Clinical correlates of the coronary arteriogram

This report reviews my experience, as well as that of others, correlating available clinical data with coronary arteriographic observations in patients with coronary artery disease (CAD). The severity of CAD (number of vessels involved with significant disease and coronary score) increases with age; however such a finding can in part be explained by patient referral selection. The duration of clinical heart disease on referral for evaluation was directly related to age. Severity of CAD was noted to be related to the duration of clinical heart disease. Evaluating patients with symptoms of 1 year or less revealed no differences in severity of CAD in all age groups over 39 years; however, in age group 30 to 39 CAD was less severe, with over 60% having single-vessel disease. The left anterior descending artery was the vessel most frequently involved while the right coronary artery was the artery most commonly involved with complete obstructive disease. The frequency of significant disease of the left anterior descending and main left coronary artery was directly related to age. There was no evidence that the severity of disease, vessels involved, or lesion (total vs. subtotal) is related to sex. Frequency of coronary artery calcification is directly related to age, regardless of the presence or absence of CAD, and has diagnostic significance for the presence of CAD under the age of 60. The functional state of the patient (functional class, stable or unstable angina) cannot predict the severity of CAD or particular vessel involvement. Congestive heart failure is usually associated with more severe and extensive disease and a higher frequency of occlusive disease, compared with patients without heart failure. The role of various risk factors as related to severity of CAD has been extensively studied. Such factors as smoking, hypertension, family history, and obesity do not appear to influence severity of CAD. Studies evaluating the relationship of diabetes mellitus and blood lipids have been either inconclusive or conflicting and thus warrant further investigation. Radiographic evidence of cardiomegaly, usually associated with a poor prognosis, can be correlated with severe CAD and is almost invariably associated with disease of the left anterior descending artery. The electrocardiogram (ECG) has been useful in predicting patient groups with severe CAD. Left atrial P wave abnormality and atrial fibrillation suggest severe CAD. Ventricular arrhythmias are better indicators of left ventricular dysfunction. A normal ECG (QRS complex) is usually correlated with less severe CAD, compared with ECG finding of a myocardial infarction; however, a normal ECG has both a poor sensitivity and specificity for predicting the extent of CAD. Almost half of the patients with main left CAD have a normal QRS complex. ECG evidence of a myocardial infarction is more commonly associated with multiple-vessel involvement and an obstructive lesion related to localization of the infarction. Extensive studies indicate that exercise stress testing can be related to the severity of CAD or the presence of main left disease when such variables as the magnitude of ST depression (ischemic response), work load, heart rate, or blood pressure response is taken into account. Finally, nuclear medicine methods (thallium-201 perfusion imaging and gated pool radionuclide cineangiography)—when combined with exercise stress testing—have been found useful not only in increasing the sensitivity for detecting CAD, but also may be helpful in identifying patients with severe CAD, as well as localization to a particular coronary artery.