ABSTRACTS

MYOCARDIAL COMPROMISE AND SUDDEN DEATH IN ABERRANT TRANSIENT ST SEGMENT ELEVATION IN UNSTABLE ANGINA: PROG- CORONARY ARTERY ORIGIN FROM THE AORTA NOSTIC SIGNIFICANCE. Richard R. Liberthson, MD; Robert E. Dinsmore, MD, FACC; Peter C. Block, MD, FACC; Gerald M. Pohost, MD, FACC; and H. William Strauss, MD, Massachusetts General Hospital, Boston, MA

Aberrant coronary artery origin from the aorta (Ao) may lead to myocardial compromise or sudden death because of proximal obstruction of the aberrant coronary artery (AA) if it passes between the aorta and the right ventricu- lar infundibulum (RVI). Seventeen patients (pts) with AA passing between the Ao and RVI are presented.

Of 12 pts with left AA, 4 pts (ages l-16 yrs) had exer- tional sudden death, 2 had exertional syncope (ages 36 and 41 yrs) - 1 with no arrhythmia on Holter monitoring, and 1 with ventricular fibrillation (VF) following syncope. In these pts, the AA had proximal hypoplasia, kinking, or atherosclerosis. One pt had an anterolateral acute in- farction (AMI), and 2 had ischemia on stress thallium scan. The other 6 pts with left AA were identified by an- giography performed for chest pain (ages 54-63 yrs), 5 had diffuse atherosclerosis, but none had localized AA narrow- ing.

Of 5 pts with right AA, all were identified by angiog- raphy performed for chest pain. No pt had syncope, no pt had demonstrable AA narrowing, 4 had diffuse atherosclero- SiS, and 1 had inferior wall ischemia on stress thallium scan.

In summary, left AA may be lethal when the AA is severe ly narrowed, and should be considered in the evaluation of young pts with AMI, VF, or syncope. However, in the older pt, longevity itself generally attests to the absence of critical AA compromise. In right AA, proximal AA narrow- ing is rare as are clinical sequelae.

CORONARYARIERY SPASMINEWXDBY'IHECQLD PRESSORTEST. Albert E. Raipler, M.D., FACC, Tetsu, Ishinxxi, M.D., Robert A. &ahine, M.D., FE, Nssiruddin Janal, M.D., Baylor College of I&d. & V.A. Hospital, Houston, Texas

The Cold Pressor (CP) test has been shoxn to reflexly increase ccmnaryvascularresistance. To detenninewheth- erthisreflexresponsemlghtbeofclinicalirrportwce, we Derforwd the CF' test in 17 Datients (Dts) with chest pa.& syndra~s undergoing cor&ry arte&gr&hy. Clini- cally, 6 pts had classical angina, 8 had atypical chest pain wd 3 had mtal’s variant angina.

FollowFng CP stimulaticn, (1 minute hand-imrersion in ice water), aortic systolic pressure rose 20.7 f 2.9 (mean + SE) m (P c.01) end heart rate increased 4 + 2 beats/i&n (NS). Corcnarv arterv suasmresultinz in c&ii- plete'obstruction or critical 'co&mazy artery ;;arrowLng was observed in 4 of the 17 patients (incidence of 24%). TWJ of the 3 patients with wtal's angina developed spasm(ccmplete occlusionof the anterior descending in ~,subtotalrightFntheother)withchestpainorFs- cheinic EKG -es. The third F'&zretalDt. had been given isceorbi& dinitrate prior to the study and did riot mtmifestspasmwith CP orwith ergowwine. ??,xQ of the patients thavght to have classic angina also menifested CP-spasm: Ckuz pt. had recurzxnc e of previously observed spontaneous spasmofthe anterior &scendingwithCP, and slept. withmstable, restFng zmginawhohadno critical corowrylesions develqxdcritical rightcorcnary spasm with CP. All e-induced spaanorxunkdin areas ofpre- existent disease. No ccnplications resulted fran CP.

Thus, Quaybe wiqortantandsafeprovocativetest for identifykg those patients with ischemic heart disease in whan coronary artery spasm may be playing a significant role.

Gary D. Plotnick, MD and C. Richard Conti, MD, FACC, Johns Hopkins University and V.A. Hospital, Baltimore, Maryland and University of Florida, Gainesville, Florida.

The prognostic significance of the direction of ST seg- ment shift was examined in 82 consecutive patients (pts) with unstable angina (UA) defined as rest angina with transient ECG abnormalities and no enzyme rise. Einhteen pts with transient ST segment elevation (ST4) with Gain were followed for 66.3 months (range 42-84) (Group I) and sixty-four pts with transient ST segment depression (ST+) were followed for 58.2 months (range 24-82)(Group II).

Based on life table analysis, one, three and five year survival was 75%, 75% and 687 o respectively for Group I and 77%, 72% and 67% for Group II. In those pts re- ceiving only medical therapy, survival was 73%. 73% and 64% for Group I and 71%, 71% and 66% for Group II. Non-fatal myocardial infarctions occurred in 3 of 12 survivors in Group I and 8 of 37 survivors in Group II.

Mortality in each group was related to the extent of coronary artery disease and left ventricular function and not the direction of the ST segment shift. Thus, pts with UA and transient ST4 do not have a worse prog- nosis than patients with UA and transient ST+.

VARIANT ANGINA:CORONARY ANGlOGRAPHIC PATTERNS AND RESULTS OF MEDICAL AND SURGICAL THERAPY IN 42 CONSECUTIVE PATIENTS Allen Johnson,MD FACC; Hilary Stroud,MD; WVR Vieweg,MD FACC; John Ross, Jr.,MD FACC, Univ of Calif, San Diego,Ca.

In 42 patients (pts) with variant angina (VA), coronary (C) angiographic patterns were correlated with therapeutic responses over an average follow-up period of 21 mos. 24 pts had rest pain alone; 18 also had exertional angina. II pts (24%) had no significant C obstruction [normal cor- onaries (Grade 0) in 4, and minor luminal irregularities (Grade I) in 71. 31 had significant atherosclerotic ob- struction [greater than 75% narrowing (Grade II)]; only I artery was involved in 16 pts, and multiple vessel in- volvement in 15. Rest angina only was present in 9 of the 11 (82%) with Grade 0 or I, whereas 16 of the 18 (89%) with both rest and exertional angina had Grade II disease. C artery spasm was documented in 8 pts, of whom 4 had Grade 0, 3 had Grade I, and 1 had Grade II disease; no pt had pain and ST segment elevation during cath without documented spasm. Only 1 of the 42 pts had died during follow-up. 27 pts had C artery bypass grafting, including 3 with spasm; of the latter pts, 1 had Grade II, and 2 had Grade I associated with pain and refractory arrhyth- mias. No pt treated surgically has had recurrence of VA or serious arrhythmias. Of 15 pts managed medically with nitrates, 7 continue to have symptoms or have had myocar- dial infarction; 3 of these pts had Grade II and 4 Grade 0 or Grade I disease. We conclude: (1) the clinical pre- sentation of VA does not allow accurate prediction of cor- onary anatomy, and C arterlography should be performed prlor to planning therapy in all pts; (2) C spasm plays a significant role both in pts wfth normal C arteries and those with various degrees of atherosclerosis; (3) surgi- cal treatment should be considered In all pts with signi- ficant atherosclerotic obstructlons, and in pts without significant obstruction refractory to medical treatment.

358 February 1978 The American Journal of CARDIOLOGY Volume 41