Coronary Atherosclerosis in Valvular Heart Disease Jerome Lacy, M.D., Robert Goodin, M.D., Daniel McMartin, M.D., Ronald Masden, M.D., and Nancy Flowers, M.D. ABSTRACT To evaluate the usefulness of routine coronary arteriography in patients undergoing cardiac catheterization for the evaluation of valvular heart disease, we performed coronary arteriographic studies routinely in a series of 201 patients primarily catheterized for such evaluation. Coronary artery obstructive lesions in excess of 50% of the lumen were present in 45 of the 201 patients. In 18 of the 45 there was no history of chest pain. Three of the 18 had three vessels involved while 2 had two vessels involved. A total of 27 patients (13.4%) had luminal obstruction greater than 70%, and 9 of these had no pain. In 35 of the 201 patients, classic angina pectoris existed in the absence of radiographicallysignificant disease. Severe coronary disease was found to coexist with hemodynamically severe valvular heart disease and was not predictable noninvasively.

the added risk and cost of coronary arteriography could be avoided in such patients. The purpose of this study was to determine the incidence of coronary artery disease in our patients with valvular heart disease and to evaluate the accuracy with which it can be predicted by noninvasive clinical means alone. Further, we wished to test the assertions made by others that significant coronary atherosclerosis would necessarily be revealed by hemodynamically significant valvular heart disease and that coronary arteriography is thus not indicated in such patients in the absence of angina pectoris [l,21.

Materials and Methods During a period of two and one-half years, coronary arteriography was carried out in 201 adult patients undergoing cardiac catheterization for evaluation of valvular heart disease. The paThe need for routine coronary arteriography in tients were studied without regard to factors patients undergoing cardiac catheterization be- that might suggest coronary artery disease or a cause of valvular heart disease has received con- predisposition to it. The group included 104 flicting reports in the literature. Several inves- women with a mean age of 49 years and 97 men tigators have suggested that all patients over 40 with a mean age of 53 years. The age range for years of age have coronary arteriography as part the group was 18 to 74 years. Historical evaluation included determination of their preoperative catheterization and that bypass surgery be considered if significant of functional cardiac class according to the New coronary disease exists [4,71. Other reports have York Heart Association classification, the stated that coronary arteriography is an un- cataloging of risk factors for coronary disease, necessary procedure unless the patient with val- and detailed inquiry into the presence and vular heart disease also has angina pectoris [l, character of chest pain. Physical examination 21. Concomitant coronary artery disease has was further supported by phonocardiograms been implicated in the operative and postopera- and external pressure pulse recording in most tive morbidity and mortality of patients under- patients, and all patients had electrocardiogoing valve replacement, and identification of grams and chest roentgenograms. Catheterizathis group of patients is desirable [71. If such a tion data included left ventriculography and group is predictable by clinical judgment alone, coronary arteriography in all patients, and pulmonary arteriography in most patients. HemoFrom the Section of Cardiology, Department of Medicine, dynamic measurements from both the right and University of Louisville School of Medicine, Louisville, KY. left cardiac chambers were recorded. Accepted for publication Nov 9, 1976. Patients were classified as to age, sex, type of Address reprint requests to Dr. Flowers, Section of Cardiolvalve disease, and the presence and severity of ogy, University of Louisville School of Medicine, 323 E Chestnut St, Louisville, KY 40202. coronary artery disease. Severity was judged in 429

430 The Annals of Thoracic Surgery Vol 23 No 5 May 1977

terms of the estimated percentage of luminal obstruction (based on multiple views) and number of vessels involved. Patient groups identified were those without chest pain, those with pain atypical for angina pectoris, and those with typical angina. To be designated as having “typical” angina pectoris the patients had to have anterior ch.est, neck, or arm pain with at least one of the lollowing: precipitation of pain by exertion, emotional stress, or exposure to cold, or consistent relief of pain by rest or nitroglycerin. Anterior chest pain without the specified characteristics was considered pain atypical for angina pectoris.

100

-- a0 0

(u

-

60

0

3 I-

fn 40 I0

c

20

Results From the total population of 201 patients with valvular heart disease, 83 (41%) were found to have coronary artery disease, ranging from luminal irregularity of a single vessel to complete occlusion of two major vessels. Forty-five patients (22%) had what was termed radiographically significant coronary disease with at least 50°/0 obstruction in one or more vessels, and 27 patients (13%) had lesions greater than 70%. There were 19 women and 26 men with a mean age of 57 years. The occurrence of radiographically significant coronary disease was 27% for men and IS% for women (Fig 1). Considerations of ‘4ge The frequency of coronary disease rose with increasing age. The only patient below the age of 40 who had significant disease was a 39-year-old woman with single-vessel disease whose only risk factor was cigarette smoking (Fig 2). Considerations of Valvular Abnormalities The severity and distribution of coronary artery lesions in patients with valve abnormalities are listed in Table 1. MITRAL STENOSIS. The study included 67 patients (49 women and 18 men) in whom mitral stenosis was the predominant lesion. There were 21 patients .with coronary artery disease, and 13 (19O/0) had significant obstructing lesions; this subgroup was made up of 10 female and 3 male patients with a mean age of 54 years (Fig 3). One patient had three-vessel disease, 6

2 2%

0 MALE

FEMALE

Fig 1 . Coronary artery diseuse (CAD)in patients with valvular disease.

had two-vessel disease, and 6 had one-vessel disease. Three patients were in Functional Class 11, 9 were in Class 111, and 1was in Class IV. MITRAL REGURGITATION. Thirty-three patients (19 women and 14 men) had mitral regurgitation as the predominant lesion. Twelve patients had coronary artery disease, with 6 (18%) having significant disease; this subgroup included 2 women and 4 men with a mean age of 61. Two patients had three-vessel disease, 1had two-vessel disease, and 3 had one-vessel disease. Five patients were in Class I11 or IVwith 3+ to 4+ regurgitation. One patient had the click murmur syndrome with 2+ regurgitation. AORTIC STENOSIS. The predominant lesion was aortic stenosis in 56 patients (17 women and 39 men) who were studied. Thirty-three had coronary artery disease, and 12 (21%) had significant obstructing lesions. The mean age was 60 for the 8 men and 4 women making up this subgroup. Two patients had three-vessel disease, 3 had two-vessel disease, and 7 had single-vessel disease. Gradients across the aortic valve ranged from 58 to 132 mm Hg except for 1 patient with a gradient of 22 mm Hg and another in whom we were unable to cross the valve. Seven patients were in Class 111, 1 was in Class IV, and 1 was in Class 11.

431

Lacy et al: Coronary Atherosclerosis in Valvular Heart Disease

n 0

AGE

~ 3 0

4.2%

19.6%

21.1%

41%

30-39

40-49

50-59

60-69

40%

70-79

Fig2. Age and sexdistribution. (CAD= coronary artery disease.) AORTIC REGURGITATION. Of the 30 patients (11 women and 19 men) who had predominantly aortic regurgitation, 11had coronary artery disease, with 9 of these (30%) having significant obstructing lesions. This subgroup consisted of 1woman and 8 men with a mean age of 56. Two patients had three-vessel disease, 2 had twovessel disease, and 5 had single-vessel disease. Three patients were in Class 11,l was in Class IV, and the remainder were in Class 111. PROSTHETIC VALVES.Fifteen patients (8 women and 7 men) were studied for evaluation

of prosthetic valve dysfunction. Six had coronary artery disease, 5 of whom had significant disease. This subgroup included 2 women and 3 men with a mean age of 48. Three patients had two-vessel disease and 2 had single-vessel disease. All patients were in Class I11 or IV.

Considerations of Pain No history of chest pain could be elicited in 18 (40%) of 45 patients considered to have significant coronary disease. Fourteen patients (31%) had some type of chest pain considered atypical

Table 1. Severity and Distribution of Coronary Artery Lesions by Valve Abnormality Involvement and Degree

MS

MR

1 6 6 13

2 1 3 6

2

3

5 6 13

1

AR

P. Valves

2 3

2 2

7 12

5 9

0 3 2 5

6 3

2

AS

Total

No. of

diseased vessels 3

2 1

Total

Obstruction 2 90% 70-90% 50-70%

Total

2 6

1 6

3 12

MS = mitral stenosis; MR = mitral regurgitation; AS = aortic stenosis; AR valve dysfunction.

9 =

3 1 1 5

7 15

23 45

16 11 18 45

aortic regurgitation; .'I valves = prosthetic

432 The Annals of Thoracic Surgery VoI 23 No 5 May 1977

UCbO Normal

FEMALE

0

MALE

31Y

I

c

n

3

8

a I-

4

L.-'

+

2

w

19.4%

18.2%

214%

30%

33.3%

MS

M I?

AS

AR

PV

Fig 3 . T y p e of valve disease and coronary artery disease (CAD). (MS=: mitralstenosis; MR= mitral regurgitation; AS= aortic stenosis; AR = aortic regurgitation; PV = prosthetic valve dysfunction.)

for angina pectoris, and 13 patients (29%) were thought to have chest pain typical for angina pectoris (Fig 4). NO PAIN. In the total population of 201 patients, 93 gave no history of chest pains; 18 (19'/0) of these patients had asymptomatic significant coronary disease. There were 10 women and 8 men with a mean age of 57 and 62, respectively. This subgroup included 5 patients with mitral stenosis (1lo/o), 3 with aortic stenosis (6.7%), 4 with imitral regurgitation (8.9%), 4 with aortic regurgitation (8.9%), and 2 evaluated for valve dysfunction (4.4%). Three of the patients had three-vessel disease, 2 had two-vessel disease, and 13 had single-vessel disease. Nine patients had obstructing lesions greater than 70% (Fig 5, Table 2 ) . ATYPICAL PAIN. Sixty patients in the series of 201 had atypical chest pain, and 14 (23%) were found to have significant coronary artery disease. There were 6 women and 8 men with a mean age of 55 This subgroup included 5 patients with mitral stenosis (11O/0), 2 with aortic stenosis (4.4%:1, 1 with mitral regurgitation (2.2%), 4 with aortic regurgitation (8.970),and 2 evaluated for valve dysfunction (4.4%). One individual had three-vessel disease, 8 had two-

No Pain

Atypical Pain

Typical Pain

Fig4. Symptoms of pain in patients with coronary artery disease (CAD).

100

-

90

-

80

-

5 N

CAD

70

(1

60

I

0

w 50 n 3 I-

NORMAL

40

-

-

-I

a I-

3020 -

19.3%

No Pain

23.3% Atypical Pain

27.1 %

Typical Pain

Fig5. Symptoms of pain and coronary artery disease (CAD) in totalgroup with valvular heart disease.

433 Lacy et al: Coronary Atherosclerosis in Valvular Heart Disease

Table 2. Distribution and Severity of Coronary Artery Lesions by Type of Pain Involvement and Degree

No Pain

Atypical Pain

3 2 13 18

1 8 5 14

4 5 9 18

4 3 7 14

Typical Pain

Total

No. of

diseased

vessels 3 2 1

Total

Obstruction 3 90% 70-90% 50-70°/o

Total

3 5

5

13 8

3

2 13

7

15 23 45 16 11 18 45

vessel disease, and 5 had single-vessel disease (see Fig 5, Table 2). Of the 201 patients studied, 48 TYPICAL PAIN. gave a history of pain considered typical for angina pectoris. Thirteen (27'/0) of them had significant coronary disease. There were 3 women with a mean age of 59 and 10 men with a mean age of 54. This subgroup consisted of 3 patients with mitral stenosis (6.7%), 7 with aortic stenosis (l6%), 1 with mitral regurgitation (2.2%), 1with aortic regurgitation (2.2%), and 1 evaluated for valve dysfunction (2.2%). Three patients had three-vessel disease, 5 had twovessel disease, and 5 had single-vessel disease. Eleven patients were found to have luminal obstruction greater than 90°/0 (see Fig5, Table 2).

showed Q waves greater than 30 msec in the electrocardiogram. Other findings included nonspecific S-T and T abnormalities, ventricular enlargement, and rhythm disturbances, mainly atrial fibrillation or premature ventricular beats. COMPLICATIONS OF ARTERIOGRAPHY. There were no deaths, arterial thromboses, or acute infarctions. One patient developed ventricular fibrillation on injection of the right coronary artery and was successfully defibrillated without sequelae. The patient was 73 years old and had severe aortic stenosis and a 30% proximal lesion in the right coronary artery. Risk factors for coronary arRISK FACTORS. tery disease were found with equal frequency in patients with and without coronary disease; risk factors were no more common in patients with typical pain than in those without pain.

Comment The 22% of our patients who were shown to have coronary artery disease when evaluated for valvular heart disease represent a sizable population. Further, the 27 patients with luminal obstruction in excess of 70°/0 represent 13.4% of the total population studied for valvular heart disease. In a recent arteriographic study by Kasparian and co-workers [61, 32% of 136 patients had coronary artery disease. In a recent postmortem series of patients with rheumatic valvular disease, Coleman and Soloff [3] reported coincident coronary disease in 13%. Investigations of paA N G I N A PECTORIS A N D NORMAL CORONARY tients with aortic stenosis by coronary arteriogARTERIES. There were 35 patients (17%) in the raphy have shown the incidence of significant total group of 201 individuals studied who had coronary artery disease to be as high as 56% [5, classic angina pectoris but did not have signifi- 81. In our study, patients with mitral stenosis, cant coronary artery disease. Eighteen (8.9%) of mitral regurgitation, and aortic stenosis showed these patients had completely normal coronary a similar incidence of coronary disease. Patients anatomy. There were 23 patients with aortic with aortic regurgitation showed a higher incistenosis (17 men and 6 women), 5 with mitral dence even though their mean age of 56 years stenosis (4 women and 1 man), 3 with aortic was lower than that of the group with mitral regurgitation (2 men and 1 woman), and 2 regurgitation and aortic stenosis. However, the evaluated for prosthesis dysfunction (2 men). group with aortic regurgitation contained a The mean age was 54.8 years in the men and 52 higher percentage of men than the other groups years in the women (see Fig 5). (see Fig 3). Otherwise, a suggestion of sex difference was clearly manifest only in the seventh Other Relevant Considerations decade (see Fig 2). A 39-year-old woman with single-vessel disease was the only patient below ELECTROCARDIOGRAM. Only 5 of the 45 patients with significant coronary artery disease age 40 found to have coronary disease.

434 The Annals of Thoracic Surgery Vol 23

No 5 May 1977

In those patients studied with no history of chest pain, 19% were found to have significant coronary disease. A similar incidence has been reported by others [6]. In contrast, an investigation by Bonchek and associates [2] of 100 patients having a valve replaced reported no patients with significant asymptomatic coronary disease, and they postulated that the increased myocardial work imposed by chronic valvular disease would make any significant comronary obstruction symptomatic. As pointed out by Bonchek, patients with pure mitral stenosis usually do not have abnormal left ventricubr function and conceivably could be more likely to have asymptomatic coronary disease. However, patients without pain in our series included individuals with mitral regurgitation and aortic valve disease as well as mitral stenosis. Only 27% of thee patients with typical angina had significant coronary disease, but a large number of patients with aortic stenosis were in this group. However, 71% of our patients with coronary disease did not have typical angina or a history of previoiis myocardial infarction, thus making the historical diagnosis of atherosclerotic heart disease somewhat insensitive in our patient population. The severity of coronary disease when related to symptoms of chest pain did not show a close correlation. Three-vessel disease occurred with equal frequency in patients with and without typical angina, but single-vessel disease was more common in the group without pain. Obstructive lesions greater than 70% occurred in 11 patients with typical angina and 9 patients without pain. Lesions greater than 90% were more common in individuals with typical pain, and lesions less than 70% were more frequent in patients without pain (see Table 2). Several factors may have contributed to the inadequacy of noninvasive prediction of coronary artery disease. Patients who have catheterization done because of valvular heart disease commonly are taking digitalis and have abnormal resting ECGs and functional impairment severe encough either to preclude exercise stress testing or to make its interpretation difficult. The presence of Q waves of greater than 30 msec occurred in only a small number of our

patients, and in only 2 patients without typical angina. Also, risk factors for coronary atherosclerosis were found with equal frequency in patients with and without coronary disease. The risk of coronary arteriography must be considered; the risk varies according to the catheterization laboratory doing this procedure. A very low complication rate should be expected in those centers doing a large number of procedures. In our laboratory all complications, including vascular thromboses, life-threatening arrhythmias, and myocardial infarctions, occur in less than 1%.Mortality is less than 0.2%, and there have been no deaths associated with the last consecutive 1,100 catheterizations, all but 1of which included coronary arteriography. Within the period of this study there were 15 mitral valve replacements with one or more concomitant saphenous vein bypass graft procedures performed. There were no early deaths, nor have there been any late deaths as of this writing. When aortic valve replacement was done at the time of coronary bypass surgery, however, 4 deaths occurred in 12 patients so treated. This mortality is compared with a perioperative, in-hospital mortality of 3% for aortic valve replacement alone. In both groups the indications for bypass surgery were either severe, medically unresponsive angina pectoris or lesions 70% or greater (usually subtotal occlusions) in locations considered to be critical, such as the left main coronary artery or the very proximal portion of its left anterior descending branch. In conclusion, we found coronary disease of radiological significance to exist in an asymptomatic form in many patients with symptomatic, hemodynamically severe valvular heart disease, as well as in patients with chest pain. In spite of carefully done precatheterization evaluations, we were not able to detect such disease with the degree of reliability that is desirable in an individual patient. We believe insufficient time has elapsed for the impact of specific delineation of coronary disease to be evaluated as an important element in determining appropriate medical and surgical management, and therefore the ultimate outcome, in these patients with valvular heart disease. We do believe that if data obtained through ar-

435 Lacy et al: Coronary Atherosclerosis in Valvular Heart Disease

teriography emerge as important determinants of the course of action, our study supports the thesis that they can be obtained with minimal risk; they cannot be reliably deduced or extrapolated by noninvasive means. With these considerations, in laboratories with comparable morbidity and mortality to our own, we believe the results of coronary arteriography should be a routine part of the presurgical data base. References 1. Basta LL, Raines RD, Najjar S, et al: Clinical, hemodynamic and angiographic correlates of angina pectoris in severe aortic valve disease (abstract). Clin Res 215310, 1973 2. Bonchek LI, Anderson RP, Rosch J: Should coronary arteriography be performed routinely before valve replacement? Am J Cardiol 31:462, 1973

3. Coleman EH, Soloff LA: Incidence of significant coronary artery disease in rheumatic valvular heart disease. Am J Cardiol 25:401, 1970 4. Flemma RJ, Johnson WD, Lepley D, et al: Simultaneous valve replacement and aorta-to-coronary saphenous vein bypass. Ann Thorac Surg 12:163, 1971 5. Hancock EW: Clinical assessment of coronary artery disease in patients with aortic stenosis (abstract). Am J Cardiol 35:142, 1975 6. Kasparian H, Duca PR, Goodman S, et al: The diagnosis and management of obstructive coronary disease in patients with significant chronic valvular disease. Cardiovasc Clin 5:307, 1973 7. Linhart JW, Wheat MW: Myocardial dysfunction following aortic valve replacement: the significance of coronary artery disease. J Thorac Cardiovasc Surg 54:259, 1967 8. Moraski RE, Russell RO, Rackley CE: Aortic stenosis, angina pectoris and coronary artery disease (abstract). Circulation 49,5O:Suppl 3:7, 1974