Coronary Arterial and Left Ventriculographic Findings in Patients with Double-Vessel Disease and Angina Pectoris*,t

Transcription

1 Clin. Cardiol. 3, (1 980) 0 G. Witzstrock Publishing House, Inc. Coronary Arterial and Left Ventriculographic Findings in Patients with Double-Vessel Disease and Angina Pectoris*,t W.V.R. VIEWEG. M.D.,*S.E. WARREN, M.D.,s J.S. ALPERT, M.D., A.D. HAGAN, M.D.~ Cardiology Branch, Department of Internal Medicine, the Clinical Investigation Center, Naval Regional Medical Center, San Diego, California, and the Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts, Worcester, Massachusetts, USA Summary: The distribution and severity of coronary artery disease and left ventricular wall abnormalities are described in 1 19 patients with double-vessel disease and angina pectoris. The coronary arterial patterns were divided into right (84), mixed (1 7), and left (1 8) systems, depending upon the blood supply to the inferior surface of the left ventricle. Patterns of double-vessel disease were separated into those with 50% or greater reduction of luminal diameter involving the left anterior descending and circumflex/obtuse marginal arteries (2-LC), circumflex/obtuse marginal and right coronary arteries (2-CR), and left anterior descending and right coronary arteries (2-LR). The following relationships were noted: (I) Left anterior descending and right coronary artery disease occurs with twice the frequency of 2-LC or 2-CR disease, supporting the thesis that of the three major coronary arteries, the circumflex/obtuse marginal arteries contribute least to angina pectoris. (2) The mid portion of the left anterior descending artery is most commonly involved and the left main coronary artery * This study was supported in part by the Bureau of Medicine and Surgery Clinical Investigation Program Project The opinions or assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the Navy Department. * Captain, Medical Corps, United States Navy Lieutenant Commander, Medical Corps, United States Navy Address for reprints: Capt. W. V. R. Vieweg, M.C., U.S.N. Cardiology Branch Naval Regional Medical Center San Diego, California 92134, USA Received: December 12, 1979 Accepted: February 8, 1980 least commonly involved in patients with double-vessel disease. (3) Left ventricular wall motion abnormalities are found in one-half of patients with double-vessel disease and angina pectoris with hypokinesis usually found in all areas except at the apex where dyskinesis is usually seen. Key words: coronary arterial patterns, double-vessel disease, left ventricular wall motion abnormalities, coronary artery disease, cardiac catheterization, coronary arteriography Introduction Common classifications of coronary artery disease include division of patients into those individuals with single-, double-, and triple-vessel disease. In patients presenting with angina pectoris there is interest in the distribution and severity of coronary arterial lesions and left ventricular wall motion abnormalities that account for the patients symptoms. The purpose of this paper is to describe the angiographic findings in patients with double-vessel disease presenting with angina pectoris. Such a meticulous review has not been reported heretofore. Methods In a review of the coronary arteriograms and left ventriculograms of 500 patients with angina pectoris studied between 1972 and 1977, 119 patients were found to have double-vessel disease. This paper describes that subgroup. The coronary arteriograms and left ventriculograms were reviewed carefully by three angiographers. When differences

2 W. V. R. Vieweg er al.: Double-vessel disease and angina 247 existed in the interpretation of this material, a consensus was reached. Such differences were rare and minor in nature. Patients with coronary arterial anomalies, congenital heart disease, valvular heart disease, or primary heart muscle disease were excluded. All patients had at least one lesion of greater than 50% reduction of luminal diameter in a major coronary artery. Only films of excellent quality were included in this study. Ninety-five percent of the studies were performed percutaneously from the leg; the remainder were performed using a cutdown in the arm. The arteriograms and ventriculograms were exposed on 35-mm film using Philips 6-inch and 9-inch cesium iodide image intensifier systems, respectively (Philips Medical Systems, Inc., Shelton, Connecticut, USA). During coronary arteriography, multiple left anterior oblique and right anterior oblique projections were used. In the last 80% of the studies, hemiaxial projections were employed routinely. For the left ventriculograms, 45 ml of 76% meglumine diatrizoate were introduced into the left ventricle in 3 s using a power injector. Films were exposed at 60 frames/s in the right anterior oblique projection. Only frames removed from ectopic beats by at least two cardiac cycles were evaluated. Coronary arterial patterns were classified as right, mixed, and left systems according to the blood supply to the inferior surface of the left ventricle (Fig. 1). In right systems the right coronary artery (RCA) supplies the posterior descending artery and posterolateral artery. In mixed systems the RCA supplies the posterior descending artery, and the left atrioventricular groove artery (AV groove artery) supplies the posterolateral artery. In left systems the RCA terminates at the acute margin of the right ventricle and the AV groove artery supplies the posterolateral artery and the posterior descending artery. The size of the coronary artery just proximal to a lesion was measured by comparing its diameter to the known diameter of the catheter. A more detailed description of our measuring technique has been described by us elsewhere (Vieweg er al., 1975, 1976) and used by others (Van Tassel et al ). Vessels smaller than 1.5 mm in diameter were not included. Lesions were measured as reductions in arterial diameter and 4 Right Mixed 4 Left Composite FIG. 1 Coronary arterial patterns divided into 13 sections in right, mixed, and left systems: I, left main coronary artery; 2, left anterior descending artery proximal to first septal perforator; 3, mid left anterior descending artery; 4, distal left anterior descending artery; 5. diagonal branch of the left anterior descending artery; 2-5, diagonal branch arising proximal to first septal perforator; 3-5, diagonal branch arising distal to first septal perforator; 6, intermediate artery; 7, left circumflex artery; 8. obtuse marginal artery; 9, atrioventricular groove artery; 10, posterolateral artery; 11, posterior descending artery: 12, distal right coronary artery; 13, proximal right coronary artery. Arrows in composite diagram show breaks creating right (arrow I). mixed (arrow 2), and leji (arrow 3) systems. Abbreviations for composite diagram: LAD, left anterior descending; D, diagonal branch; SP. septal perforator; 1, intermediate; C, circumflex; M, obtuse marginal; A, atrioventricular groove; PL, posterolateral; PD, posterior descending.

3 ~~ 248 Clin. Cardiol. Vol. 3, August 1980 were scored as,,, and % reductions in coronary arterial luminal diameter. The left ventriculograms in the right anterior oblique projection were divided into five areas (anterobasal, anterolateral, apical, diaphragmatic and posterobasal), as shown in Fig. 2. Each of the five areas was scored as normal, hypokinetic, akinetic, or dyskinetic. Anterobasal disease compared with 0% in single-vessel disease and 13% in triple-vessel disease. ly obstructing lesions occurred most commonly in the mid left anterior descending and right coronary arteries. A summary of lesions representing >50% reduction of luminal diameter in double-vessel disease is shown in Fig. 3. In patients with double-vessel disease, 48% of those with 2-LC disease, 57% of those with 2-CR disease, and 58% of those with 2-LR disease had left ventricular wall motion abnormalities (Table IV). Wall motion abnormalities were absent in the anterobasal area. Otherwise, hypokinesis was found most commonly in all areas except at the apex, where dyskinesis appeared most commonly. Mitral Diaphragmatic I! FIG. 2 Left ventriculogram in right anterior oblique projection divided into five areas. 4 Results The mean age of the 119 patients with double-vessel disease was 48.4 years, which was not different statistically from the entire population of 500 patients (mean 49.2 years) with single-, double-, and triple-vessel disease. Table I shows the distribution of double-vessel disease according to coronary arterial system. Among the entire 500 patients, 72% had right systems, 18% had mixed systems, and 10% had left systems. However, among patients with double-vessel disease, 7 1 % had right systems, 14% had mixed systems, and 15% had left systems. The distribution of right, mixed, and left systems among patients with 2-LR disease (lesions in the left anterior descending and right coronary arteries) was similar to that of the entire population with double-vessel disease. However, in 2-LC disease (lesions in the left anterior descending and circumflex/obtuse marginal arteries) mixed systems were not seen, and in 2-CR disease (lesions in the circumflex/obtuse marginal and right coronary arteries) left systems were virtually absent. A detailed analysis of the distribution and severity of coronary arterial lesions in double-vessel disease according to coronary arterial system and patterns of double-vessel disease appears in Tables I1 and 111. Left main coronary arterial lesions occurred in 2% of patients with double-vessel FIG. 3 Summary of lesions of 50% or greater reduction of luminal diameter in patients with double-vessel disease and angina pectoris. See composite diagram of Fig. I to identify coronary arteries. TABLE I Distribution of double-vessel disease in 119 patients according to coronary arterial system" System 2-LC 2-C R 2-LR Right Mixed Left Abbreviations: 2-LC, left anterior descending and circumflex artery; 2-CR. circumflex and right coronary artery; 2-LR, left anterior descending and right coronary artery a To determine double-vessel disease in mixed and IeJt systems, the composite diagram of Fig. 1 was used to make lesions in the atrioventricular groove artery, posterolateral artery, and posterior descending artery in mixed and lejt systems analogous to lesions in right systems.

4 W. V. R. Vieweg et al.: Double-vessel disease and angina 249 Discussion The frequency with which double-vessel disease is found among patients complaining of angina pectoris ranges between 17 and 36% (Gensini and Buonanno, 1968; Moraski et al., 1975; Proudfit et al., 1967; Reeves et al., 1974; Scanlon et al., 1973). Thus, our finding of 23.8% frequency of double-vessel disease in a population with coronary artery disease is not surprising. Although we found very little difference between the mean age of those with double-vessel disease (48.4 years) and the entire group of 500 patients (49.2 years), it is interesting to note that the mean age of the patients with double-vessel disease fell between the mean age of those with single- (46.7 years) and triple-vessel (50.4 years) disease. The explanation for the suggestion that coronary arterial patterns (righl, mixed, and left systems) alter the distribution of coronary arterial lesions (Table I) in patients with double-vessel disease and angina pectoris remains elusive. In double-vessel disease, right systems appear in about 70% of the cases of 2-LC, 2-CR, and 2-LR disease. This prevalence is the same as that among all 500 patients with coronary artery disease and angina pectoris, and is similar to that reported elsewhere in the literature in patients free of coronary artery disease (Vieweg et al., 1975). However, patients with mixed systems (1 4%) are under-represented and those with left systems (15%) are over-represented among patients with double-vessel disease. This finding 'supports Schlesinger's thesis (1940) that patients with mixed systems are least vulnerable and those with left systems are most vulnerable to coronary artery disease. Our frequency of 2-LC (24%), 2-CR (25%), and 2-LR (50%) disease among patients with double-vessel disease is similar to that found in the literature. Proudfit et al. (1967) and Bruschke et al. (1973) reported frequencies for 2-LC, 2-CR, and 2-LR disease of 30,23, and 46% and 23,17, and 60%, respectively. Given that the common denominator in our population is angina pectoris, it appears that the circumflex/obtuse marginal arteries contribute least to angina pectoris because 2-LR disease is twice as common as 2-LC or 2-CR disease. Tables I1 and 111 and Fig. 3 support this concept with fewer lesions found in the circumflex/obtuse marginal arteries as compared with the left anterior descending and right coronary arteries. The mid left anterior descending artery was the section most commonly involved (52% of cases), followed by the distal right coronary artery (37% of cases), proximal left anterior descending artery (34% of cases), and proximal right coronary artery (34% of cases). The left main coronary artery was involved in 2% of our cases of double-vessel disease, compared with an overall frequency of 1 1.5% reported by the Cleveland Clinic (Proudfit et al., TABLE II Distribution and severity of coronary arterial lesions in double-vessel disease according to coronary arterial systema Sections in right systems (84)b I Sections in mixed systems ( I 7)b I I I I I I I I Obstruction (YO) Sections in lefi systems (1 8) I I 0 1 a Section I in the left main coronary artery; sections 2,3, and 4 in the left anterior descending artery; sections 6.7, and 8 in the intermediate, circumflex, and obtuse mqrginal arteries; and sections 9, 10, 1 I, 12, and 13 in the atrioventricular groove, posterolateral, posterior descending, and right coronary arteries are derived from Fig. 1 (p. 247). These data are summarized in Fig. 3 (p. 248). Indicates number of patients

5 250 Clin. Cardiol. Vol. 3, August ) in patients with single-, double-, and triple-vessel disease. However, in their patients with double-vessel disease, only 7% had stenosis of 50% or greater involving the left main coronary artery. Among patients with 2-LC disease and left ventricular wall motion abnormalities, the anterior surface of the left ventricle was principally involved (Table IV). In the case of 2-CR disease, the posterior surface of the left ventricle was principally involved. In 2-LR disease, both the anterior and posterior surface of the left ventricle were commonly involved. Thus, wall motion abnormalities occurred in areas supplied by diseased coronary arteries. Overall, 55% of our TABLE 111 seasea Distribution and severity of coronary arterial lesions in double-vessel disease according to patterns of double-vessel di- Sections in 2-LC disease (29)b Sections in 2-CR disease (30) II I I Sections in 2-LR disease (60)b I I See Table I for definitions of 2-LC, 2-CR, and 2-LR diseases. Section 1 in the left main coronary artery; sections 2,3, and 4 in the left anterior descending artery; sections 6.7, and 8 in the intermediate, circumflex, and obtuse marginal arteries; and sections 9, 10, 11, 12, and 13 in the atrioventricular groove, posterolateral, posterior descending, and right coronary arteries are derived from Fig. 1 (p. 247). These data are summarized in Fig. 3 (p. 248). Indicates number of patients TABLE 1V Distribution and severity of wall motion abnormalities found in patients with double-vessel disease according to double-vessel disease patterna Disease Anterobasal Anterolateral Apical Diaphragmatic Posterobasal pattern H A D H A D H A D H A D H A D 2-LCb CRC LRd See Table I for definitions of 2-LC. 2-CR. and 2-LR diseases. Abbreviations: H, hypokinesis; A, akinesis. D, dyskinesis Left ventricular areas (anterobasal, anterolateral, apical, diaphragmatic, and posterobasal) are shown in Fig. 2 (p. 248). Of 29 patients with 2-LC disease, 14 had wall motion abnormalities. Of 30 patients with 2-CR disease, 1'7 had wall motion abnormalities. Of 60 patients with 2-LR disease, 35 had wall motion abnormalities.

6 W. V. R. Vieweg et al.: Double-vessel disease and angina 25 1 patients with double-vessel disease had left ventricular wall motion abnormalities in contrast to the figure of 8 1% reported by Bruschke et al. (1973b) and 48% by Moraski et al. (1975). Hypokinesis occurred most frequently except in the apical area where dyskinesis was seen most commonly. Conclusion Double-vessel disease is found in about one-fourth of patients with angina pectoris due to coronary artery disease. Coronary arterial patterns of mixed and left systems may alter the expected appearance of coronary arterial lesions in patients with double-vessel disease. The circumflex/obtuse marginal arteries contribute least of the three major coronary arteries to angina pectoris. The mid portion of the left anterior descending artery is most commonly diseased in patients with double-vessel disease. Rarely is the left main coronary artery involved in double-vessel disease. Approximately one-half of the patients with double-vessel disease and angina pectoris will have left ventricular wall motion abnormalities with hypokinesis usually seen except at the apex where dyskinesis is usually found. References Bruschke AVG, Proudfit WL, Sones FM: Progress study of 590 consecutive nonsurgical cases of coronary disease followed 5-9 years. I. Arteriographic correlations. Circulation 47, (1 973a) Bruschke AVG, Proudfit WL, Sones FM: Progress study of 590 consecutive nonsurgical cases of coronary disease followed 5-9 years. 11. Ventriculographic and other correlations. Circularion 47, 1154 (1973b) Gensini GG, Buonanno C: Coronary arteriography: A study of cases with angiographically proved coronary artery disease. Dis Chest (1968) Moraski RE, Russell RO, Smith M, Rackley CE: Left ventricular function in patients with and without myocardial infarction and one, two or three vessel coronary artery disease. Am J Cardiol 35, 1 (1975) Proudfit WL, Shirey EK, Sones FM: Distribution of arterial lesions demonstrated by selective cinecoronary arteriography. Circulation 36, 54 (1967) Reeves TJ, Oberman A, Jones WB, Sheffield LT: Natural history of angina pectoris. Am J Cardiol 33,423 (1974) Scanlon PJ, Nemickas R, Moran JF, Talano JV, Amirparviz F, Pifarre R: Accelerated angina pectoris: clinical, hemodynamic, arteriographic, and therapeutic experience in 85 patients. Circulation 47, 19 (1 973) Schlesinger MJ: Relation of anatomic pattern to pathologic conditions of the coronary arteries. Arch Pathol 30,403 (1940) Van Tassel R, Moore R, Amplatz K: Determination of the true size of the coronary artery in coronary arteriography. Am J Roentgenol 116,62 (1972) Vieweg WVR, Smith DC, Hagan AD: A clinically useful coding system for normal coronary artery anatomy. Cathet Cardiouasc Diagn 1, 171 (1975) Vieweg WVR, Alpert JS, Hagan AD: Caliber and distribution of normal coronary arterial anatomy. Cathef Cardiovasc Diagn 2,269 (1 976)