T H E C L I N I C A L A P P L I C A T I O N O F C O R O N A R Y A R T E R I O G R A P H Y

W I L L I A M W H I T A K E R , M.D., B.Sc., F.R.C.P.

From The General Infirmary at Leeds

CORONARY arteriography is now becoming a technically satisfactory procedure. The history of its development and the methods available were surveyed in a leading article in the British Medical Journal (1961). Keates (1963) describes the tech- nique employed in Leeds. The purpose of this communicat ion is to discuss the indications for coronary arteriography as they appear f rom an analysis of the results obtained in an initial series o f forty-two patients.

The type of patient studied is shown in Table 1.

Coronary arteriography in the diagnosis of isch- aemie heart disease . - -In order to put coronary arteriography into its perspective it is desirable to give a brief account of the clinical assessment of ischaemic heart disease. Noth ing outstanding has been added to the clinical description of angina pectoris since William Heberden published his account in 1772. He noted its site, its character, its precipitation by exercise and its relief by rest, its radiation and its progression to spontaneous attacks. The strongest evidence for the diagnosis o f coronary artery disease is provided by the history and angina pectoris must be the clinical diagnosis in every patient presenting a typical story o f chest pain.

I t is accepted that the mechanism producing this pain is myocardial anoxia. Coronary artery disease is the commonest cause o f this myocardial anoxia and other causes such as anaemia, thyro- toxicosis, myxoedema, aortic valve disease, mitral valve disease, pu lmonary hypertension and arrhythmias, which are rare, can usually be con- sidered and dismissed at the bedside.

After a clinical examination o f a patient with angina pectoris one is often left with no more than the evidence of the story. The blood pressure may

TABLE 1

TYPE OF PATIENT INVESTIGATED BY CORONARY ARTERIOGRAPHY

Chest pain of uncertain origin

Ischaemic heart disease for surgery

Mitral stenosis with angina pectoris

E.C.G. of uncertain significance

Heart failure of obscure origin

28

9

3

1

1

be raised but in quite half the cases examination fails to reveal any abnormali ty of the heart. A twelve lead electrocardiographic examination is the next diagnostic step. In about half the patients with a history of angina pectoris this electrocardiogram will be abnormal at rest and thus provide evidence to clinch the diagnosis. However, in the others one still lacks objective evidence. These patients are generally next investigated by an effort test. I t has been shown by W o o d and his colleagues (1950) that ischaemic changes can be demonstrated after exercise in about 90 per cent of patients with normal electrocardiograms at rest and an unequi- vocal story of angina pectoris (Fig. 1). A positive effort test provides valuable information which will often clinch a diagnosis o f ischaemic heart disease and al though this test is not entirely without risk, it certainly justifies a place as a routine hospital investigation. At one time one felt obliged to reassure patients with a negative effort test that they had no demonstrable evidence of coronary

TABLE 2

RESULTS OF CORONARY ARTERIOGRAPHY IN PATIENTS WITH CHEST PAIN

16 with classical history of angina

Art eriosam

Failure Normal Block

4 2 4

1 i

i

pectoris I0 with normal E.C.G.'s at rest

and after exercise

3 with a normal E.C.G. at rest and a positive exercise test .

3 with inconclusive E.C.G.'s 1 right bundle branch block 2 S~S a patterns and negative

exercise test .

12 with chest pain of obscure origin 6 with normal E.C.G.'s .

4 with inconclusive E.C.G.'s 1 with L.V. strain 1 with L.V. strain and atrial

flutter . 2 with $2S ~ patterns and

negative exercise test

2 with abnormal E.C.G.'s 1 with abnormal T waves : on

anticoagulants 1 with cardiomyopathy

C06 ) 397

398 C L I N I C A L R A D I O L O G Y

FIG. 1 Electrocardiograms from a patient with angina pectoris. The resting tracing is within normal limits but the strip of V4, recorded after exercise, shows depression of the S-T segment which is

diagnostic of cardiac ischaemia.

artery disease. However, having followed several patients with a classical story of angina pectoris and negative exercise tests until they have developed cardiac infarcts, one has become more cautious in assessing the value of a negative effort test. It is in this group of patients with chest pain and negative electrocardiographic findings that coronary arteriography can provide valuable diagnostic information.

Since coronary arteriography need only be contemplated as a diagnostic measure in about 5 per cent of patients presenting with angina pectoris, it may be thought that this is no great problem. However, we should remind ourselves that in a city like Leeds with a population around half a million, three new people develop mani- festations of coronary artery disease every day. The national figures for men between the ages of forty-five and fifty-four show 500 per 100,000 deaths per annum from coronary thrombosis;

more than a tenfold increase in the last twenty-five years.

The results of coronary arteriographic studies of patients with chest pain are shown in Table 2.

Sixteen patients gave a classical history of angina pectoris. In ten of these the electrocardiograms were normal at rest and after exercise. Three had normal electrocardiograms at rest but showed ischaemic changes after exercise. Three had inconclusive electrocardiographic findings. In the ten patients where the electrocardiograms were normal at rest and after exercise, arteriography demonstrated coronary artery disease in four (Figs. 2 and 3). The examination was a technical failure in four and revealed normal coronary arteries in two. In two of the three patients with positive exercise tests where the examination was satisfactory, blocks were demonstrated. Coronary artery disease was present in the patient with a right bundle branch block pattern and also in the two

THE C L I N I C A L A P P L I C A T I O N OF C O R O N A R Y A R T E R I O G R A P H Y 399

FIG. 2 Case G. B. Electrocardiograms from a patient with angina pectoris. The resting tracings shown on the left are within normal limits. On the right the effect of exercise is shown on lead V5. Records were taken immediately after and for five minutes. None of these showed changes diagnostic of cardiac ischaemia. Coronary arteriography demonstrated a blocked right coronary

artery (Fig. 3).

FIG. 3

Case G. B. Coronary arteriogram. Left lateral view showing a block of the right coronary artery (between arrows). The ]eft coronary artery is normal.

patients showing deep S waves in standard leads 2 and 3 of the electrocardiogram but with negative exercise tests.

Although coronary arteriography is suggested as a method of investi- gating patients with angina pectoris, it is not proposed that this test should be applied to all patients where objective evidence is lacking. Ob- viously, in an elderly hypertensive man, the history alone can and should be accepted as diagnostic. However, in a young person there is often an urgency, social, domestic or profes- sional, which makes a wait and see policy undesirable. In such patients it would seem justifiable to attempt to establish or refute a diagnosis of coronary artery disease by arterio- graphy. Although I believe that coronary artery disease will inevit- ably revealitselfin the electrocardio- gram, it may take a long time to do so.

Coronary arteriography in patients with obscure chest pain.--Chest pain can arise from the involvement of sensitive structures in the medias- tinum by various pathological processes or may be

400 C L I N I C A L R A D I O L O G Y

FIG. 4 FIG. 5 Fro. 4--Case M. R. Coronary arteriogram. Left lateral view. This examination preceded that shown in Figure 5, and in this instance the catheter tip lies in the right posterior aortic sinus, medium has filled both the right and left posterior aortic sinuses, and the anterior descending and circumflex branches of the left coronary artery are demonstrated. Medium has not filled the anterior sinus owing to the position of the catheter and the right coronary artery is not shown. Fro. 5--Case M. R. Coronary arteriogram. Left lateral view. The catheter tip lies in the anterior aortic sinus, medium has filled all three aortic sinuses and both left and right coronary arteries are demonstrated. There is no sign of diseases.

Compare Figure 4.

referred from abdominal disease. While one must accept that conditions such as spontaneous pneumothorax, dissecting aneurysm of the aorta, choleeystitis, hiatus hernia and other oesophageal lesions can produce pain compatible with a diagnosis of cardiac pain, one should be sceptical about accepting these lesions as causes of classical anginal pain. Hiatus hernia has been too readily accepted as a cause of chest pain and I have several patients who have been reassured that their pain was of dyspeptic origin, due to hiatus hernia, who have gone on to develop a cardiac infarct. Some cardi- ologists overstate their disregard for this lesion as a cause of chest pain by teaching that all middle-aged obese patients with angina pectoris will have a hiatus hernia. However, I would not now care to discard a diagnosis of coronary artery disease for one of hiatus hernia in a patient giving a classical story of angina pectoris without the support of a normal coronary arteriogram. The results of the investigation of twelve patients with chest pain of obscure origin are shown in Table 2. In six with normal electrocardiograms the examination failed in two but revealed normal coronary arteries in the four where it was successful. In four patients with

inconclusive electrocardiograms, normal appear- ances were found in two, with deep S waves in standard leads 2 and 3 of the electro- cardiograms and negative exercise tests and also in one patient with atrial flutter and a left ventricular strain pattern. The examination failed in one patient who was believed to have a cardiomyopathy. Normal coronary arteries were demonstrated in a woman who had been transferred from another hospital where she had been established on anti- coagulant therapy because her chest pain was associated with an abnormal electrocardiogram (Figs. 4 and 5). The anticoagulant therapy was stopped as a result of this investigation.

Coronary arteriography in the assessment of patients with isehaemic heart disease for surgical treatment.--It is not intended to discuss the selec- tion of patients for surgical treatment since this will be covered by Allison (1962). Nine patients with coronary artery disease were investigated as candidates for surgical treatment. One of these patients died about twelve hours after an un- successful arteriographic examination. However, it is not believed that this was an operative death. Patients in this group are usually living a precarious

THE C L I N I C A L A P P L I C A T I O N OF CORONARY A R T E R I O G R A P H Y

existence and are liable to die at any time. Indeed, during the time we have been studying coronary arteriograms in ischaemic heart disease, two patients have died in hospital while awaiting in- vestigation. Sudden death is part of the natural history of these patients with intractable angina pectoris. In the eight patients where successful examinations were carried out, coronary artery disease was obvious but it seems probable that the technique of coronary cannulation devised by Mason Sones of the Cleveland Clinic will be necessary to provide the clarity of picture required before endarterectomy can be considered.

Coronary arteriography in valvular heart d i s e a s e . - It has been mentioned previously that angina pectoris occurs in patients with valvular heart disease. It is most common in severe aortic stenosis and may be due to haemodynamic disturbances secondary to the valvular lesion, or to blocking of the Coronary ostia or to associated coronary artery disease. About a fifth of patients with critical mitral stenosis also experience anginal pain due to the haemodynamic disturbances caused by a high pulmonary vascular resistance and a fixed low cardiac output, coronary emboli or associated coronary atherosclerosis. When surgical treatment is contemplated it will sometimes appear desirable to know whether angina pectoris is a manifestation of the haemodynamic disturbance produced by valvular dysfunction or whether it is due to associ- ated coronary artery disease. Three patients with mitral valve disease were investigated. One woman with intractable pain had a normal coronary arteriogram and was subsequently relieved by repair of her mitral valve. One man was shown to have severe coronary artery disease and was advised not to have a mitral valvotomy. The third patient was suspected of having a coronary embolus after a successful mitral valvotomy but his coronary arteriogram revealed nothing abnormal.

Coronary arteriography as a means of excluding coronary artery disease.--With the extension of the use of the electrocardiograph as a routine method of investigation in insurance and other forms of medical examination, an increasing number of patients are going to present with electrocardio- grams which may be abnormal and possibly

401

indicative of pre-clinical coronary artery disease. Is the young pilot with a curious electrocardiogram to be denied his career and the several hundred thousand pounds spent on his training thrown away ? Alternatively, is this man to be allowed to fly supersonic jets risking his own and other lives ? Is the budding surgeon to be advised to seek a less traumatic career in radiology because he has suspicious-looking S-T. segments ? Coronary arteriography must surely find a place as a means of excluding serious disease in this type of individual. We investigated one young man with extrasystoles and T wave changes in his electrocardiogram on exercise and were able to reassure him that he had normal-looking coronary arteries.

Other conditions which are usually confused with coronary artery disease are benign non-specific pericarditis and the cardiomyopathies. Patients with benign non-specific pericarditis are almost always originally diagnosed as suffering from a coronary thrombosis and coronary arteriography may be the only means of preventing this label from sticking and condemning a young man to unwarranted invalidism.

SUMMARY

Coronary arteriography was carried out by retro- grade aortography in forty-two patients and was technically successful in thirty-three. One patient with intractable angina died twelve hours after investigation.

It is suggested that this technique will find a place in the investigation of patients with obscure chest pain, angina pectoris and normal electrocardio- grams, angina pectoris and valvular heart disease, uncertain electrocardiograms, coronary artery disease where surgical treatment is being considered and in excluding coronary artery disease in patients who may have been so wrongly diagnosed.

REFERENCES ALLISON, P. R. (1962). Verbal communication, Faculty of

Radiologists' Symposium on Coronary Artery Disease. BRITISH MEDICAL JOURNAL (1961). Leading article, 2, 878. KEATES, P. G. (1963). Clin. Radiol. 14, 402. WOOD, P., MCGREGOR, M., MAGIDSON, O. • WHITAKER,

W. (1950). Brit. Heart o r. 12, 363.