Chest Pain as a Predictor of Coronary Artery Disease in Patients With Obstructive Aortic Valve Disease

PHILIPPE A. PAQUAY, MD QORDON ANDERSON, MD HELMUT DIEFENTHAL, MD LEONARD NORDSTROM, MD HAROLD G. RICHMAN, MD, FACC FREDARICK L. GOBEL, MD, FACC Minneapolis,

Minnesota

From the Cardiovascular Section, Department of Medicine and the Department of Diagnostic Radiology, Veterans Administration Hospital; and the Cardiovascular Division, University of Minnesota Medical School, Minneapolis, Minn. Manuscript received April 5, 1976; revised manuscript received May 28. 1976, accepted June 2, 1976. Address for reprints: Fredarick L. Gobel, MD, Veterans Administration Hospital, 54th St. and 48th Ave. S., Minneapolis, Minn. 55417.

To clarify the association between chest pain and significant coronary artery disease in patients who have aortic valve disease, 76 consecutive candidates for aortic valve replacement were evaluated prospectively with use of a historical questionnaire and coronary arteriography. Of the 76 patients, 19 (25 percent) had no chest pain, 21 (26 percent) had chest pain that was nottypical of angina pectoris and 36 (47 percent) had chest pain typical of angina pectoris. In 16 of 19 patients the absence of chest pain correlated with the absence of coronary artery disease. The single patient without chest pain who had coronary artery disease had evidence of an inferior myocardial infarction in the electrocardiogram. Thus, absence of chest pain and the absence of electrocardiographic evidence of infarction predicted the absence of coronary disease in all cases. The presence of chest pain did not predict the presence of coronary artery disease, but the more typical the pain of angina pectoris the more likely were patients to have significant coronary artery disease. Of the 21 patients with atypical chest pain, 6 (29 percent) had coronary artery disease, but of the 36 patients with typical angina pectoris 23 (64 percent) had significant coronary artery disease. In addition, when patients with chest pain not typical of angina pectoris also had coronary artery disease, the diseased vessels usually supplied smaller areas of the left ventricle than when the pain was typical of angina pectoris. In 21 of 23 patients (91 percent) with typical angina pectorts and significant coronary artery disease, lesions were present in the left coronary artery. There was no systolic pressure gradient across the aortic valve that excluded the presence of coronary artery disease, although all patients with a calculated aortic valve area of less than 0.4 cm* were free of coronary artery disease. Patients with severe iefl ventricular dysfunction were more likely to have normal coronary arteries.

In patients with aortic valve disease it is important to be confident of the status of the coronary arteries prior to aortic valve replacement because severe narrowing of the coronary ostia or vessels may interfere with adequate myocardial perfusion in the perioperative period and thereby contribute to the mortality and morbidity associated with such surgery.iJ In addition, the surgical relief of chest pain may be as dependent on relieving obstruction of the coronary arteries as on relieving left ventricular outflow obstruction. On the other hand, coronary arteriography is associated with a small but definite risk and should not be performed unnecessarily.3y4 The significance of chest pain in defining coronary arterial obstruction in patients with aortic valve disease is not entirely clear. Although one would expect that patients with both significant, although not necessarily severe, aortic stenosis and coronary artery disease would experience chest pain, this relation has not been clearly defined. Clearer definition is needed in order to define appropriately the indications for coronary arteriography and the role of coronary arterial surgery at the time of aortic valve replacement.

December1976

The American Journal of CARDIOLOGY

Volume 38

863

CHEST

PAIN

AND

AORTIC

VALVE

DISEASE-PAQUAY

ET

AL.

This study was performed to clarify further the association of chest pain and significant coronary artery disease in patients with obstructive aortic valve disease. A prospective protocol was followed in which all candidates for aortic valve replacement, regardless of the presence or absence of chest pain, were studied with coronary arteriography as part of their hemodynamic evaluation in order to assess the importance of chest pain and the electrocardiogram in predicting the status of the coronary arteries. Our data should provide information that will delineate patients at greatest risk of having coronary artery disease and in whom coronary arteriography would be helpful in the preoperative evaluation. Patients

points were possible if the pain was relieved with both rest and nitroglycerin. Less emphasis was placed on quality, duration, radiation of pain and associated symptoms, which were assigned a value of 1 point each when consistent with angina pectoris. Characteristics of chest pain that were not consistent with angina pectoris were assigned no numerical value; for example, an unusual location of pain not relieved with rest or nitroglycerin. Patients whose chest pain was subjectively judged typical of angina pectoris had at least 8 of 12 possible points, whereas those whose pain was judged atypical had fewer than 8 points (Fig. 1). In two patients with 8 points the pain syndrome was arbitrarily categorized as atypical of angina pectoris. A vectorcardiogram with the Frank lead system was recorded in 70 patients, and a standard 12 lead electrocardiogram was recorded in each patient. Electrocardiographic evidence of coronary artery disease was defined as the presence of myocardial infarction, and isolated repolarization abnormalities were not included as evidence of coronary artery disease. Cardiac catheterization studies: Right and left heart catheterization was performed in each patient. The systolic gradient across the aortic valve was determined from pressures recorded simultaneously from two Teflon” catheters. The catheter manometer recording system was shown to have a flat (f10 percent) frequency response of at least 50 hertz. Cardiac output was determined as the quotient of the oxygen consumption and the arteriovenous oxygen difference and the result compared with the value obtained with the indicatordilution technique using Cardiogreen” dye. The mean systolic gradient across the aortic valve was determined from an average of 20 beats. The aortic valve area was calculated according to the formula of Gorlin and Gorlin.” Left ventriculography and ascending aortography were performed in each patient to evaluate the presence of mitral or aortic insufficiency. The degree of aortic insufficiency was estimated from opacification of the left ventricle after aortography. A scale of 0 to 4+ was used: Insufficiency was graded

and Methods

Seventy-six of 79 consecutive men with isolated obstructive aortic valve disease who were candidates for aortic valve replacement were studied. Three patients were excluded because coronary arteriograms were not obtained. The patients ranged in age from 39 to 84 years (mean 57 years). They were treated with digitalis and diuretic agents when necessary and were in optimal clinical condition at the time of the hemodynamic studies. No patient had had previous cardiac surgery. Evaluation of chest pain: The history of chest pain was evaluated by two methods. First, a clinical history was carefully elicited by at least one of us and subjectively judged to be typical or atypical of angina pectoris. Second, patients were classified according to their response to a prospective questionnaire. Seven characteristics of chest pain were assigned a numerical value so that the total possible value was 12 points. A maximal value of 3 points was assigned to location (central, bilateral, anterior and supramammary) and to factors that aggravated or precipitated chest pain (such as eating, exercise, emotion and exposure to cold temperatures). Two

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VALUE

The American Journal of CARDIOLOGY

Volume 38

FIGURE 1. Numerical value assigned to the chest pain syndrome on the basis of response to the angina questionnaire. Patients without chest pain are assigned a value of zero. The open symbols indicate patients either with no discernible coronary arterial lesion or with lesions obstructing less than 75 percent of luminal diameter.

CHEST PAIN AND AORTIC VALVE DISEASE-PAQUAY

1+ when the left ventricle was not completely outlined by contrast material, 2+ when there was sufficient regurgitant opacification to outline the left ventricle but less well than the aorta, 3+ when the ventricle was outlined aa well as the aorta and 4+ when the ventricle was outlined better than the aorta and when it was also enlarged. The first 3 beats after opacification of the aorta were used. Patients with reflux of contrast material into the left atrium during left ventriculography greater than l+ on a scale of 0+ to 4+ were excluded as examples of coexistent mitral insufficiency. Patients were classified into threegroups according to the mean systolic pressure gradient and the degree of aortic insufficiency. Group A consisted of 48 patients with predominant aortic stenosis; all had a mean systolic gradient greater than 30 mm Hg or an aortic valve area of less than 1.5 cm2 and less than grade 2+ aortic insufficiency. Group B consisted of 23 patients with mixed aortic valve disease; all had a mean systolic gradient greater than 29 mm Hg and aortic insufficiency equal to or greater than grade 2+. Group C consisted of five patients with predominant aortic insufficiency (mean systolic gradient 20 mm Hg or less and grade 2+ to 4+ aortic insufficiency. Patients with isolated aortic insufficiency were not included in this study. Ventricular volumes and ejection fraction were estimated from single plane cineangiograms in the right anterior oblique projection (45O). Ventricular volume was calculated using the area-length method6-8 and corrected for X-ray magnification. Coronary arteriograms were obtained in all patients in the right and left oblique projections using the transfemoral percutaneous technique.9 Cineangiograms were recorded at a rate of 60 frames/set. Significant obstruction was not judged present unless at least 75 percent of the diameter of the coronary lumen was judged obliterated in at least one view from several projections.

Results Of the 76 patients, 19 (25 percent) were considered free of chest pain after careful prospective questioning (Fig. 1). Chest pain typical of angina pectoris was present in 36 patients (47 percent), all with 8 or more points on the angina questionnaire. Of the 21 patients (28 percent) judged to have atypical chest pain, all had 8 or fewer points; only 2 patients had 8 points. There was no significant age difference among these three groups. All patients but one were symptomatic (Table I). In one patient syncope was the sole symptom. Dyspnea and chest pain were commonly associated; 41

of the 58 patients with dyspnea had chest pain. Eighteen

of the 19 patients free of chest pain had severe syncope or heart failure, or both. Seventy-five percent of patients were in New York Heart Association functional class III or IV. Of the 30 patients (40 percent) with significant obstruction of one or more coronary arteries, 13 had significant disease in one coronary artery, 5 in two arteries and 12 in three arteries. Eighteen of the 19 patients without chest pain had no significant lesion. No patient had significant disease of the left main coronary artery. Correlation of chest pain and coronary arteriographic findings: The presence of chest pain correlated well with the presence of significant coronary artery disease. All but one patient with significant obstruction of one or more coronary arteries had chest pain. Whether the pain was typical or atypical of angina pectoris was not predictive of the presence or absence of coronary artery disease (Fig. 1). Of 36 patients judged to have typical angina pectoris, 23 (64 percent) had significant obstruction in one or more coronary arteries, whereas 13 (36 percent) had normal coronary arteries. Six of 21 patients (29 percent) with atypical chest pain also had significant coronary artery disease (Fig. 2). These six patients had, respectively, 2, 3,4,5,6 and 7 of 12 points on the angina questionnaire. Five of these six patients had significant disease of only the right coronary artery and the sixth had disease of only a small leftcircumflex vessel. Of patients with typical angina pectoris, only 2 had isolated lesions of the right coronary artery whereas 21 had lesions in the left coronary arterial system. Thus the more typical the chest pain of angina pectoris, the more likely were patients to have disease in the left coronary system. Of the 19 patients without chest pain only 1 had significant coronary artery disease. That patient had two lesions of the right coronary artery, each obstructing 75 percent of the lumen, and a pattern of inferior myocardial infarction in the electrocardiogram. Of the remaining 18 patients, 1 had minimal irregularity of the wall of the left anterior

NO Chest Pain

TABLE

I

Clinical

Data ;::s::

Chest Pain Syndrome None Atypical of angina pectoris Typical of angina pectoris Total

10 13

Total 19 (25%) 21 (27.6%)

With Syncope

coronary

artery,

Chest Pain Atypical Of Angina Pectoris

Typical Angino Pectorir

6/a (29%)

23/36 (64%)

3

5 (26.3%) 6 (28.6%)

With Dyspnea

VI9

17 (89.5%) 13 (61.9%)

(5%) cl

56 f 8

57*

descending

Patients (no.)

standard error of the mean) 60* 57t

ET AL.

10

36 (47.4%)

76

11 (30.6%)

22 (28.9%)

28 (77.8%)

58 (76.3%)

cl

NO S!gmfmnt “’ Coronary

Artery

Coronary

Artery

Disease

Disease

FIGURE 2. Prevalence of significant coronary artery disease in patients with obstructive aortic valve disease according to chest pain syndrome.

December 1976

The American Journal of CARDIOLOGY

Volume 36

665

CHEST PAIN AND AORTIC VALVE DISEASE-PAOUAY

TABLE

ET AL.

normal coronary arteries, two had no chest pain. The one patient in the entire study without chest pain but with coronary artery disease had electrocardiographic evidence of an inferior wall infarction and significant obstruction of the right coronary artery but a normal left coronary arterial system. Ten patients had electrocardiographic or vectorcardiographic evidence of anterior myocardial infarction. Two of these 10 patients had neither evidence of coronary artery disease nor chest pain. Each of the eight patients with electrocardiographic evidence of anterior infarction and chest pain had obstructive lesions in the left anterior descending coronary artery. Thus in this study electrocardiographic evidence of anterior wall infarction plus typical angina pectoris was predictive of a significant lesion in the left anterior descending coronary artery. Correlation of chest pain with severity of aortic stenosis: The frequency of chest pain typical of angina pectoris was similar in Groups A, B and C. Table II indicates the hemodynamic features of these groups. Since the net forward flow and not the actual aortic valve flow was used to calculate aortic valve area, the latter was more likely to be underestimated in patients in Group B (mixed aortic valve disease) than in patients in group A (predominant aortic stenosis). The systemic flow was not significantly greater in group B (5.52 f 1.98 liters/ min) (mean f standard deviation) than in Group A (4.79 f 1.14 literslmin) (P

Chest pain as a predictor of coronary artery disease in patients with obstructive aortic valve disease.

Chest Pain as a Predictor of Coronary Artery Disease in Patients With Obstructive Aortic Valve Disease PHILIPPE A. PAQUAY, MD QORDON ANDERSON, MD HEL...
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