Comparison of some criteria for diagnosing a myocardial infarction after aorto-coronary bypass grafting (CABG).

The incidence of myocardial infarction during a 1-year follow-up period after coronary bypass surgery (CABG), i.e. a recent myocardial infarction (RMI), was studied in 86 patients. Different criteria for the diagnosis of a RMI were compared. Clinical observation, including ECG and serum enzyme analysis, diagnosed RMI in 8% of patients. Specific ECG changes indicating RMI (ECGsp) occurred in 12% of cases, and if less specific ECG changes were also taken into account (ECGsp+nonsp) RMI was found in 30% of cases. Asynergy, detected by two-plane ventriculography, indicated RMI in 24% of the patients, and was probably the most valid of the criteria examined. The differences in diagnostic accuracy of the various criteria highlight the importance of defining diagnostic criteria.

Effects of digitalis, anti-anginal drugs and arterial hypertension on the relationships between exercise ECG and angiocardiographic variables and on the diagnostic accuracy of exercise ECG in patients with coronary heart disease.

We have previously found a statistically significant correlation between some exercise ECG variables and angiocardiographic scores used to evaluate the extent and type of coronary heart disease (CHD). In the present study we examined the effects of digitalis, beta-adrenergic blockers, slow release nitrates, calcium channel blockers, presence of arterial hypertension (AHT), and angiocardiographic changes on the exercise ECG variables. The effects of drugs and AHT were small as compared to the effects of the angiocardiographically detected pathological changes caused by the CHD. Sensitivity and specificity of the exercise ECG ST criteria in identifying patients with an angiocardiographic criterion indicating coronary insufficiency were not much different in the whole group and in the subsets with AHT or medication with digitalis and anti-anginal drugs.

Risk indicators of ischemic heart disease among male professional drivers in Sweden.

Possible risk indicators of ischemic heart disease relevant to the occupation of professional driving were identified in a cohort of 440 professional drivers and 1000 referents from the Swedish countries of Västerbotten and Norrbotten. The subjects were randomly selected. Data on cardiovascular risk indicators were collected from questionnaires, blood pressure measurements, serum lipid levels, height, and weight. The results showed that significantly more drivers than referents were overweight, smokers, and shift workers; were sedentary in their leisure time; and had a work situation characterized by high demands, low decision latitude, and low social support. There were no significant differences concerning blood pressure and serum lipid levels. The odds ratio for having a high score on a cardiovascular risk index was 3.18 (95% confidence interval 2.41-4.20) for the drivers when they were compared with the referents. When adjusted for age, heredity, shift work, educational level, marital status, and working class, the odds ratio was 2.34 (95% confidence interval 1.70-3.21).

Relationships between exercise ECG and angiocardiographic indices of coronary insufficiency and myocardial fibrosis in coronary heart disease.

Patients with coronary heart disease were examined with exercise ECG and angiocardiography. Maximum work capacity expressed as a percentage of the predicted normal exercise tolerance (Wmax%) was significantly associated with the angiocardiographic score of the myocardial mass subserved by obstructed coronary arteries (MCOS). Variables related to myocardial fibrosis (MF) such as post infarction ECG signs, the left ventricular wall motion score (LVMS) and the ejection fraction of the left ventricle (LVEF) correlated significantly as did variables related to reversible myocardial ischaemia or coronary insufficiency (CI), such as ST depression during exercise (STdepr), ST/W and ST/HR indices, effort angina (EA/W) index, the extent of collaterals (CollS), and 'MCOS-LVMS'. MF variables correlated weakly with CI variables. Wmax% covariated with the variables related to both CI and MF, and most closely with MCOS. Discrepancies between results of exercise ECG and angiocardiography have to some extent been overcome by comparing appropriate parameters.

Acute haemodynamic effects and pharmacokinetics of ramipril in patients with heart failure. A placebo controlled three-dose study.

The aim of the present study was primarily to evaluate the haemodynamic effects of the ACE-inhibitor ramipril which is active via its metabolite ramiprilat. Ramipril 1.25, 2.5 and 5 mg and placebo was administered orally to 4 groups of 12 patients with heart failure (NYHA III) in a double-blind randomised, parallel study. Haemodynamics were monitored for 24 h and blood was sampled and urine collected for up to 96 h. In the placebo-treated group the cardiac index (CI) was significantly increased (15.8%) and right atrial pressure decreased (26.6%). Ramipril 1.25 mg had insignificant haemodynamic effects compared to placebo and the 2.5 mg dose had significant effects on some haemodynamic variables. Ramipril 5 mg had pronounced and sustained effects on pulmonary artery pressure, which fell by 43.7%, and pulmonary capillary wedge pressure (PCWP; -59.1%); systemic vascular resistance was also decreased 21%. A significant effect on CI was only seen after 2.5 mg ramipril (+7.4%). The mean maximal degree of ACE inhibition was 73.2, 90.4 and 98.5%, respectively, after the three doses of ramipril. Complete inhibition of ACE-activity was seen at a mean plasma concentration of ramiprilat of 4.7 ng.ml-1. The degree of inhibition declined with a half life of about 75 h. There was a significant relation between the degree of ACE-inhibition and change in PCWP but not with the change in SVR. Ramipril was mainly eliminated in the form of ramiprilat and inactive metabolites.

Mortality in circulatory diseases, especially ischaemic heart disease, among Swedish professional drivers: a retrospective cohort study.

The aim of the investigation was to study mortality from circulatory diseases, especially ischaemic heart disease (IHD), in a cohort of Swedish professional drivers. The cohort included 1,731 male members of the Swedish Transport Workers Union. During the follow-up period, 1974-1985, 123 drivers died. Information concerning the cause of death was acquired from the Cause-of-Death Register. Standardized Mortality Ratio (SMR) for circulatory diseases and ischaemic heart disease were significantly higher among professional drivers (SMR = 127 and 138, respectively) than in the reference group consisting of Swedish males.

Relationships between coronary artery obstruction, asynergy, presence of collaterals and the ejection fraction of the left ventricle in patients with coronary heart disease.

Cardioangiographic scores of coronary artery obstructions and corresponding myocardial involvement (MCOS), presence of collaterals (CollS), and asynergy of the left ventricular wall (LVMS) as well as the left ventricular ejection fraction (EF) were examined in 67 patients with coronary heart disease. A covariation was found between LVMS, EF, ECG changes, and a history indicating a previous myocardial infarction (MI). In a multiple regression analysis the EF covariated with LVMS but not with MCOS and CollS. LVMS indicated a previous MI with at least the same sensitivity and specificity as EF. MCOS and CollS give additional information. Collaterals as well as a high MCOS in relation to the LVMS indicate obstruction of coronary arteries which subserve 'non-fibrotic' myocardium. A patient with a high MCOS and CollS and a low LVMS should be expected to gain most functional improvement from coronary bypass surgery. The scores MCOS, CollS and LVMS are comparatively easy to determine and give a more diversified picture of the state of the myocardium than the EF alone.

Left ventricular asynergy score as an indicator of previous myocardial infarction.

Sixty-eight patients with coronary heart disease (CHD) i.e. a history of angina of effort and/or previous 'possible infarction' were examined inter alia with ECG and cinecardioangiography. A system of scoring was designed which allowed a semiquantitative estimate of the left ventricular asynergy from cinecardioangiography--the left ventricular motion score (LVMS). The LVMS was associated with the presence of a previous myocardial infarction (MI), as indicated by the history and ECG findings. The ECG changes specific for a previous MI were associated with high LVMS values and unspecific or absent ECG changes with low LVMS values. Decision thresholds for ECG changes and asynergy in diagnosing a previous MI were evaluated by means of a ROC analysis. The accuracy of ECG in detecting a previous MI was slightly higher when asynergy indicated a 'true MI' than when autopsy result did so in a comparable group. Therefore the accuracy of asynergy (LVMS greater than or equal to 1) in detecting a previous MI or myocardial fibrosis in patients with CHD should be at least comparable with that of autopsy (scar greater than 1 cm).

Prevalence of coronary artery disease in patients with valvular heart disease.

To evaluate the usefulness of preoperatie coronary angiography in patients undergoing preoperative investigation because of valvular heart disease, we performed coronary angiography in a consecutive series of 329 patients. The prevalence of significant coronary artery disease was 32%. Asymptomatic coronary artery disease was present in 13%. Angina pectoris proved to be a poor predictor of coronary artery disease in aortic valve disease. In mitral valve disease, however, the specificity was high. A cost-benefit calculation was carried out in order to assess what advantage routine coronary angiography might have. According to this, coronary angiography should be performed in all patients suffering from valvular heart disease with angina pectoris, whereas it can be omitted in younger patients without angina. A cut-off point of 60 years seems appropriate for aortic valve disease and 65 years for mitral valve disease.

Decreased removal of triglycerides from the blood--a mechanism for the hypertriglyceridemia in male patients with coronary artery disease.

We determined serum apolipoprotein A I and A II concentrations and triglyceride and cholesterol concentrations in serum lipoprotein density classes in 28 male patients with severe ischaemic heart disease (IHD) and with angiographically verified coronary artery disease (CAD) and in age-matched controls. Both triglyceride and cholesterol concentrations in very low density lipoproteins and in low density lipoproteins were higher in IHD-patients than in the controls. The triglyceride but not the cholesterol concentration in serum was higher in IHD-patients than in the controls. The cholesterol in high density lipoproteins and the serum apolipoprotein A I concentration were lower in IHD-patients than in the controls. At least in part the higher triglyceride concentration in very low density lipoproteins could be attributed to a decreased removal of triglycerides from the blood since the fractional removal rate of an i.v. injected artificial triglyceride emulsion (Intralipid) was slower in IHD-patients than in the controls.