarction was defined as loss of R wave a n d / o r a p p e a r a n c e of new Q waves of at least 0.04 second in d u r a t i o n and 0.1 mV. in depth along with clinical a n d enzymatic evidence of m y o c a r d i a l infarction. All patients were e v a l u a t e d by a t least one s t a f f cardiologist for historical a n d physical d a t a prior to coronary angiography. Blood pressures were averaged t h r o u g h o u t the hospital stay. H e i g h t and weight were recorded on all p a t i e n t s at t h e time of admission to the hospital. Obesity was defined as a weight 15 per cent or m o r e a b o v e t h a t considered ideal by Air Force s t a n d a r d s for a given height. Chest x-ray a n d e l e c t r o c a r d i o g r a m
American Heart Journal
551
S a v r a n et al.
Table I. History and physical parameters
Age H i s t o r y of hypertension + F H of infarction ~ Smokers Obesity A n g i n a pectoris
Group I
I GroupII
I
p
34 + 2.5 3/21
35 _+ 1.2 1/17
12/21
8/17
NS
19/21 13/21 3/21
15/17 8/17 10/17
NS NS < 0.01
NSt NS
÷ FH Positive family history. ÷NS Not significant. =
=
tability or reproduction of chest pain was considered further confirmatory data but such tests were not considered positive in the absence of ischemic ST-segment changes. Selective coronary arteriography by either the Judkins or Sones technique was performed by 35 mm. cineangiography at 60 frames per second with a General Electric Fluorocon II Image Intensifier System. Left ventriculograms were obtained in the 30 degrees RAO-60 degrees LAO biplane positions. Ventricular volumes were calculated from the single-frame 30 degrees RAO left ventriculograms by the method of Sandler and Dodge. Patients were divided into two groups on the basis of their cineangiographic findings. Group I consisted of 21 patients. Eighteen of these had a high-degree (greater than 75 per cent) obstructive lesion in the major coronary artery felt to be responsible for the prior myocardial infarction, but no other significant obstructive lesions. Three patients with normal coronary arteriograms were placed in Group I. These three patients, all under age 31 at the time of their infarction, had unequivocal enzyme and ECG evidence of transmural myocardial infarction and in the two patients in whom left ventriculography was able to be performed, abnormal myocardial contractility in the area of the previous myocardial infarction was present. Group II, consisting of 17 patients, had similar high-degree obstructions felt to be responsible for the prior myocardial infarction, as well as at least one 75 per cent or greater lesion in a major vessel anatomically removed from the area of infarction. All parameters studied utilized comparison between these two groups. Statistical analysis was performed with Student's t test and Fisher's test. TM
Table II. Laboratory parameters
I GroupI Cholesterol (mg. p e r 100 ml.} Triglycerides (mg. p e r 100 m l . ) Lipids (mg. per 100 ml, ) F B S * ( m g . p e r 100 ml.) 2 hr. PPBSt (mg. p e r 100 m l . ) Uric acid (mg. per 100 ml. )
264 z
I
P
232 _-- 15
NS
246 _~ 153
156 m 28
NS
8 2 4 _~ 107
744 m 72
NS
97 z
52
Group II
17
115 _~ 23 6.8 z
0.4
99 _
7
NS
116 m 19
NS
5.8 _
0.5
< 0.001
*FBS = Fasting blood sugar. t2 hr. PPBS = 2 hour postprandial blood sugar.
(ECG) were performed by standard methods. Serum cholesterol, triglycerides, and total lipids were measured as previously described. 6-~ Fasting and 2 hour postprandial blood sugars were performed by the standard direct O-toludine method on the Auto Analyzer. Uric acid was also determined by the standard AutoAnalyzer method. Treadmill exercise tolerance testing was performed by the method of Bruce and Hornsten ~ to at least 90 per cent of predicted maximum heart rate in all patients with negative tests, or the occurrence of angina a n d / o r positive ST-segment changes in those patients with positive tests. The diagnosis of an ischemic response to exercise was made when 1 mm. or greater ST-segment depression, horizontal or downsloping for a~ least 0.08 second after the J point, was noted on three consecutive beats during a n d / o r after exercise. The presence of exercise-induced ventricular irri-
552
Results History and physical. No significant differences were noted between the two groups with regard to age, systolic blood pressure, obesity, family history of coronary artery disease, or tobacco use (Table I). Very few of the patients in Group I (3/ 21), or in Group II (1/17) had a history of hypertension. Twelve of 21 patients in Group I and eight of 17 patients in Group II had a history of myocardial infarction in their immediate family. Thirteen of the 21 patients in Group I and 10 of the 17 patients in Group II were obese. T h e mean weights in both Groups I and II were 15 per cent above ideal. Approximately 90 per c e n t of
May, 1976, Vol. 91, No. 5
Coronary cineangiography and myocardial infarction both groups smoked at least one pack of cigarettes per day at the time of their myocardial infarction. In contrast to the above, the presence of angina pectoris was significantly more common in Group II than in Group I. T e n of the 17 patients comprising Group II had angina pectoris, but only three in Group I (p
