Long-Term Observations in Patients with Angina and Normal Coronary Arteriograms

Abstract

Thirty-seven patients (mean age 42.7 years) with angina pectoris (AP), ischemic myocardial abnormalities, and normal coronary arteriograms were followed for 4.1 years (mean). Twenty patients had typical and 17 atypical AP. Ten had abnormal serum lipids, and eight had abnormal glucose tolerance tests. Rest-to-exercise hemodynamics revealed increased left ventricular (LV) end-diastolic pressure (mean 11.2 2.6 mm Hg 19.1 3.6, P < 0.05), while stroke-work index increased (+29%). LV ischemia was detected by abnormal lactate extraction with atrial pacing in 10 or >1 mm S-T segment depression during exercise or pacing in 27 patients.After a mean follow-up period of 4.1 years, AP decreased in 80% of cases and remained stable in the other 20% of cases. One patient died suddenly, and autopsy revealed normal coronary arteries and myocardium. In the remainder, complications of ischemia, i.e. progression of symptoms, infarction, and heart failure were absent. Seven patients restudied 4.5 years (mean) later had no changes in their previously documented hemodynamic abnormalities and normal coronary arteriograms.The fate of patients with AP and normal coronaries with ischemic LV abnormalities (ECG, metabolic, or hemodynamic) appears favorable. AP responds to nitrate and propranolol therapy. These long-term clinical observations with angiographic and hemodynamic restudies suggest a nonprogressive disorder.

Coronary Flow Reserve Is a Comprehensive Indicator of Cardiovascular Risk Factors in Subjects With Chest Pain and Normal Coronary Angiogram

“…Despite much research and interest, the pathophysiologic mechanism of this disease remains elusive, 4 and the continuous nature of the chest pain driving a continuous need for anti-anginal medications and in some cases re-hospitalizations are certainly troublesome to the patients and their physicians. 3 CFR is defined as the ratio of baseline PDV to maximal hyperemic PDV. Several methods have been established for measuring CFR, which is important to the understanding of …”

“…Therefore, a normal coronary angiogram itself may not provide any benefit to the patient or the physician. 3 In the context of chest pain, the presence of ST-segment depression during rapid atrial pacing and normal coronary angiogram findings has been termed "microvascular angina", which has been classified as a form of angina pectoris; but despite much research and interest, the characterization of this disease remains elusive. 4 …”

Clinical Characteristics and Follow-up in Patients With Microvascular Angina.

“…[11][12][13][14][15][16][17][18][19][20] Kaski et al studied 99 patients with syndrome X and found a complete absence of death, myocardial infarction and changes in ventricular function during their follow-up period. 13 Recently Foussas et al reported that of 160 patients, only 1 suffered a sudden cardiac death and 2 had a nonfatal myocardial infarction.…”

“…With regard to the prognosis of syndrome X and microvascular angina, there have been some reports showing favorable prognoses in patients with angina-like chest pain and normal coronary arteriograms; [11][12][13][14][15][16][17][18][19][20] However, progressive reduction in left ventricular function has also been described in other reports from Western countries, 9,10 but to date there have been few reports on the prognosis of syndrome X in Japanese patients. 20 This study describes the clinical features and long-term prognosis of patients with microvascular angina, diagnosed by our strict criteria, who underwent cardiac catheterization and endomyocardial biopsy from 1988 to 1997 at Showa University Hospital.…”

Reduced coronary dilatory capacity and ultrastructural changes of the myocardium in patients with angina pectoris but normal coronary arteriograms.

“…5 Myocardial ischemia that is caused by an abnormal affinity of hemoglobin for oxygen, coronary arterial spasm or occlusive disease of small coronary arteries not visualized by coronary arteriography have been suggested as possible causes of this syndrome. 4' 6, 14 To evaluate further patients who have angina pectoris but normal coronary arteriograms, the following studies were performed in addition to left ventricular and coronary angiography: (1) Coronary blood flow (CBF) was measured at rest and during dipyridamoleinduced coronary vasodilatation; (2) biopsy specimens were taken from left ventricular myocardium for microscopic evaluation of intramyocardial vessels and of myocardial cells; (3) myocardial lactate metabolism was studied at rest and during atrial pacing; and (4) left ventricular function was assessed during rest and during exercise. Group …”