Distribution of Arterial Lesions Demonstrated by Selective Cinecoronary Arteriography

Transcription

1 Distribution of Arterial Lesions Demonstrated by Selective Cinecoronary Arteriography By WILLIAM L. PROUDFIT, M.D., EARL K. SHIREY, M.D., AND F. MASON SONES, JR., M.D. SUMMARY The distribution of obstructions exceeding 3% of the normal diameter of the lumen of one or more major coronary arteries was studied in 627 of 1, patients who had selective cinecoronary arteriograms. An additional 99 patients had lesser degrees of narrowing, and in the arteriograms of 274 patients, normal arteries were demonstrated. An average of 2. lesions resulting in at least 5% luminal narrowing of major arteries was found per patient. The anterior descending coronary artery was involved slightly more frequently than were other vessels. More than 75% of the symptomatic patients had 9% or more obstruction of at least one vessel, and more than 5% had total occlusions of one or more vessels. A single major artery was the site of obstruction exceeding 3% of the luminal diameter in 131 patients (2.9% of the 627 patients), and in 43 of these (6.9%) the other arteries appeared to be entirely normal. Severe involvement of single arteries was most frequent in patients who had myocardial infarction without angina pectoris or in those who had rest pain only. No pattern of arterial involvement was pathognomonic of a clinical syndrome. Downloaded from by on December 3, 218 Additional Indexing Words: Cineangiography Coronary occlusion Coronary failure Myocardial infarction Heart failure THE DISTRIBUTION of obstructive lesions in the coronary arteries has been described in reports of postmortem studies. There are conflicting opinions about the frequency of involvement of the various arteries, and no attempt has been made to compare the anatomic findings with the clinical syndromes in large groups of patients. The development of selective cinecoronary arteriography has made possible the demonstration of the extent and the distribution of obstructive lesions during life. In a previous report' we discussed the correlation of the severity of the maximal arterial obstructions and various clinical syndromes in 1, patients studied by this technique. The present study details the distribution of the obstructive lesions in those patients. From the Departments of Clinical Cardiology and Cardiovascular Disease and the Cardiac Laboratory, The Cleveland Clinic Foundation, Cleveland, Ohio. Angina pectoris Methods The patients who formed the basis of the previous report' were studied relative to the distribution of arterial lesions. The classifications of clinical diagnoses and severity of obstructions were the same as reported previously. The following clinical classes* were used: Angina Pectoris (Class I, II, or III, Functional Classification). Pain somewhere in the upper half of the body which was precipitated by walking and relieved promptly (within 15 minutes) by rest. Other precipitating or potentiating factors were common in this group but all had exertional pain. None had rest pain. Angina Pectoris (Class IV, Functional Classification). Pain at rest as well as on physical exertion. Rest Pain Only. Pain that appeared to be characteristic of angina but was not precipitated by exertion; pain lasted less than 15 minutes. Coronary Failure. Pain that occurred with or without apparent precipitation and persisted 15 minutes to several hours (coronary insufficiency, premonitory pain, intermediate syndrome). *Courtesy of Proudfit, Shirey, and Sones.1

2 DISTRIBUTION OF CORONARY LESIONS 55 Table 1 Incidence and Location of Obstructions Exceeding 3% of the Arterial Lumen in 627 Patients Coronary artery involved, no. of patients Severity of Anterior obstruction Left descending Total > 3 and <5% to <9% % Complete Total ,46 % of 627 cases Downloaded from by on December 3, 218 Myocardial Infarction. QRS abnormalities that were considered characteristic at the time of arteriographic study. Most patients in this group had typical histories of prior infarction. One patient, originally classified as having myocardial infarction and functional class IV angina pectoris, was found on review to have been functional class IV due to congestive failure but class III from the standpoint of angina pectoris. The classification was therefore changed in the tables. Only obstructions of the four major arteries (left main coronary artery, left anterior descending artery, circumflex artery, and right coronary artery) or their major branches were considered. The previous study indicated that at least 5% obstruction was present in almost all symptomatic patients; therefore, emphasis was placed on the distribution of severe obstructions. A total of 627 of the 1, patients had obstructive lesions of one or more arteries exceeding 3% of the diameter of the normal lumen, and this group is the subject of this report. The data concerning the 99 patients who had mild obstruction are not tabulated, and normal arteriograms were found in 274 patients. In the group with myocardial infarction, a statement relative to the location of infarction is required. The numbers of anterior and posterior myocardial infarctions demonstrated electrocardiographically were fairly even: 84 anterior or anteroseptal, 65 posterior, 14 posterolateral, six anterior and posterior, and three anterolateral. Results The distribution and severity of obstructions exceeding 3% of the arterial lumen are shown in table 1. The left main coronary artery showed moderate or severe obstruction in 11.5% of the 627 patients. The percentages of patients with such obstruction of the anterior descending artery (82.5%), circumflex artery (66.% ), and right coronary artery (72.9%) did not vary greatly. However, mod- Cifrculation, Volume XXXVI, July 1967 erate (more than 3 but less than 5%) obstruction occurred more commonly in the circumflex artery than in the other vessels. Severe (5% or greater) but not total obstruction was most frequent in the anterior descending artery. Complete occlusion was most common in the right coronary artery. Obstruction of 5 to almost 9% of the luminal diameter constituted the largest group, followed by complete occlusion, moderate obstruction, and finally, obstruction of at least 9% of the lumen but less than total occlusion. The average number of obstructed major arteries (obstruction exceeding 3% of the luminal diameter) per patient was 2.3, and an average of about 2. vessels were narrowed by at least 5%. Of the 627 patients who had lesions that narrowed the arterial lumen more than 3%, only 39 had maximal lesions of moderate severity (that is, 3 to 5% narrowing). The distribution in the other 588 patients having obstruction of at least 5% is shown in table 2. The largest single group was that in which the anterior descending, circumflex, and right coronary arteries were all severely obstructed; the group totaled 134 patients (22.8%). The relatively short left main coronary artery was involved in 59 patients (1.%). Severe lesions affected a single major vessel in 199 patients (33.8%), though many of these patients also had less than 5% obstruction in other arteries. The incidence of predominantly single-vessel obstruction of more than 3% is shown in table 3. In each of 131 (2.9%) of the entire group of 627 patients, one vessel was the principal site of moderate or severe involvement. In 88 (14.%) of the 627 patients, there were

3 56 PROUDFIT ET AL. Table 2 Distribution of Obstruction of at Least 5% of the Arterial Lumen in 588 Patients Coronary artery obstructed Left only Left with: and circumflex and right, circumflex, and right alone with: alone with right alone Total Patients No. % of total O Downloaded from by on December 3, 218 Table 3 I to IV with or without myocardial infarc- Obstruction Exceed- tion, 4.4% of those who had myocardial infarc- Predominantly Single-Vessel ing 3% of Arterial Lumert in 131 Patients tion without angina, and 7.7% of those who Coronary artery obstructed main Left Anterior Total descending Other vessels involved, no. of patients had coronary failure pain. Single-vessel inone <3% obstruction Total volvement affected the anterior descending 1 1 artery more frequently than other vessels Combinations of severe obstruction in the an terior descending, circumflex, and right coro nary arteries, or the anterior descending and right coronary arteries were the largest groups, except in patients who had myocardial inons in other vessels, farction without angina or those who had minor obstructive lesi( but in 43 (6.9%), no otbter arterial obstruction rest pain. Figure 2 shows, in graph form, the was demonstrated. Thee anterior descending percentages of patients in each clinical group coronary artery was involved more frequently who had obstruction of one, two, three, or than were other vesselis. The occurrence of four main arteries. single-vessel obstructioin in relation to the The locations of the obstructions of at least clinical diagnosis is sh( own in table 4. Most 9% of the vessel lumen are shown in table 6. of the patients with sinigle-vessel disease had In the larger clinical groups, 73 to 8% of all symptoms characteristi( c of coronary artery patients having obstructions of at least 5% disease. had one or more obstructions of at least 9%. The distribution of arterial obstruction The incidence was slightly higher in the small amounting to at least 5i% of the diameter of groups of myocardial infarction and angina the lumen in relation t( o various clinical syn- pectoris, functional classes I to III (87.2%) dromes is shown in tab le 5 and figure 1. In- or class IV (9.%). Total obstruction of one volvement in the left main coronary artery or more major arteries was present in 52 to alone or in combination with lesions in other 67% of all groups except for the small group vessels occurred in from 1 to 15% of patients of 29 patients who had rest pain only (table who had angina pecto. ris, functional classes 7). The incidence was highest in patients

4 DISTRIBUTION OF CORONARY LESIONS 57 Table 4 Clinical Diagnosis of Obstruction Exceeding 3% of a Single Artery Total Single-vessel involvement patients having Mainly* Only Clinical diagnosis > 3% obstruction No. % No. % Normal Probably normal Atypical angina Angina, classes I to III Angina, class IV Rest pain Coronary failure Myocardial infarction Possible myocardial infarction Congestive failure Othert 2 1 *Normal or not more than 3% obstruction in other vessels. tone arrhythmia, one electrocardiographic abnormality only. Downloaded from by on December 3, z w I - A.eI-E A.P. M.I. M.I. M.I. REST NO A.P A.PI-N A.PI PAIN LEFT MAIN ANTERIOR DESCENDING Figure 1 Incidence of at least 5% obstruction of coronary arteries in various clinical syndromes. who had myocardial infarction and angina pectoris, functional classes I to IV. Patients have syndromes or a combination CORONARY FAILURE CIRCUMFLEX mright of syndromes, and the clinician is concerned with the probable distribution of severe arterial obstructions for a specific patient. The

5 58 PROUDFIT ET AL. Downloaded from by on December 3, 218 Fifty Per Cent or More Each Clinical Group* Coronary artery obstructed Left only Left with: and circumflex and right, circumflex, and right only with: only only Total patients Table 5 Obstruction of Lumen, Expressed as Percentage of Total Number of Patients in No infarction (%) Angina, classes I-III Angina, class IV Myocardial infarction (%) No Angina, Angina, Coronary angina classes I-III class IV Rest pain failure (%) (%) *Expression in percentages facilitates comparison of clinical groups. Numbers of patients may be found by multiplying percentages by total number of patients in each clinical group (bottom line). Note: Rest pain refers to pain of the character, distribution, and duration of angina pectoris, but occurring only at rest. Coronary failure is an anginal type of pain lasting more than 15 minutes (coronary insufficiency, intermediate syndrome). w w a ~3-2- I1 A.PC.I-N A.PC.IZ M.I. M. I. M.I. REST CORONARY NOA.P A.PC.I-M A.PIY PAIN FAILURE n I ARTERY m 3 ARTERIES lm2 ARTERIES 4 ARTERIES Figure 2 Number of arteries obstructed at least 5% in various clinical syndromes.

6 DISTRIBUTION OF CORONARY LESIONS 59 Downloaded from by on December 3, 218 Table 6 Ninety Per Cent or More Obstruction of Lumen, Expressed as Percentage of Patients Having at Least 5%o Obstruction in Each Clinical Group* No infarction (%) Myocardial infarction (t) Coronary Coronary artery Angina, Angina, No Angina, Angina, Rest pain failure obstructed classes I-III class IV angina classes I-III class IV (%) (%) Left only Left with: and circumflex.7.9 and right.9, circumflex, and right 2.6 only with: only with right only Totals With 9% obstruction, no With 5% + obstruction, no % having 9% + obstruction *The total of all fractional percentages in each clinical group is in the bottom line of the table; this total may also be derived by dividing the total number of patients having I 9% or more obstruction by the total number of patients having at least 5% obstruction in each group. tables shown may be studied from this standpoint. It is apparent that patients who have angina pectoris may also have myocardial infarction) so that those with angina pectoris cannot be considered a single uniform group. There appeared to be only minor differences in the distribution of obstruction in patients who had angina pectoris classes I to III and those who had class IV symptoms in the absence of myocardial infarction. The combination of myocardial infarction and angina pectoris had little effect on the distribution of obstructions of at least 5%, though obstructions of at least 9% and total occlusion were more common in patients who had myocardial infarction in addition to angina pectoris. Complete occlusion of a single artery was most frequent in the right coronary artery in all groups of patients who had angina pectoris. Patients who had myocardial infarction without angina pectoris had obstruction of at least 5% involving a single artery more frequently than patients who had angina pectoris with or without myocardial infarction (46.6% for myocardial infarction alone and 17 to 27.3% for various groups having angina pectoris). The anterior descending artery was the only artery severely obstructed in 28% of patients who had myocardial infarction only. The right coronary artery was involved frequently as a single vessel (14.8%) when compared with those groups of patients who had angina pectoris (5.5 to 1.3%). However, total obstruction of the right coronary artery was

7 6 PROUDFIT ET AL. Downloaded from by on December 3, 218 Table 7 Complete Obstruction of Lumen, Expressed as Percentage of Total Number of Patients Having at Least 5% Obstruction in Each Clinical Group* Coronary artery obstructed Left only Left with: and circumflex and right, circumflex, and right only with: only with right only Totals With complete obstruction, no. With 5% + obstruction, no. % having complete obstruction No infarction (%) Angina, Angina, classes I-III class IV No angina Myocardial infarction (%) Angima, Angina, classes I-III class IV Rest pain (%) Coronary failure (%) *The total of all fractional percentages in each clinical group is in the bottom line of the table; this total may also be derived by dividing the total number of patients: having 9% or more obstruction by the total number of patients having at least 5% obstruction in each group. more common in the various groups of patients with angina pectoris (18.9 to 3.7%) than in patients who had myocardial infarction alone (13.6%). The incidence of almost total or total obstruction of at least one major artery was slightly higher in patients who had myocardial infarction and angina pectoris compared to those who had myocardial infarction alone. Patients who had rest pain only had a high incidence of single-vessel involvement (44.8%) and an equal frequency of anterior descending and right coronary artery obstruction. However, the obstruction was less severe than in other clinical groups (62.1% had 9% or more narrowing and 27.6% had total occlusion). The distribution of lesions in patients who had coronary failure was similar to that encountered in angina pectoris. Discussion The distribution of obstructive lesions in the coronary arteries demonstrated by selective technique during life has not been reported in regard to any large series of cases. Differences in selection of patients, numbers of patients studied, classification of clinical diagnoses, details of arteriographic technique, and estimates of the degree of arterial obstruction make comparison of our results with published reports difficult. It is apparent, however, that Likoff and associates2 found lesser degrees of arterial obstruction in symptomatic patients than we encountered. Cohen

8 Downloaded from by on December 3, 218 DISTRIBUTION OF CORONARY LESIONS and associates,3 and Elliott and Gorlin4 found the anterior descending artery affected in 92 and 93% of patients, respectively, in contrast to our 73% who had severe obstructions. The series of Hale and associates5 was small, including only 12 patients who had angina pectoris and arterial lesions. The statement that it is impossible to decide from arteriography alone whether the pain is due to cardiac ischemia if only a single vessel is involved is difficult to understand. The same might be said even in the presence of multiple arterial obstructions. Parker and associates6 reported lesser degrees of arterial obstruction than we found, and the right coronary artery was the vessel most frequently affected. Although in our study lesions were more common in the anterior descending branch of the left coronary artery than at other sites, the difference in incidence in comparison with involvement of the right coronary artery and the circumflex branch of the left coronary artery was not striking. Total occlusion was most frequent in the right coronary artery, severe obstruction in the anterior descending artery, and moderate obstruction in the circumflex artery. Multiple-vessel involvement was common; the average number of arteries affected by lesions exceeding 3% of the luminal diameter per patient was 2.3; the average number narrowed by at least 5% was 2.. However, among the 588 patients who had at least 5% obstruction, 199 (33.8%) had severe lesions in only a single vessel. When lesions exceeding 3% were considered, 131 (2.9% of the 627 total) had a single vessel involved, and 43 of these (6.9% of the 627) had no other recognized arterial obstruction. Patients who had been considered to have noncoronary symptoms or atypical angina had a high incidence of single-vessel involvement when lesions were demonstrated. Predominantly single-vessel severe obstruction was common in patients who had myocardial infarction, especially in the absence of angina pectoris, and in those who had rest pain only. Study of the distribution of severe arterial obstructions did not reveal a pattern characteristic of a clinical syndrome. Only limited conclusions can be reached. Lesions in the left main coronary artery were less common in patients who had myocardial infarction without angina pectoris than in the various groups of patients who had angina pectoris with or without myocardial infarction. The incidence of severe obstruction in only a single vessel was high in patients who had myocardial infarction without angina pectoris (46.6%), in contrast to a much lower incidence in the other clinical groups except in those who had only rest pain (44.8%). The anterior descending artery was much more frequently and severely affected in those who had myocardial infarction without angina, but this predominance was not noted in those who had rest pain only. Obstruction of 9% or more was slightly more common in patients who had myocardial infarction, especially with angina pectoris, than in other clinical groups. In regard to complete obstruction, the anterior descending artery was involved frequently in patients who had myocardial infarction without angina, but the right coronary artery was affected oftener when angina occurred with myocardial infarction. In the absence of anatomic patterns characteristic of clinical syndromes, symptoms must depend on other variables such as the rapidity of development of obstruction, the adequacy of collateral circulation, the presence of functional arterial constriction, the viability of the myocardium distal to the obstruction, the arterial blood pressure, the cardiac output, and the regional coronary blood flow. In this study the presence or absence of evidence of collateral circulation was noted, but this information is difficult to tabulate. The distribution and severity of coronary arterial obstructions demonstrated arteriographically during life may not correspond to the findings obtained in postmortem injection studies, even if it were true that the latter indicated the actual status of the circulation just before death. The postmortem findings frequently represent the end stages of the disease process, unless the patient died of an arrhythmia or a noncoronary cause, but 61

9 62 the arteriograms demonstrate the changes at some clinical stage of the disease process. Anatomic obstruction in certain locations may be incompatible with life, particularly if the onset or accentuation of the degree of obstruction is sudden. References 1. PROUDFIT, W. L., SHREY, E. K., AND SONES, F. M., JR.: Selective cine coronary arteriography: Correlation with clinical findings in 1, patients. Circulation 33: 91, LIKOFF, W., KASPARIAN, H., SEGAL, B. L., No- VACK, P., AND LEHMAN, J. S.: Clinical correlation of coronary arteriography. Amer J Cardiol 16: 159, PROUDFIT ET AL. 3. COHEN, L. S., ELLIOTT, W. C., KLEIN, M. D., AND GORLIN, R.: Coronary heart disease: Clinical, cinearteriographic and metabolic correlations. Amer J Cardiol 17: 153, ELLIOTT, W. C., AND GORLIN, R.: Coronary circulation, myocardial ischemia, and angina pectoris (II). Mod Concepts Cardiov Dis 35: 117, HALE, G., DEXTER, D., JEFFERSON, K., AND LEATHAM, A.: Value of coronary arteriography in the investigation of ischaemic heart disease. Brit Heart J 28: 4, PARKER, J. O., DI GIORGI, S., AND WEST, R..: Selective coronary arteriography: Arteriographic patterns in coronary heart disease. Canad Med Ass J 95: 291, Downloaded from by on December 3, 218 Aortic Regurgitation-Hodgkin (1827) Thou wilt probably recollect having pointed out to me, a few months ago, a particular state of the valves of the aorta, which, by admitting of their falling back towards the ventricle, unfits them for the performance of their function. A force calculated to effect the dilatation of the first part of the aorta, if exerted through the medium of a fluid, as e.g. the blood, must, from its pressing equally on all sides, have also a tendency to send the valves backwards towards the heart. Though I am not aware that such an injury has hitherto been noticed by any author, as occurring in the aortic valves, examples are not wanting of partial ruptures having taken place in other parts of the heart, as a consequence of urgent straining. Corvisart has given three cases in which the carniae columnae, and tendons of the valves, were ruptured from this cause; and Laennec and Bertin have each added another. A previously diseased state of the structure of the artery is probably an important condition as a predisposing cause; and its dilatation may also contribute to induce retroversion of the valves, precisely as Bichat explains the imperfect action of the valves of the veins. -THOMAS HODGKIN: On Retroversion of the Valves of the Aorta. London Med Gaz 3: 433, 1829.