Contribution of the coronary arteriogram to diagnosis of coronary heart disease

Contribution of the Coronary Arteriogram

to Diagnosis of Coronary Heart Disease*

HARALD ELIASCH, M.D., OLOF EDHAG, M.D., ARNE GREPE, M.D. and GUNNAR BI~RCK, M.D.

Stockholm, Sweden

T HE DIAGNOSIS of coronary heart disease is usually made from a “typical history,”

either of angina pectoris or of a myocardial infarction (recent or old) in combination with a resting, exercise or postexercise electrocardiogram compatible with myocardial ischemia.

Although reports from many investigators have appeared, the evaluation of the place of coronary arteriography in the over-all diagnostic work-up in patients with suspected coronary artery disease is not yet clear. Data from 65 patients who have been studied with coronary angiography during the years 1962-1965 have been analyzed with this in mind, and the results are presented below.

MATERIAL

During 1962 to 1965 coronary arteriograms were made in 80 patients hospitalized either for prospective coronary surgery or for clarifying a doubtful diagnosis of ischemic heart disease. In this report, 15 patients were excluded; in 7, the technical quality of the roentgenologic examination did not allow for complete visualization of the main coronary arteries; in 8, the electrocardiogram could not be interpreted with respect to possible ischemic S-T pattern either because of bundle branch block or digitalis medica- tion. Thus, the present report was based on 65 patients, between 29 and 59 years of age (mean 48). Fifty-one patients were male, aged 30 to 59 years (mean 49), and 14 were female, aged 29 to 52 years (mean 45). There was no clinical evidence of valvular heart disease or congestive heart failure in any of these patients.

The patients zoere divided into four groups (A-D) according to their claim of “typical” or “atypical” angina1 pain, on the one hand,l and the presence of “typical” versus “atypical” or absent ischemic electrocardiographic change on the other:

Group A comprised 35 patients with “typical”

history of angina and ischemic electrocardiographic change.

Group B comprised 14 patients with “atypical” chest pain or discomfort and “atypical” or normal electrocardiogram.

Group C comprised 10 patients with “typical” history of angina and “atypical” or normal electrocardiogram.

Group D comprised 6 patients with “atypical” chest pain or discomfort and ischemic electrocardiographic change.

METHODS

Coronary arteriography was performed by way of thoracic aortography. The details of the method have been described before.2 General anesthesia was employed. The catheter was introduced percu- taneously into the right femoral artery, and the tip of the catheter positioned above the aortic valve. As the intrabronchial pressure was raised to 25 to 50 cm. of water, injection of the contrast medium was made on two occasions in two different projections. The Gidlund-Elema biplane roll-film exchanger was used. Twenty-three examinations were made at the Department of Roentgenology, the Thoracic Clinics, Karolinska Sjukhuset3 In that series a straight tip catheter was used and 80 ml. of 76 per cent Uro- grafin@ was injected. In the remaining patients the examination was performed at the Department of Roentgenology, Serafimer Hospital. Here, a loop-end catheter4s5 was used and 40 ml. of 75 per cent Isopaque@ injected.

Evaluation of the coronary arteriogram was made by the roentgenologist without knowledge of the pertinent clinical data. The number and the sites of vascular abnormalities were registered (not reported here); the vascular changes were graded according to severity as follows: 1, no visible change; 2, arterial narrowing; 3, arterial occlusion.

Complications: In 1 man, aged 56, with a typical history of angina pectoris and an electrocardiogram compatible with myocardial ischemia, impending cardiac tamponade developed during the investiga-

* From the Departments of Medicine and Roentgenology, Karolinska Institutet at Serafimerlasarettet, Stockholm, Sweden. This study was supported by grants from the Swedish National Association against Heart and Chest Diseases.

502 THE AMERICAN JOURNAL OF CARDIOLOGY

Evaluation of Coronary Arteriogram .503

rion. Blood was removed at a subsequent pericardial rap. and the patient improved rapidly. One month later a complete coronary arteriography was performed with no untoward reactions.

In a woman, aged 51, dysarthria and partial loss of memory developed subsequent to the examination. Neurologic examination revealed no signs of a focal cerebral lesion. During the past year she has almost completely recovered.

Electrocardiographic Examination: The electrocardiogram was recorded at rest in the supine and in the standing posture, then during bicycle ergometry and thereafter during a recovery period of 5 to 10 minutes. Except for the exercise period leads I, II, III, aVR, aVL, aVF, CR2, CR4, CRS, CR7 and V,, Vz, Vq, V5 and VT were used. During exercise CH?, CHIl CHS and CH7 were recorded.* The electrocardiograms were interpreted according to the criteria of Lepeschkin6 and Mattingly.’ S-T depres- sion of at least 1 mm. with a straight or downward sloping S-T segment was interpreted as ischemic change. Exercise was performed until the point of pain was reached, or until the appearance of repeated ventricular premature beats or a heart rate of 100-l 60 beats/min.

Serum Lipid Determination: Serum cholesterol was determined by the method of Zak et a1.,8 with the Technicon Instruments Autoanalyzer; serum triglycerides, by the method of Blankenhorn et aLg In a random samplelo of twins (118 male and 75 female, aged 38 to 75 years, average 50) the mean serum cholesterol level was 300 mg./lOO ml., S.D. 55, and the mean serum triglyceride level 160 mg./lOO ml., S.D. 65.

RESULTS

GROUP .4 (FIG. 1)

In the 35 patients with a typical history of angina pectoris and ischemic S-T pattern in the postexercise electrocardiogram, arterial narrowing only was seen in 16 patients and arterial occlusion in 18\ patients. In these 34 patients with structural change, 4 being female, the age ranged between 39 and 58 years. Fourteen patients had a family history of coronary heart disease, and 6 additional patients, a family history of diabetes mellitus. The duration of symptoms of typical angina1 pain varied con- siderably, from six months to more than ten years. In 10 patients a diastolic blood pressure over 100 mm. Hg was recorded. The serum lipids were as a whole elevated. Thus,

serum cholesterol below 300 ml. was in only patients and serum triglyceride below 160 in 3

* CH leads denote the indifferent is positioned the forehead.

19, APRIL

only. The at rest normal 13 patients. thcsc, - arterial occlusion 5 had narrowing, lvhile

remaining patient case report had a arteriogram.

Case Coronary Heart :uth .\‘ormal Arteriogram: ‘I‘his a man 43, with

12 month of angina1 after walking M. His died of infarction at aye of One brother myocardial infarction the age 42. The had a weight. no of valvular disease and normal-sized heart

roentgenogram. His pressure \vas 90 mm. Laboratory tests a serum lesterol level 370 mg./lOO and a triglyceride of 293 ml. .%n glucose tolerance yielded a half-life time.” ischemic S-T \vas re-

both during immediately after exercise test. the subsequent arteriogram all main arteries well visualized, there was sign of change. Since discrepancy be-

the arteriogram the clinical be- came the exercise was re-

after injection 5 mg. intra- venously. was administered minutes after was given, the beta blockade was from the of cardioaccelera-

The electrocardiogram not change; im- plied increased sympathomimetic was not for the electrocardiogram.

GROUP (FIG. 2)

14 patients chest pain discomfort reported in history, but resting or electrocardiogram did

show an pattern compatible ischemic heart In 13 no

arterial was visible; ages ranged

29 and years and were female. familial history coronary heart was

reported 3 and diabetes by -Ml pa- had a blood pressure 9.5

mm. In 4 the serum level exceeded mg./lOO ml., the serum

level exceeded rng., ‘100

in only patient. Arterial was visible 1 patient,

case report

Case Report. Chest Discomfort Abnormal Coronary This was air force aged 39. had no symptoms of heart disease. engaged in training with to participate marathon ski-run. routine ex-

a negative wave in and V5 recorded. additional change recorded on exercise electrocardiogram. physical Tvorking

504 Eliasch et al.

Aw Heredity Duratton of symptoms

000 .

00 . years

@I-

0

40-

-

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blood press.

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. 00

00 .

00 .

.

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Heredity

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.

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Cholesterol

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1 0 0: - .

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FIG. 1. Group A. Clinical data and results of coronary arteriography in 35 patients with a “typical” history of angina1 pain and ischemic S-T pattern in the resting or the exercise electrocardiogram, or in both. The results of coronary arteriography are graded as: 1 (0) = no vascular change; 2 (a) = obliterative change; 3 (0) = occlusive change. Circles denote male, squares denote female patients.

capacity was excellent. A subsequent coronary ar- pectoris was disclosed, but the resting or post- teriogram revealed an isolated narrowing in the exercise electrocardiogram did not show the descending ramus of the left coronary artery. Three years later, this patient is still physically active and has

ischemic S-T pattern. Their ages ranged be-

no symptoms. His electrocardiogram is unchanged. tween 39 and 59 years; 3 were women. In 4 of the 10 patients no arterial change was

GROUP C (FIG. 3)

In 10 patients a typical history of angina

visible on angiography; of the remaining 6, 2 had arterial narrowing, and 4 had arterial occlusion. A familial history of coronary heart

THE AMERICAN JOURNAL OF CARDIOLOGY

Evaluation of Coronary Arteriogram 505

disease and diabetes mellitus was more fre- quent in those having visible arterial change. As far as duration of symptoms, level of diastolic blood pressure and serum lipid levels were con- cerned, both patients without and those with arterial change showed a similar pattern.

GROUP D (FIG. 4)

In 6 patients (2 female) aged 30 to 51, either the resting or exercise electrocardiogram, or both, disclosed a typical ischemic pattern while angina1 pain was not present. In 3 of these patients no arterial change was visible on arteriography; arterial narrowing was seen m 2, and signs of arterial occlusion were cvi- dent in the remaining patient. Family history, blood pressure and serum lipid levels were essentially alike in those without compared to those with arterial change. The electrocardiogram at rest was normal in 4 patients; 1 had arterial occlusion, 1 had arterial narrowing, and the remaining 2 had a normal arteriogram.

COMMENTS

The evaluation of the place of coronary arteriography in clinical diagnosis of coronary disease at the present time has to be based on reports from many sources. The aim of this paper has been to present data which might contribute to the answer to the following ques- tions: Is the technic safe enough to permit the use of coronary angiography for diagnostic purposes, even though the idea of a specific surgical intervention may be remote? To what extent does the information obtained by coronary angiography corroborate clinical and electrocardiographic “evidence” of coronary heart disease? Can coronary angiography give a decisive answer as to the presence or absence of structural changes in the coronary arterial tree in patients with a questionable history arid,;‘‘‘’ an electrocardiogram of doubtful or noninformative significance? What are the present indications considered justifiable for coronary arteriography in routine clinical work- up of patients with either or both symptoms and signs of coronary heart disease?

Safrty: As documented from several sources, the modern technic of coronary arteriography has proved to be a safe investigative procedure that can be added to the list of possible methods for diagnosing coronary heart disease.“~4~‘“J3 In this study, which excluded patients with congestive heart failure or valvular heart lesions, the nimlber and the severity of observed com-

VOLUME 19, APRIL 1967

mmHg

120

?

60 1

4L--_ 1 2 3

400- o - 0

0

3oo- B 8 0

2w

1 8

1 100 1

, ; ;

mg-,. 300 4

i 0

2wJ

I

1 00 x m- m

i 3

i_-- I 2 3

FIG. 2. Group B. Clinical data and results of coronary arteriography in 14 patients with “atypical” chest pain and no ischemic S-T pattern in the resting or the exercise electrocardiogram, or in both. Symbols as in Figure 1.

plications were within the range that may prevail in a laboratory where selective angio- cardiography is routinely performed for the diagnostic work-up of patients with congenital or acquired cardiac lesions. Thus, in as much as coronary arteriography may be needed for cases in which there are special reasons for making a precise diagnosis, its use seems justifiable.

Clinical Indications and A@lications: In 34 of

the 35 patients with typical angina1 pain and ischemic S-T pattern in the electrocardiogram, the presumptive clinical diagnosis of coronary heart disease was corroborated by structural change in the coronary arteries depicted on the arteriogram. This close relation agrees with the experience of others.14-I7 Also, finding only one inconsistency suggests that the method of coronary arteriography seems already suf- ficiently developed to confirm the clinical diagnosis of myocardial ischemia. Likewise, in 14 patients whose clinical history and electrocardiographic findings were not considered

506 Eliasch et al.

Duratfon of symptoms

Age Heredity

. CHD 8

POS.

. Heredity

Diab. . .

years

co- 0

0

0

.

”

6-

4-

1 2

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1 a

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0 8

.

1 .

0

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3CQ- Ep

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.

1 100

1 1 100

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llj ;ij

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1 2 3

FIG. 3. Group C. Clinical data and results of coronary arteriography in 10 patients with a “typical” history of angina1 pain without ischemic S-T pattern in the resting or the exercise electrocardiogram, or in both. Symbols as in Figure 1.

compatible with ischemic heart disease, structural change in the coronary arteries could not be seen, except for one patient. The experience thus gained amplifies the value of the coronary arteriogram in supporting the clinical suspicion not only of the presence but also of the absence of structural change.

The place of diagnostic coronary arteriography in these two patient categories is uncertain. Since the clinical history together with the electrocardiographic changes were of definite pre-

dictive value, the diagnostic gain was small. As for the patients with obstructive disease, apart from the implicit need for an arteriogram should surgery be considered, the main value will be to improve our understanding of the relative contribution of such factors as clinical history, electrocardiographic changes and abnormalities in the lipid or carbohydrate metabolism in the diagnosis and prognosis of structural change in the coronary arteries. As for the group with essentially no structural changes, the arterio-


Evaluation of Coronary Lkteriogram 5 0.7

i 60;

i *

I 2 3

FIG. 4. Grouqi I). Clinical data and results of coronary arteriography in 6 patients with “atypical” chest pain but with ischemic S-T pattern in the resting or the exercise electrocardiogram, or in both. Symbols as in Figul-c 1.

c__--____

mg %

1 . 300 “,

0

1 xc 1 0

1 100

i,

I 2 3 L

1 2 3

gram could, in many instances, provide reas- surance to the patient and his physician.

In the 2 remaining patient categories where the clinical history and the electrocardiogram were dissociated, the presence of structural change could be verified in 9 of the 16 patients. None of the other recorded clinical or laboratory data were of predictive value. Since the number of these types of patients was too small, comments OII this problem must be premature. Alore experience is needed for clarifying the contradictory findings. However, in these patient groups coronary arteriography may very well pro\-ide the only clue to the presence or absence of coronary heart disease and thus supply the physician with an important diagnostic tool.

Since the aim of the present study was to analyze the contribution of the coronary arteriogram to the diagnosis of coronary heart disease, we have refrained from discussing the various sites, the number and severity of visualized lesions and their relation to the various clinical

aud laborator>. findings. Srlffice it to remark that the diagnostic )-ield of the postcxercise electrocardiogram in patients with strllctural arterial change was high, as has been pre- viously reported.‘” Finally. altholqh patients with strrlctural change had a definitely hiSher serum lipid Ic\~l compared to those withollt \.isi- ble lesions, the significance of this observation cannot be evaluated since the present patients were not selected on the basis of their lipid vallles. These values Inay, instead, bear a secondary relation to the parameters used in our selection of patients.

SUMMARY

Sixty-five patients were studied by coronary arteriography over a period of three years in order to analyze the relation between the roentgenologic findings and the presence or absence of “typical” angina1 pain and ischelnic electrocardiographic change. Complications caused by the examination were rare and nonfatal.

In 34 of 35 patients with typicai angina1 pain together with an ischemic electrocardiographic pattern, the coronary arteriogram showed structural change. In 13 of 14 patients without the aforementioned clinical and electrocardiographic features, 110 arterial change was \isiblc. In 16 patients whose clinical history and electrocardiographic patterns were dissociated, arterial change was present in 9. The results suggest that coronary arteriography can provide a11 important clue to the diagnosis of coronary- heart disease. Appraisal of the prognostic \-alue of coronary arteriography is important and lnust await follow-up exaininations.

,&XiNOWLEDGMENTS

Twenty-three of the coronary angiograms reported were performed by Dr. B. Nordenstrtim, and his coll- aborators. The lipid chemistry values were determined at the Department of Clinical Chemistry (brad: Dr. R. Blomstrand), and the electrocardiograms were made at the Department of Clinical Physiology (head: Dr. B. Pernow), the Seraphimer Hospital, Stockholm.

REFERENCES

1. World IHealth Organization. Arterial Hypertension and Ischaemic Heart Disease. Preventive As- pects. IV.H.0. Technical Report Series, No. 231, 1962.

2. NORDENSTR~~M, B. Contrast examination of the cardiovascular system during increased intrabronchial pressure. Acta rodiol., Suppl. 200, 1960.

3. MALBORG, R. O., NORDENSTR~~M, B. and T&NELL,

G. Coronary angiography. Acta med. scandinm., Suppl. 426: 17, 1964.

VOLUME 19, APRIL 1967

508 Eliasch et al.

4. PAULIN, S. Coronary angiography. A technical, anatomic and clinical study. Acta radial., Suppl. 223, 1964.

5. BELLMAN, S., FRANK, H. A., LAMBERT, P. B., LITT- MAN, D. and WILLIAMS, .I. A. Coronary arteriography. I. Differential opacification of the aortic stream by catheter of special design-experimental development. New England J. Med., 262: 325, 1960.

6. LEPESCHKIN, E. Exercise tests in the diagnosis of coronary heart disease. Circulation, 22: 986, 1960.

7. MATTINGLY, T. W. The postexercise electrocardiogram. Its value in the diagnosis and prognosis of coronary arterial disease. Am. J. Cardiol., 9: 395, 1962.

8. ZAK, B., DICKENHAM, R. C., WHITE, E. G., BURNETT, H. and CHERNEY, P. J. Rapid estimation of free and total cholesterol. Am. J. Clin. Path., 24: 1307, 1954.

9. BLANKENHORN, D. H., ROUSER, G. and WEIMER, T. J. A method for the estimation of blood glycerides employing florisil. J. Lipid Res., 2: 281, 1961.

10. LUNDMAN, T. Smoking in relation to coronary heart disease and lung function in twins. A co-twin control study. Acta med. scandinav., Suppl. 455, 1966.

11. WAI~LBERG, F. Intravenous glucose tolerance in myocardial infarction, angina pectoris and inter- mittent claudication. Acta med. scandinav., Suppl. 453, 1966.

12. SONES, F. M. and SHIREY, E. K. Cine coronary arteriography. Mod. Concepts Cardiovas. Dis., 31 : 735, 1962.

13. GENSINI, G. G. Coronary angiography. Prog. Cardiovas. Dis., 6: 155, 1963.

14. FORSBERG, S. A., PAULIN, S., VARNAUKSAS, E. and WERKO, L. Coronary angiography in the diagnosis of coronary heart disease. Acta med. scandinav., 173: 269, 1963.

15. KATTUS, A. .4., MAC ALPIN, R., LONGMIRE, W. P., O’LOUGHLIN, B. J. and BISHOP, H. Coronary angiograms and the exercise electrocardiogram in the study of angina pectoris. Am. J. Med., 34: 19, 1963.

16. COHEN, L. S., ELLIOTT, W. C., KLEIN, M. D. and GORLIN, R. Coronary heart disease. Clinical, cinearteriographic and metabolic correlations. Am. J. Cardiol., 17: 153, 1966.

17. HALE, G., DEXTER, D., JEFFERSON, K. and LEA- THAM, A. Value of coronary arteriography in the investigation of ischaemic heart disease. Brit. Heart J., 28: 40, 1966.


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Contribution of the coronary arteriogram to diagnosis of coronary heart disease