This study was performed to determine whether inferior ST segment depression during early stages of acute transmural anterior myocardial infarction identifies patients with multivessel coronary artery disease and additional inferior ischemia. Coronary and left ventricular angiography were performed within 3.4 months in 33 patients with acute transmural anterior infarction. Initial electrocardiograms, 2 to 5 hours after onset of chest pain, revealed significant ST segment depression (greater than or equal to 0.1 mV) in at least two of leads II, III and a VF in 15 patients (45%) (group B); in 18 patients (group A) this finding was absent. Compared with group A, patients in group B had greater anterior ST elevation (1.2 versus 0.7 mV, p less than 0.025); higher serum peak creatine kinase (2,475 versus 1,147 IU/liter, p less than 0.005); higher Killip scores (2.1 versus 1.3, p less than 0.001); more in-hospital complications (60 versus 17%, p less than 0.05); lower mean left ventricular ejection fraction (34 versus 55%, p less than 0.001); more frequent regional left ventricular dysfunction in anterolateral (91 versus 44%, p less than 0.05), posterolateral (36 versus 0%, p less than 0.05) and inferior (100 versus 6%, p less than 0.005) regions; greater wall motion abnormality scores (10.0 versus 5.5, p less than 0.005); higher frequency of concomitant left circumflex or right coronary artery disease, or both (80 versus 28%, p less than 0.01); more frequent postinfarction angina (100 versus 39%, p less than 0.001) and lower New York Heart Association functional classification scores (1.7 versus 2.4, p less than 0.05) at 6 month follow-up. The time course of inferior ST depression differed from that of anterior ST elevation. Thus, inferior ST depression was maximal in the first 48 hours and decreased (p less than 0.05) thereafter. In contrast, ST elevation in leads V1 to V6 and I appeared to decrease (p = NS) between days 4 and 7. However, inferior ST depression "mirrored" ST elevation in lead aVL, which also decreased (p less than 0.05) after 48 hours. Thus, inferior ST depression during anterior infarction is associated with more extensive infarction, greater morbidity and higher frequency of multivessel coronary disease. Such inferior ST depression might reflect not only "reciprocal change," but also ischemia in adjacent lateral and remote inferior regions.

An unusual case of right ventricular outflow obstruction and right heart failure due to an isolated unruptured congenital sinus of Valsalva aneurysm originating from the right coronary sinus in a 75-year-old-man is described. The diagnosis was made by two-dimensional echocardiography and cardiac catheterization. Successful surgical resection of the aneurysm resulted in dramatic symptomatic improvement.

Of the last 200 consecutive patients undergoing PTCA procedures at our institution, 29 (15%) had unstable angina; and angioplasty was performed at the time of diagnostic coronary arteriography. There were 26 males and three females with an age range of 31-82 (mean 57) years. Factors favoring PTCA at the time of initial coronary arteriography included clinical indications for revascularization, appropriate anatomy based on high-quality fluoroscopy, and availability of emergency surgery if required. Of 34 coronary lesions in 29 patients, 19 involved the anterior branch of the left anterior descending coronary artery (LAD), eight the circumflex branch (Cx); and seven the right coronary artery (RCA). Five patients had two vessels dilated (one LAD + RCA, two LAD + Cx, and two RCA + Cx). Of the coronary artery lesions, 19 were concentric, seven were eccentric, 20 were single and discrete, six were long or multiple in the same vessel; eight vessels were totally occluded, and in nine patients there was good collateral circulation. Twenty-nine (85%) arteries were successfully dilated. Of the unsuccessful cases, one was from failure to cross a totally occluded lesion, and three residual lesions and/or postdilatation pressure gradients remained significant. One patient required emergency aortocoronary bypass surgery because of total occlusion of the LAD immediately post-PTCA. There were no postprocedural myocardial infarcts or deaths. It is concluded that, in selected patients with unstable angina, PTCA can be performed successfully and with low risk at the time of initial diagnostic coronary arteriography. This approach offers certain clinical financial advantages.

With the substantial advances in technology and further refinements in the technique of coronary angioplasty, the potential for and manifestations of complications may have changed from those observed in populations studied previously. We describe a rare complication of percutaneous transluminal coronary angioplasty (PTCA), a large air embolus obstructing coronary flow, which is related to the newer technology. The air embolus was successfully extracted by aspiration through the balloon angioplasty catheter.

Cardiac amyloidosis (CA) presenting with intractable congestive heart failure, electrocardiographic (ECG) normal or low voltage, and conduction or rhythm disturbances, is rapidly fatal. During life, CA often mimics other cardiomyopathies so that definitive diagnosis depends on demonstration of amyloid on myocardial biopsy. On two‐dimensional echocardiography (2‐D echo), nonspecific features, such as increased ventricular wall thicknesses, predominant diastolic dysfunction, and diffuse myocardial “sparkling,” are consistently found in CA. The combined presence of these 2‐D echo features and normal or low voltage on ECG is highly suggestive of CA, allows differentiation from other cardiomyopathies, and might be useful in noninvasive screening before myocardial biopsy.