Paradox of Normal Selective Coronary Arteriograms in Patients Considered to Have Unmistakable Coronary Heart Disease

Likoff, William; Segal, Bernard L.; Kasparian, Hratch

doi:10.1056/nejm196705112761904

Cited by 376 publications

(102 citation statements)

References 4 publications

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“…22 " 24 The increased incidence of abnormal stress test results in hypertensive patients in the absence of angiographic coronary artery disease noted in earlier radionuclide ventriculographic studies 4 and the trends observed in the present study of thallium perfusion may reflect supply-demand imbalance independent of coronary anatomy.…”

Section: Discussionsupporting

confidence: 55%

Thallium-201 stress imaging in hypertensive patients.

Schulman¹,

Francis²,

Black³

et al. 1987

Hypertension

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SUMMARY To assess the potential effect of hypertension on the results of thallium-201 stress imaging in patients with chest pain, 272 thallium-201 stress tests performed in 133 hypertensive patients and 139 normotensive patients over a 1-year period were reviewed. Normotensive and hypertensive patients were similar in age, gender distribution, prevalence of cardiac risk factors (tobacco smoking, hyperlipidemia, and diabetes mellitus), medications, and clinical symptoms of coronary disease. Electrocardiographic criteria for left ventricular hypertrophy were present in 16 hypertensive patients. Stepwise probability analysis was used to determine the likelihood of coronary artery disease for each patient. In patients with mid to high likelihood of coronary disease (>25% probability), abnormal thallium-201 stress images were present in 54 of 60 (90%) hypertensive patients compared with 51 of 64 (80%) normotensive patients. However, in 73 patients with a low likelihood of coronary disease ( s 25% probability), abnormal thallium-201 stress images were present in 21 patients ( SINCE hypertension is a major risk factor for the development of coronary artery disease, the reliability of stress testing for the evaluation of chest pain in patients with abnormal blood pressure elevation is an important clinical concern. Interpretation of routine exercise treadmill testing with electrocardiographic monitoring may be limited in these patients by the presence of baseline electrocardiographic abnormalities associated with left ventricular hypertrophy, medication effects, left bundle branch block, or advanced age. "3 Furthermore, in a study of hypertensive patients with chest pain, exercise radionuclide angiography was found to be an inadequate screening test for coronary artery disease because of the frequent occurrence of false-positive responses. 4 Since stressinduced thallium-201 myocardial defects are a more specific indicator of abnormal regional myocardial perfusion than are electrocardiographic or hemodynamic criteria, exercise testing with thallium-201 imaging may be a more useful test in hypertensive patients. Therefore, thallium-201 stress imaging may be more suited than other diagnostic techniques for the identification of ischemia.5 There is little information concerning the effects of hypertension and possibly associated left ventricular hypertrophy on thallium-201 imaging in patients evaluated for chest pain. To assess the effects of hypertension on the results of thallium-201 stress testing, we reviewed our experience over a 1-year period with normotensive and hypertensive patients who were referred for exercise testing with thallium-201 imaging. The patients were categorized according to their likelihood of having coronary artery disease. We hypothesized that hypertensive patients would have a higher incidence of abnormal thallium-201 imaging than would their normotensive counterparts.

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Section: Discussionsupporting

confidence: 55%

Thallium-201 stress imaging in hypertensive patients.

Schulman¹,

Francis²,

Black³

et al. 1987

Hypertension

View full text Add to dashboard Cite

show abstract

“…Initial works have described typical stress-induced angina pectoris in subjects without significant epicardial coronary lesions or LV dysfunction. 6 Strauer and colleagues 7 described reduced CFR in hypertensive subjects with angina pectoris and LVH with no angiographically significant epicardial coronary lesions. However, Strauer also reported normal CFR with haemodynamically compensated LVH.…”

Section: Discussionmentioning

confidence: 99%

“…With this regard, early experimental and clinical invasive studies reported association of LVH with reduced CFR. [6][7][8][9][10] However, others failed to find significant independent relationship between CFR and LVH, [11][12][13][14][15][16][17] and the independent relation between LVH and abnormal CFR remains disputed. In addition, LVH is independently associated with coronary artery disease, 18 which may confound the relation between LVH and CFR.…”

Section: Introductionmentioning

confidence: 99%

Relations of left ventricular mass and systolic function to endothelial function and coronary flow reserve in healthy, new discovered hypertensive subjects

et al. 2005

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Left ventricular hypertrophy (LVH) is prognostically relevant, associated with major cardiovascular risk factors and with atherosclerosis. However, whether LVH is independently associated with impaired coronary flow reserve (CFR) and with endothelial dysfunction is disputed. We assessed the relationship of LV mass and systolic function to CFR and endothelial function in new discovered never treated subjects with essential arterial hypertension, but without coronary artery disease or microalbuminuria. LVH, ejection fraction (EF) and stress-corrected midwall shortening (MWS, a measure of myocardial contractility) were assessed by echocardiography. CFR was assessed by single-photon emission computed tomography and dipyridamole infusion. Endothelial function was evaluated by assessing 1-min postischaemic flow-mediated dilatation of the brachial artery (FMD); nitroglycerine-mediated dilatation (NMD) of the same brachial artery was used as measure of nonendothelium-dependent vasodilatation. In approximately 1 year, we enrolled 21 subjects who met stringent inclusion criteria (47710 years old, 26.672.8 kg/m 2 , 78% men). Five patients showed LVH. Multivariate analyses showed a significant negative correlation of LV mass index with FMD (b ¼ À0.61, Po0.05) but not with NMD, neither with CFR. Stress-corrected MWS showed independent correlation with CFR (b ¼ 0.51, Po0.05). Thus, in clinically healthy, new discovered hypertensive subjects, never treated and mostly in the early stage of arterial hypertension, LVH can be associated with endothelial dysfunction while maximal dipyridamoledependent CFR may be preserved; nevertheless, a cardiac phenotype presenting with tendency to impaired myocardial contractility, assessed by stress-corrected MWS, showed association with lower CFR in the early stage of arterial hypertension.

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“…15,16) In some of these patients, stress ECG abnormalities, pathologic lactate extraction during isoproterenol infusion or atrial pacing, or inadequate increase in coronary flow during dipyridamole infusion can be detected. [17][18][19] However, such abnormalities are generally not detectable in basal conditions, and can be induced only through adequate physical and/or pharmacological stress.…”

Section: Discussionmentioning

confidence: 99%

<b>Comparison of Exercise QRS Amplitude Changes in Patients with Slow Coronary Flow Versus Significant Coronary Stenosis</b>

et al. 2004

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SUMMARYExercise Q, R, and S wave amplitude changes, called the QRS score, have been reported to be a marker of exercise-induced myocardial ischemia. Therefore, in this study, using the exercise QRS score, we sought to determine if slow coronary flow (SCF) phenomenon is associated with the exercise-induced myocardial ischemia.This retrospective study included 23 patients evaluated for suspected coronary artery disease and found to have SCF (group I) and 19 subjects with angiographically-defined significant coronary artery stenosis (group II). All study subjects underwent treadmill exercise testing using the modified Bruce protocol. For each subject the amplitude of the Q, R, and S waves in leads aVF and V 5 was measured manually using calipers before and immediately after exercise. The QRS score was calculated by subtracting the Q, R, and S wave differences in leads aVF and V 5 .There was no difference between the two groups with respect to demographic properties. The peak heart rate achieved, baseline and peak systolic-diastolic blood pressure, exercise duration, and the metabolic equivalent values were similar in both groups. The maximum ST-segment depression ratio was significantly lower in patients with SCF than those of significant coronary stenosis (0.8 ± 0.4 vs 1.3 ± 0.5 P = 0.001, respectively). However, the exercise QRS score was found to be similar in both groups (3.3 ± 2.3 vs 2.1 ± 3.0 P = 0.2, respectively).The data suggest that SCF phenomenon may alone lead to myocardial ischemia even in the absence of obstructed major epicardial coronary arteries as detected by similar exercise QRS scores to those of significant coronary artery stenosis. (Jpn Heart J 2004; 45: 419-428)

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Paradox of Normal Selective Coronary Arteriograms in Patients Considered to Have Unmistakable Coronary Heart Disease

Cited by 376 publications

References 4 publications

Thallium-201 stress imaging in hypertensive patients.

Thallium-201 stress imaging in hypertensive patients.

Relations of left ventricular mass and systolic function to endothelial function and coronary flow reserve in healthy, new discovered hypertensive subjects

<b>Comparison of Exercise QRS Amplitude Changes in Patients with Slow Coronary Flow Versus Significant Coronary Stenosis</b>

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