ABSTRACTS

RBSDLTS OF MEDICAL AND SURGICAL M4NASEM5Nl OF HIGH-RISK UNSTABLE ANGINA Robert Vogel, M.D., George Pappas, M.D., Peter Levitt, M.D., Dennis Battock, M.D., and Peter Steele, M.D., Denver Veterans Administration Hospital, Denver, Co

Controversy exists as to the management of unstable angina. In the past 3 years, 27 patients (all men, ave age 52 years) have been seen with high-risk, unstable angina, &fined as angina lasting for longer than 30 min- utes, with associated ischemia ST and T changes, while being hospitalized after being treated with isosorbide dinitrate and propranolol for more than 2 days. Seven received only medical treatment (MED) and 20 underwent coronary artery bypass surgery (CAB). Evidence of prior myocardial infarction (MI) was present in 16 of 27 (59%) (4 of 7 (51%) MED and 12 of 20 (60%) CAB) and MI within 3 weeks of CAB occurred in 5 of 20 (25%). Coronary angio- graphy was undertaken without incident in 25 of 27 and all had significant 2 or 3 vessel coronary obstruction with left anterior descending obstruction in all and 8 (32%) had left main obstruction. Of the 7 MSD, all have had MI and 6 of 7 have died (.2-13 months ave 5.2 months). Of the 20 GAB there was 1 operative death, no late deaths and MI, although 4 of 20 (20%) had electrocardiographic evidence of ischemic injury post-operatively. Good to excellent relief of angina has occurred in 18 of 19 C4B survivors (follow-up, l-36 months; ave 10 mos). Results suggest that high-risk unstable angina is a serious ill- ness, MBD is not satisfactory, angiography can be safely undertaken, multi-vessel coronary disease is present and c4B can be performed with low risk and with expectation of good clinical results.

EXTENT AND SEVERITY OF CORONARY ARTERY DISEASE IN PATIENTS DYING FROM CARDIOGENIC SHOCK OR CON- GESTIVE HEART FAILURE FOLLOWING ACUTE MYOCAR- DIAL INFARCTION. Fran8 J. Wackers,MD; Kong I. Lie,M, D; Anton E. Becker,MD, FACC; Hein J. WelIens,MD,FACC; and Dirk T)urrer,MD,FACC. Departments of Cardiology and Pathology, WiIhelmina Gasthuis, Amsterdam, The Netherlands.

Of 800 patients consecutively admitted tc the coronary care unit because of acute myocardial infarction (AMI), 147 died within 8 weeks of onset of infarction (18.4%). Of these 92 p (63% of deaths) died from pump failure, including 68 p from cardiogenic shock (CS) and 24 p from congestive heart failure (CHF), CS became manifest within 24 hours after onset of AMI in 84% (5’7/68 p).Of these 94% (64/68 p) died within three days after AMI. Onset of CHF was randomly distributed over a 3 week period following AMI. Of these 71% (I?‘/24 p) died within 1 to 8 weeks after AMI. The coronary arteries (CA) were studied postmortem by angicgraphy and serial sectio- ning in 51 p (37 p with CS and 14 with CHF), In both groups there was a 75% incidence of severe disease (at least 76% occlusion) over a locg segment of the left anterior descen- ding artery (LAD). There were differences hcwever in involvement of the other CA in the group with CS versus CHF, Three vessel disease (occlusion of 75% or more) was present in 68% (25/37 p) with CS, but only in 29% (4/14 p) with CHF @<O. 02). 64% (9/14 p) with CHF showed no or less than 75% narrowing of the circumflex artery. 64% (9/14 p) with CHF had severe local narrowing of the right CA. 71% (lo/14 p) with CHF had two vessel disease or less, the LAD nearly always being severely affected over a long segment. In view of the extent and severity of CA disease long term success from circulatory assist and cardiac surgery seems very unlikely in p with CS, Only p with CHF might profit from these procedures.

LEFT ATRIAL ENLARGEMENT:ECHOCARDIOGRAPHIC VALIDATION OF ELECTROCARDIOGRAPHIC CRITERIA Alan D. Waggoner; Ajit V. Adyanthaya, MD; Miguel A. Quinones, MD; James K. Alexander, MD, FACC, Baylor College of Medicine, Houston, Texas.

The reliability of the electrocardiogram (ECG) in de- tecting left atria1 enlargement (LAE) was evaluated in 334 patients (pts) using echography (echo) as a standard for comparison. ECC criteria in sinus rhythm (302 pts)

were: duration of P wave in lead I or II Z 0.12 set with or without abnormal P wave in VI (L); duration of nega- tive terminal P in VI/PR segment Z 1.0 (V,); negative P terminal force in VI 7 0.03 mm see (Vb). Echo LAE criteria were: I-LA dimension > 4.0 cm; II-LA/aorta ratio > 1. 17 with or without criterion I. Echo - Percent of Patients- Total No. Criteria Pos. ECG Neg. ECG of Pts.

L Va Vh Total

1 (+) 53 7.0 ;j 69 31’ 71

(-) 9 1.0 14 24 +* 76 231

II (+) 45 6.0 13 64 37 * 104

(-1 6 0.5 13 19.5 ** 80 198 * % false negative +* % false positive

Greater ECG specificity (81%) but lower sensitivity

(64%) was observed when echo criterion II was utilized.

ECG criterion Vb appeared unreliable regardless of

echo criteria. Excluding Vb increased ECG specificity

to 94% and diminished sensitivity to 61%. In 32 pts with

atria1 fibrillation (27 with LAE) coarse vs fine fibrillary

waves were unreliable in predicting LAE. Using

appropriate criteria the ECG appears to be a highly

specific but less sensitive indicator of LAE.

TRANSPOSITION OF ‘DiS GREAT ARTERIES WIM INTACT VENTRICU- LAR SEPTUM AND PATENT DIJCTUS ARTERIOSUS J. Deane Waldman, MD; Milton H. Paul, MD, FACC; Edgar A. Newfeld, MD; Alexander J. Muster, MD, FACC; Farouk S. Idriss, MD; Depts. of Pediatrics and Surgery, Northwestern Univ.-McGaw Med. Ctr., Chicago, Illinois.

A persistent patent ductus arteriosus (PDA) with intact ventricular septum (IVS) was demonstrated by angiography in 34 of 118 infants with D-transposition of the great arteries (TCA) undergoing balloon atria1 septostomy @AS). Sixteen (14%) were considered angiographically large. ‘lhese infants were distinguished clinically by early re- ferral (median age 1.5 days) with tachypnea rather than intense cyanosis as a major sign. Cyanosis was slight in half the group; aortic 02 saturation was high (median 60%, range 21-812) for TCA with IVS but several infants with severe heart failure had marked unsaturation. Continuous murmurs and prominent pulses were noted in only 4 infants. Initial clinical improvement occurred following RAS, but 8 infants (50%) required early additional procedures to en- large the interatrial communication (IAC) compared to 15% of infants with TGA and IVS in our clinic. Early spontane- ous closing (8-18 days) of large PDA was documented in 6 infants and associated in several with sudden deteriora- tion. Eight infants had successful total correction, 2 in- fants died shortly after RAS from extreme acidosis and 4 died during early atria1 surgery. he infant with TGA, IVS and large PDA represents a difficult management problem because: 1)persistent large PDA ten lead to unremitting congestive heart failure, 2)BA.S appears to be less satis- factory as a palliative procedure in the large PDA group, 3) spontaneous or surgical closure of the large PDA can lead to rapid cardiovascular collapse in the absence of an adequate IAC, 4)hemodynamic and histologic data appear to link persistence of a large PDA with early pulmonary vesc- ular obstructive disease in infants with TCA and IVS.

January 1975 The American Journal of CARDIOLOGY Volume 35 175