Stable Angina, Unstable Angina, and - Coronary Artery Disease ...
makalah Angina Stable 2
6
8/9/2019 makalah Angina Stable 2 http://slidepdf.com/reader/full/makalah-angina-stable-2 1/6 Pathology of Stable and Unstable Angina Pectoris By RICHARD B. GUTHRIE, M.D., ZEEV VLODAVER, M. D., DEMETRE M. NICOLOFF, M.D., AND JESSE E. EDWARDS, M.D. SUMMARY The clinical and pathological data from 46 patients who died during or shortly after coronary bypass sur- gery and one patient who died shortly after angiography were studied. Each patient was placed into one of three clinical categories of angina pectoris. Twelve were classified as having unstable angina pectoris, 20 as stable severe angina, and 15 as stable moderate angina. No significant difference was found between the three categories when age, sex, presence of hypertension, lipid abnormalities, diabetes, smoking, family history of myocardial infarction, or history of previous myocardial infarction were examined. Most patients in all classes of angina had extensive atherosclerotic coronary disease: 12 patients had triple vessel plus left main disease; 25, triple vessel disease; nine, double vessel disease; and only one, single vessel disease. There was no difference in severity or distribution of coronary disease when the three categories of angina were compared. Thirty-six of the 47 patients had evidence of scarring of one or more aspects of the left ven- tricular wall. There was likewise no significant difference between extent and distribution of myocardial scarring between the three clinical categories. Four of the 12 patients with unstable angina pectoris had pathologic evidence of preoperative myocardial infarction, whereas this was not found in any of the 35 patients with stable angina. Additional Indexing Words: Coronary atherosclerosis Coro I N THE ANGINAL PATIENT, only unusual circumstances allow for a correlation of the pathological changes present at or near the time of clinical evaluation. In this study, we examined the clinical and pathological features in 47 anginal patients who had been evaluated clinically. Forty-six of these were operated upon soon after examination and died either at the time of or shortly after coronary bypass surgery. With this patient selection, it was felt that any pathological changes occurring subsequent to opera- tion could be identified. Pathological changes not so identified could thus be correlated with clinical studies, usually done within two weeks of operation. Specific pathological profiles corresponding with the various clinical types of angina were sought. Of in- terest, also, was the question of frequency of clinically unidentified acute myocardial infarction in patients with unstable angina pectoris. From the Department of Pathology, United Hospitals-Miller Division, St. Paul, Minnesota, and from the Departments of Pathology, Surgery and Medicine, University of Minnesota, Minneapolis, Minnesota. Supported by Public Health Service Research Grant 5 R01 HL05694 and Research Training Grant 5 TOI HL05570 from the National Heart and Lung Institute. Address for reprints: Dr. Jesse E. Edwards, M.D., Department of Pathology, United Hospitals-Miller Division, 125 W. College Avenue, St. Paul, Minnesota 55102. Received January 10, 1975; revision accepted for publication January 18, 1975. Circulation, Volume Si, June 1975 cmary heart disease Materials andMethods Forty-seven patients with various types of angina were studied. Forty-six died after a coronary bypass procedure and one other patient died shortly after coronary arteriography. From the clinical records, each patient was classified as to the type of angina according to the following definitions. Angina pectoris was subdivided into major types, stable and unstable. Stable angina was defined as anterior thoracic pain related to effort and relieved by rest. The duration varied from between three and ten minutes. The pattern of occurrence of stable angina does not change but may be of varied severity and may be subdivided into the moderate and severe types. Characteristic of stable angina was prompt relief of discomfort with rest or nitroglycerin. Unstable angina was characterized as angina of recent onset less than three weeks prior to clinical evaluation) or as angina characterized by a recent change in pattern i.e., stable angina which has recently worsened in terms of fre- quency, severity, intensity and ease of provocation). Noctur- nal or angina at rest, as well as episodes of prolonged angina, were often characteristic in these patients. There was no electrocardiographic or enzymatic evidence of recent myo- cardial infarction. Most patients with unstable angina had been hospitalized for at least four days prior to operation, and clinical evalua- tion, including electrocardiographic and enzyme studies, had not shown evidence of acute myocardial infarction. The clinical records were abstracted for a history of previous myocardial infarction, valvular disease, diabetes and smoking habits, as well as levels of blood pressure, cholesterol and triglycerides. Also, the presence or absence of a family history of myocardial infarction was noted. At autopsy the hearts of each of the 47 cases were ex- amined and the cardiac weight and thickness of the left ven- tricular wall were recorded. The coronary arteries were ex- 1059 by guest on March 24, 2015 http://circ.ahajournals.org/ Downloaded from
Transcript of makalah Angina Stable 2
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P a t h o l o g y o f
S t a b l e
a n d
U n s t a b l e
A n g i n a
P e c t o r i s
B y
R I C H A R D B .
G U T H R I E ,
M . D . ,
Z E E V
V L O D A V E R , M. D . ,
DEMETRE M.
N I C O L O F F ,
M . D . ,
AND
J E S S E E .
E D W A R D S ,
M . D .
SUMMARY
T h e
c l i n i c a l a n d
p a t h o l o g i c a l
d a t a f r o m 4 6
p a t i e n t s w h o
d i e d
d u r i n g or
s h o r t l y a f t e r
coronary
b y p a s s sur-
gery
a n d
one
p a t i e n t
w h o d i e d
s h o r t l y
a f t e r
a n g i o g r a p h y were s t u d i e d . E a c h
p a t i e n t was
p l a c e d i n t o
one
o f
t h r e e
c l i n i c a l
c a t e g o r i e s
o f a n g i n a p e c t o r i s .
T w e l v e
were
c l a s s i f i e d
as
h a v i n g u n s t a b l e
a n g i n a
p e c t o r i s , 2 0 as
s t a b l e
severe
a n g i n a , a n d 1 5
as
s t a b l e
m o d e r a t e
a n g i n a . No
s i g n i f i c a n t d i f f e r e n c e
was f o u n d
b e t w e e n t h e
t h r e e
c a t e g o r i e s
w h e n
age,
s e x , presence
o f h y p e r t e n s i o n ,
l i p i d
a b n o r m a l i t i e s ,
d i a b e t e s ,
s m o k i n g , f a m i l y
h i s t o r y o f m y o c a r d i a l
i n f a r c t i o n ,
or
h i s t o r y o f p r e v i o u s
m y o c a r d i a l
i n f a r c t i o n were e x a m i n e d .
M o s t
p a t i e n t s
i n
a l l
c l a s s e s o f a n g i n a h a d
e x t e n s i v e a t h e r o s c l e r o t i c
coronary
d i s e a s e : 1 2
p a t i e n t s
h a d t r i p l e
v e s s e l
p l u s
l e f t
m a i n
d i s e a s e ; 2 5 , t r i p l e
v e s s e l
d i s e a s e ;
n i n e , d o u b l e
v e s s e l
d i s e a s e ; a n d
o n l y
one, s i n g l e v e s s e l
d i s e a s e .
T h e r e was
no
d i f f e r e n c e i n
s e v e r i t y
or
d i s t r i b u t i o n o f
coronary d i s e a s e
w h e n
t h e
t h r e e
c a t e g o r i e s o f a n g i n a
were c o m p a r e d .
T h i r t y - s i x
o f t h e
4 7 p a t i e n t s
h a d e v i d e n c e
o f s c a r r i n g o f
one
or
more a s p e c t s
o f
t h e
l e f t
ven-
t r i c u l a r w a l l .
T h e r e was l i k e w i s e no
s i g n i f i c a n t
d i f f e r e n c e
b e t w e e n
e x t e n t
a n d
d i s t r i b u t i o n
o f
m y o c a r d i a l
s c a r r i n g
b e t w e e n t h e t h r e e
c l i n i c a l
c a t e g o r i e s .
F o u r
o f
t h e
1 2
p a t i e n t s w i t h
u n s t a b l e
a n g i n a p e c t o r i s
h a d
p a t h o l o g i c
e v i d e n c e
o f
p r e o p e r a t i v e
m y o c a r d i a l
i n f a r c t i o n ,
w h e r e a s
t h i s
was
n o t
f o u n d
i n
any
o f
t h e
3 5
p a t i e n t s
w i t h
s t a b l e
a n g i n a .
A d d i t i o n a l
I n d e x i n g
W o r d s :
C o r o n a r y
a t h e r o s c l e r o s i s
C o r o
I
N
THE
ANGINAL
P A T I E N T ,
o n l y
u n u s u a l
c i r c u m s t a n c e s a l l o w
f o r a c o r r e l a t i o n
o f t h e
p a t h o l o g i c a l
c h a n g e s
p r e s e n t a t o r
n e a r
t h e
t i m e
o f
c l i n i c a l
e v a l u a t i o n .
I n
t h i s
s t u d y ,
w e
e x a m i n e d
t h e c l i n i c a l
a n d
p a t h o l o g i c a l
f e a t u r e s
i n
4 7
a n g i n a l
p a t i e n t s
w h o
h a d
b e e n
e v a l u a t e d
c l i n i c a l l y .
F o r t y - s i x o f
t h e s e
w e r e
o p e r a t e d
u p o n s o o n
a f t e r
e x a m i n a t i o n a n d
d i e d
e i t h e r
a t
t h e
t i m e o f o r s h o r t l y
a f t e r
c o r o n a r y
b y p a s s
s u r g e r y .
W i t h t h i s
p a t i e n t
s e l e c t i o n ,
i t
w a s f e l t t h a t
a n y
p a t h o l o g i c a l
c h a n g e s
o c c u r r i n g
s u b s e q u e n t t o o p e r a -
t i o n c o u l d
b e
i d e n t i f i e d .
P a t h o l o g i c a l c h a n g e s
n o t
s o
i d e n t i f i e d c o u l d
t h u s b e
c o r r e l a t e d
w i t h c l i n i c a l
s t u d i e s ,
u s u a l l y d o n e
w i t h i n
t w o w e e k s o f
o p e r a t i o n .
S p e c i f i c
p a t h o l o g i c a l
p r o f i l e s
c o r r e s p o n d i n g
w i t h t h e
v a r i o u s
c l i n i c a l
t y p e s
o f
a n g i n a w e r e
s o u g h t . O f
i n -
t e r e s t ,
a l s o ,
w a s t h e
q u e s t i o n o f
f r e q u e n c y o f
c l i n i c a l l y
u n i d e n t i f i e d
a c u t e
m y o c a r d i a l
i n f a r c t i o n
i n
p a t i e n t s
w i t h u n s t a b l e
a n g i n a p e c t o r i s .
From t h e
D e p a r t m e n t
o f
P a t h o l o g y ,
U n i t e d
H o s p i t a l s - M i l l e r
D i v i s i o n ,
S t .
P a u l ,
M i n n e s o t a ,
a n d f r o m t h e
D e p a r t m e n t s
o f
P a t h o l o g y , S u r g e r y
a n d
M e d i c i n e ,
U n i v e r s i t y
o f
M i n n e s o t a ,
M i n n e a p o l i s ,
M i n n e s o t a .
S u p p o r t e d b y
P u b l i c
H e a l t h S e r v i c e R e s e a r c h
G r a n t
5
R 0 1
HL05694
a n d R e s e a r c h
T r a i n i n g
G r a n t
5
T O I
HL05570 f r o m
t h e
N a t i o n a l
H e a r t a n d
L u n g
I n s t i t u t e .
A d d r e s s
f o r
r e p r i n t s :
D r .
J e s s e
E .
E d w a r d s , M . D . , D e p a r t m e n t
o f
P a t h o l o g y ,
U n i t e d
H o s p i t a l s - M i l l e r
D i v i s i o n ,
1 2 5
W.
C o l l e g e
A v e n u e ,
S t .
P a u l ,
M i n n e s o t a
5 5 1 0 2 .
R e c e i v e d
J a n u a r y 1 0 , 1 9 7 5 ;
r e v i s i o n
a c c e p t e d
f o r
p u b l i c a t i o n
J a n u a r y
1 8 , 1 9 7 5 .
C i r c u l a t i o n ,
V o l u m e
S i ,
J u n e
1 9 7 5
c m a r y
h e a r t d i s e a s e
M a t e r i a l s
a n d M e t h o d s
F o r t y - s e v e n
p a t i e n t s w i t h
v a r i o u s t y p e s
o f
a n g i n a
w e r e
s t u d i e d .
F o r t y - s i x
d i e d
a f t e r a
c o r o n a r y b y p a s s
p r o c e d u r e
a n d o n e
o t h e r
p a t i e n t
d i e d s h o r t l y a f t e r
c o r o n a r y
a r t e r i o g r a p h y . F r o m t h e
c l i n i c a l
r e c o r d s , e a c h p a t i e n t
w a s
c l a s s i f i e d a s
t o t h e
t y p e
o f
a n g i n a
a c c o r d i n g
t o t h e
f o l l o w i n g
d e f i n i t i o n s .
A n g i n a p e c t o r i s w a s s u b d i v i d e d
i n t o m a j o r
t y p e s , s t a b l e
a n d
u n s t a b l e . S t a b l e
a n g i n a
w a s
d e f i n e d
a s
a n t e r i o r
t h o r a c i c
p a i n
r e l a t e d
t o
e f f o r t
a n d
r e l i e v e d
b y r e s t . T h e
d u r a t i o n
v a r i e d
f r o m
b e t w e e n t h r e e
a n d
t e n
m i n u t e s . T h e
p a t t e r n
o f
o c c u r r e n c e
o f s t a b l e
a n g i n a
d o e s
n o t
c h a n g e b u t
m a y b e
o f
v a r i e d
s e v e r i t y a n d
m a y b e
s u b d i v i d e d
i n t o t h e
m o d e r a t e
a n d s e v e r e
t y p e s .
C h a r a c t e r i s t i c
o f s t a b l e
a n g i n a
w a s
p r o m p t
r e l i e f o f
d i s c o m f o r t
w i t h r e s t
o r
n i t r o g l y c e r i n .
U n s t a b l e a n g i n a
w a s c h a r a c t e r i z e d
a s
a n g i n a
o f
r e c e n t
o n s e t
l e s s
t h a n
t h r e e
w e e k s
p r i o r
t o
c l i n i c a l
e v a l u a t i o n )
o r
a s
a n g i n a c h a r a c t e r i z e d
b y
a
r e c e n t
c h a n g e
i n
p a t t e r n
i . e . ,
s t a b l e
a n g i n a
w h i c h
h a s
r e c e n t l y
w o r s e n e d
i n t e r m s o f
f r e -
q u e n c y ,
s e v e r i t y , i n t e n s i t y
a n d
e a s e
o f
p r o v o c a t i o n ) .
N o c t u r -
n a l
o r
a n g i n a
a t
r e s t ,
a s
w e l l
a s
e p i s o d e s
o f
p r o l o n g e d
a n g i n a ,
w e r e
o f t e n
c h a r a c t e r i s t i c i n
t h e s e
p a t i e n t s .
T h e r e w a s n o
e l e c t r o c a r d i o g r a p h i c
o r
e n z y m a t i c
e v i d e n c e
o f
r e c e n t
m y o -
c a r d i a l i n f a r c t i o n .
M o s t
p a t i e n t s
w i t h
u n s t a b l e
a n g i n a
h a d
b e e n
h o s p i t a l i z e d
f o r
a t l e a s t f o u r
d a y s p r i o r
t o
o p e r a t i o n ,
a n d
c l i n i c a l
e v a l u a -
t i o n ,
i n c l u d i n g
e l e c t r o c a r d i o g r a p h i c
a n d
e n z y m e
s t u d i e s ,
h a d n o t
s h o w n
e v i d e n c e
o f
a c u t e
m y o c a r d i a l
i n f a r c t i o n .
T h e
c l i n i c a l r e c o r d s w e r e
a b s t r a c t e d
f o r a
h i s t o r y
o f
p r e v i o u s
m y o c a r d i a l
i n f a r c t i o n ,
v a l v u l a r
d i s e a s e , d i a b e t e s
a n d
s m o k i n g h a b i t s ,
a s
w e l l a s
l e v e l s o f b l o o d
p r e s s u r e ,
c h o l e s t e r o l
a n d
t r i g l y c e r i d e s .
A l s o ,
t h e
p r e s e n c e
o r
a b s e n c e
o f
a
f a m i l y h i s t o r y
o f
m y o c a r d i a l
i n f a r c t i o n w a s
n o t e d .
A t
a u t o p s y
t h e
h e a r t s
o f
e a c h o f t h e 4 7
c a s e s
w e r e
e x -
a m i n e d a n d
t h e c a r d i a c
w e i g h t
a n d
t h i c k n e s s
o f t h e
l e f t
v e n -
t r i c u l a r
w a l l
w e r e
r e c o r d e d .
T h e
c o r o n a r y
a r t e r i e s
w e r e
e x -
1 0 5 9
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GUTHRIE,
VLODAVER,
NICOLOFF,
EDWARDS
a m i n e d b y
m a k i n g m u l t i p l e c r o s s - s e c t i o n s
a b o u t 3
mm
a p a r t .
T h e r e s u l t s
o f
o b s e r v a t i o n s
were r e c o r d e d
a c c o r d i n g
t o
s u b d i v i s i o n s o f
t h e a r t e r i e s
as
f o l l o w s :
t h e a n t e r i o r
d e -
s c e n d i n g
a r t e r y
a n d l e f t c i r c u m f l e x
a r t e r y
e a c h
i n t o
p r o x i m a l
a n d d i s t a l
h a l v e s . T h e r i g h t coronary a r t e r y
was d i v i d e d
i n t o
t h r e e s e g m e n t s . T h e s e
were 1 ) t h e
a n t e r i o r
f r o m i t s o r i g i n
t o
i t s m a r g i n a l
b r a n c h ) , 2 )
t h e i n t e r m e d i a t e
f r o m
t h e
m a r g i n a l
b r a n c h
t o
t h e
o r i g i n
o f
t h e
p o s t e r i o r
d e s c e n d i n g
b r a n c h ) ,
a n d 3 )
t h e p o s t e r i o r d e s c e n d i n g
a r t e r y . T h e
m a i n
l e f t coronary
a r t e r y was
n o t s u b d i v i d e d .
T h e
a r t e r i a l
o b s t r u c t i o n b y a t h e r o s c l e r o s i s
was
g r a d e d
on
a b a s i s o f 1 - 4 .
G r a d e
1
was f r o m
0 - 2 5 c
o b s t r u c t i o n o f
t h e
l u m e n ;
g r a d e 2 , 2 6 - 4 9 ;
g r a d e 2 + , 5 0 - 7 4 ; g r a d e
3 , 7 5 ;
g r a d e 3 + , 7 6 - 9 9 C c
o b s t r u c t i o n ;
a n d
g r a d e
4 ,
c o m p l e t e
o c c l u s i o n .
G r a d e s
3 , 3 + ,
or
4
h e r e i n a f t e r w i l l b e
d e s i g n a t e d
as s i g n i f i c a n t
a t h e r o s c l e r o s i s .
S e c t i o n s o f
t h e coronary
a r t e r i e s a l s o
were
s t u d i e d f o r t h e
presence
or
a b s e n c e o f
t h r o m b i .
T h e
v e n t r i c u l a r
myocar-
d i u m was e x a m i ne d b y
m a k i n g gross
s e r i a l s e c t i o n s f r o m t h e
b a s e t o t h e
apex, e a c h
v a r y i n g
1 t o
1
1 / 2 c m
i n
h e i g h t .
R e c o r d s
were
m a d e
as t o
t h e
s i z e
a n d l o c a t i o n o f scars
a n d
represen-
t a t i v e s e c t i o n s f o r
h i s t o l o g i c
s t u d y
were
o b t a i n e d f r o m
t h e
m y o c a r d i u m .
T h e
h e a r t s
were
a l s o
e x a m i n e d
f o r
e v i d e n c e
o f
v a l v u l a r
d i s e a s e .
Any
l e s i o n s w h i c h
were
c o n s i d e r e d
com-
p l i c a t i o n s
o f
t h e s u r g i c a l
p r o c e d u r e
were n o t
c o n s i d e r e d a s
p a r t
o f
t h e
b a s i c
p a t h o l o g i c processes.
P a t h o l o g i c
e x a m i n a t i o n
was d o n e
w i t h o u t
k n o w l e d g e
a s
t o
t h e t y p e
o f
a n g i n a
w h i c h
h a d
b e e n
p r e s e n t c l i n i c a l l y .
R e s u l t s
O f t h e
4 7
cases r e v i e w e d ,
1 2
were
c l a s s i f i e d
as
h a v i n g u n s t a b l e
a n g i n a a n d 3 5 as
s t a b l e . T h e
l a t t e r
were s u b d i v i d e d
i n t o 2 0 w i t h severe s t a b l e a n g i n a
a n d
1 5
w i t h m o d e r a t e
s t a b l e a n g i n a
( t a b l e 1 .
O f
t h e 4 6
o p e r a t e d
p a t i e n t s ,
2 4
d i d n o t
s u r v i v e
t h e
o p e r a t i o n ,
2 1
o f
t h e d e a t h s
b e i n g
c a r d i a c
i n
o r i g i n
w h i l e
t h r e e r e s u l t e d f r o m
h e m o r r h a g e . E i g h t
o f
t h e
p a t i e n t s w h o d i e d b e t w e e n
t h e f i r s t
a n d t h e s e v e n t h
p o s t o p e r a t i v e d a y s h a d
e x p e r i e n c e d e i t h e r
a r r h y t h -
m i a s or l o w
c a r d i a c
o u t p u t
a n d
t h r e e p o s t o p e r a t i v e
h e m o r r h a g e . When d e a t h o c c u r r e d
b e t w e e n t h e
s e v e n t h a n d
t h i r t i e t h
p o s t o p e r a t i v e d a y s ( 1 1
p a t i e n t s ) ,
t h e
cau se o f
d e a t h
was
u s u a l l y n o n c a r d i a c .
T h e
f o r t y -
s e v e n t h
p a t i e n t h a d n o t
b e e n o p e r a t e d
b u t d i e d
s h o r t l y
a f t e r coronary
a r t e r i o g r a p h y . T h e r e was
no
d o m i n a n c e o f
one
t y p e
o f
a n g i n a over
a n o t h e r among
t h e
p a t i e n t s
i n e a c h
o f
t h e
o p e r a t i v e
or p o s t o p e r a t i v e
groups.
C l i n i c a l Features
From t h e
c l i n i c a l
d a t a ,
t h e r e w s
no
d i f f e r e n c e
b e t w e e n t h e
p a t i e n t s
w i t h
v a r i o u s
t y p e s
o f
a n g i n a a s
r e g a r d s f a c t o r s
o f
age,
s e x , b l o o d
pressure, l i p i d
l e v e l s ,
s m o k i n g , d i a b e t e s ,
f a m i l y h i s t o r y or t h e
p a t i e n t ' s own
h i s t o r y o f a n t e c e d e n t a c u t e
m y o c a r d i a l
i n f a r c t i o n
( t a b l e
1 .
I n
t h e
e n t i r e
s e r i e s ,
t h e
m a l e
w s
t h e
d o m i -
n a n t
s e x ,
as t h e r e were 3 9
men
8 3 )
a n d
e i g h t
women.
T h e
average age
o f t h e e n t i r e
g r o u p was 5 4
y e a r s .
H y p e r t e n s i o n
wa s p r e s e n t
i n
1 4 o f
4 5
3 1 )
i n
w h i c h t h e
b l o o d
pre s s u r e h a d b e e n
r e c o r d e d
i n t h e
h o s p i t a l
r e c o r d s .
A b n o r m a l i t i e s o f
s e r u m l i p i d s
were
p r e s e n t i n
4 7
a n d
d i a b e t e s
i n 2 8 . O f t h e 3 4
p a t i e n t s i n whom n
a d e q u a t e
h i s t o r y
o f
s m o k i n g
c o u l d b e
o b t a i n e d ,
65
were
s m o k e r s .
A f a m i l y
h i s t o r y o f
m y o c a r d i a l i n f a r c t i o n
was
p r e s e n t
i n 41 o f
t h e
p a t i e n t s
a n d
t h e r e was a
h i s t o r y
o f
p r e v i o u s
m y o c a r d i a l
i n f a r c t i o n
i n
6 0 .
P a t h o l o g i c a l F e a t u r e s
Among p a t i e n t s
w i t h
a l l
t y p e s
o f
a n g i n a ,
s i g n i f i c a n t
coronary a t h e r o s c l e r o s i s wa s
e x t e n s i v e
( t a b l e 2 , b o t h
a s
t o
n u m b e r s
o f v e s s e l s
i n v o l v e d
a n d
a s
t o
m u l -
t i p l i c i t y
o f
l e s i o n s i n
i n v o l v e d
a r t e r i e s .
C h a r a c -
t e r i s t i c a l l y ,
w h e n s i g n i f i c a n t
a t h e r o s c l e r o s i s was pres-
e n t
i n a g i v e n
v e s s e l ,
t h e r e were
m u l t i p l e
f o c i
o f s u c h
i n v o l v e m e n t . T h e r e
was no
s i g n i f i c a n t d i f f e r e n c e i n
d i s t r i b u t i o n o f
severe
coronary
a t h e r o s c l e r o s i s among
t h e
t h r e e c a t e g o r i e s o f
a n g i n a s t u d i e d f i g .
1 .
I n
most
o f
t h e
cases
( 3 7 )
t h e r e
was
c o i n v o l v e m e n t
o f
t h e
a n t e r i o r d e s c e n d i n g , l e f t c i r c u m f l e x
a n d
r i g h t cor-
onary
a r t e r i e s b y s i g n i f i c a n t
a t h e r o s c l e r o s i s , e i t h e r
w i t h or w i t h o u t
s i m i l a r
i n v o l v e m e n t o f
t h e main l e f t
coronary a r t e r y .
I n
n i n e
o t h e r
cases, o n l y two
co r onary
a r t e r i e s
were
i n v o l v e d w i t h
s i g n i f i c a n t
o b s t r u c t i o n ,
w h i l e i n
o n l y
one case was
t h e r e s i n g l e v e s s e l
d i s e a s e
( t h e r i g h t coronary
a r t e r y ) .
When
two v e s s e l s
were
i n -
v o l v e d ,
t h e mo s t common p a t t e r n
o f d i s t r i b u t i o n was
i n v o l v e m e n t
o f
t h e
r i g h t coronary
a r t e r y
w i t h e i t h e r
t h e a n t e r i o r
d e s c e n d i n g or t h e
l e f t c i r c u m f l e x a r t e r i e s .
I n
o n l y
two
o f t h e
4 7 cases
was t h e r i g h t coronary
a r t e r y
n o t
a f f e c t e d
b y
s i g n i f i c a n t
d i s e a s e
a n d
i n
t h r e e
T a b l e 1
C l i n i c a l
C h a r a c t e r i s t i c s
o f
P a t i e n t s
G r o u p e d
A c c o r d i n g
t o
C a t e g o r y o f
A n g i n a
C a t e g o r y
Number
A v e r a g e
S e x
L i p i d
F a m i l y
h i s t o r y
H i s t o r y o f
p r e -
o f
o f
a g e
d i s t r i b u t i o n
a b n o r -
o f m y o c a r d i a l v i o u s
m y o c a r d i a l
a n g i n a p a t i e n t s
( y e a r s )
F e m a l e s M a l e s H y p e r t e n s i o n
m a l i t i e s
D i a b e t e s S m o k i n g
i n f a r c t i o n i n f a r c t
U n s t a b l e 1 2
5 3 4
8 4 / 1 2
3 / 1 1 1 / 1 2
7 / 9
3 / 8 7
S t a b l e
s e v e r e
2 0
5 5 2
1 8
5 / 1 8
1 2 / 1 7 9 / 1 9 9 / 1 2
6 / 1 6
1 0
S t a b l e m i l d
t o
m o d e r a t e
1 5
5 5
2 1 3 5 / 1 5
5 / 1 5 3 / 1 5
6 / 1 1
6 / 1 3
1 5
T o t a l
4 7
5 4
8
3 9 1 4 / 4 5
2 0 / 4 3
1 3 / 4 6
2 2 / 3 4
1 5 / 3 7
2 8
P e r c e n t
o f
t o t a l 1 0 0
1 7 8 3
3 1
4 7 2 8
6 3 4 1
6 0
C i r c u l a t i o n ,
V o l u m 1 e
5 1 .
J u n e
1 9 7 5
1 0 6 0
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STABLE AND
UNSTABLE ANGINA
T a b l e 2
N u m b e r
o f
V e s s e l s
I n v o l v e d
b y S e v e r e G r a d e
3 o r
H i g h e r )
A t h e r o s c l e r o t i c
L e s i o n s i n
t h e
T h r e e C a t e g o r i e s
o f A n g i n a
Angina
P r e s e n c e o f s i g n i f i c a n t
a t h e r o s c l e r o s i s *
T o t a l
3
Type
c a s e s
1 2 3 L.M.
U n i s t a b l e
1 2 0
2
8
2
S t a b l e s e v e r e
2 0
i t
3 1 1
5
S t a b l e
m i l d
t o
m o d e r a t e
1 5 0
4
6
5
T o t a l
i n a l l
c a t e g o r i e s
4 7
1
9 2 5
1 2
* 1 =
s i n g l e
v e s s e l ;
2 = d o u b l e
v e s s e l ;
3
=
t r i p l e
v e s s e l ;
3
L . M . =
t r i p l e
v e s s e l
l e f t
m a i n .
t R i g h t c o r o n a r y a r t e r y
w i t h
m u l t i p l e
l e s i o n s .
c a s e s
t h e a n t e r i o r d e s c e n d i n g
a r t e r y w a s s p a r e d .
When
t h e d i s t r i b u t i o n
o f s i g n i f i c a n t
l e s i o n s
i n
t h e
r i g h t
c o r o n a r y a r t e r y
w a s
e x a m i n e d ,
i t
w a s
f o u n d
t h a t
i n v o l v e m e n t o f
t h e a n t e r i o r a n d
i n t e r m e d i a t e
s e g m e n t s o f
t h i s a r t e r y
t o g e t h e r
w a s
t h e
m o s t c o m m o n
p a t t e r n
( 2 6
o f
4 5
c a s e s ) .
I n t h e a n t e r i o r
d e s c e n d i n g
a r t e r y ,
t h e p r o x i m a l s e g m e n t
w a s
m o r e
c o m m o n l y
i n -
v o l v e d t h a n t h e
d i s t a l .
I n
t h e l e f t
c i r c u m f l e x
a r t e r y ,
t h e
p r o x i m a l
s e g m e n t
w a s
m o r e
c o m m o n l y
o b s t r u c t e d
t h a n
t h e d i s t a l
b u t
t h e d i f f e r e n c e
w a s
n o t a s
s t r i k i n g
a s
i n t h e a n t e r i o r
d e s c e n d i n g
a r t e r y .
I n
t h e
e n t i r e
s e r i e s
o f 4 7 c a s e s ,
t h e i n t e r m e d i a t e
s e g m e n t
o f t h e
r i g h t
c o r -
o n a r y
w a s t h e
m o s t
c o m m o n l y
i n v o l v e d
b y
s e v e r e
o b s t r u c t i v e d i s e a s e
( 9 3 ) ,
f o l l o w e d
b y
t h e
p r o x i m a l
l e f t
a n t e r i o r d e s c e n d i n g
( 8 9 ) ,
a n d
i n
t u r n , b y
t h e
p r o x i m a l
s e g m e n t
o f
t h e
l e f t
c i r c u m f l e x
( 7 7 )
a n d
a n t e r i o r s e g m e n t
o f
t h e
r i g h t
c o r o n a r y
a r t e r y ( 7 5 )
f i g . 2 .
No
c o r r e l a t i o n
w a s
p r e s e n t
b e t w e e n
t h e
i n t e r m e d i a t e
R CC
P r o x i m a l
L . A . D .
A n t e r i o r
R . C .
P r o x i m a l
C i r c .
L C .
o f
C a s e s
T y p e s o f A n g
U n s t a b l e S t a b l e / / / / / / / /
/ /
t : : : : : :
: : : : : :
t a b :
::::i
:
1
U n s t a b l e
S t a b l e S e v e r e
S t a b l
E L X
E >
. .
,, ;;
; . . . . . . . . . . . . . . . .
m I T T T l T T T T I I I T I I I
so
9 0
l o o
l l l l l l l l l l l l
i t e
M o d e r a t e
F i g u r e
1
D i s t r i b u t i o n
o f g r a d e s
I I I
o r IV
a t h e r o s c l e r o s i s
b y
a r t e r i e s
i n
t h e
s e v e r a l
t y p e s o f a n g i n a
( 4 7
c a s e s ) .
R . C .
=
r i g h t c o r o n a r y ;
L . A . D .
=
l e f t
a n t e r i o r
d e s c e n d i n g ;
C i r c .
=
c i r c u m f l e x ;
L . C .
=
l e f t
c o r o n a r y .
C i r c u l a t i o n ,
V o l u m e
5 1 , J u n e
1 9 7 5
n u m b e r o f v e s s e l s
i n v o l v e d a n d
t h e t y p e
o f
a n g i n a .
S i g n i f i c a n t a t h e r o s c l e r o s i s
o f
t h e
m a i n
l e f t c o r o n a r y
a r t e r y w a s o b s e r v e d
i n
1 4 o f t h e 4 7
c a s e s .
I n
a l l
o f
t h e s e
c a s e s t h e r e
w e r e o t h e r
s i t e s o f
s i g n i f i c a n t
d i s e a s e .
I n
1 2
o f t h e 1 4
c a s e s
w i t h s i g n i f i c a n t
d i s e a s e
o f
t h e
m a i n
l e f t
c o r o n a r y
a r t e r y , e a c h
o f t h e
r e m a i n i n g t h r e e
a r t e r i e s
w a s
a l s o
s e v e r e l y i n v o l v e d .
M a i n l e f t
d i s e a s e
w a s
a s s o c i a t e d w i t h s e v e r e
d i s e a s e o f t w o
o t h e r
a r t e r i e s i n o n e
c a s e a n d i n
o n e
c a s e
o n l y
t h e
a n t e r i o r
d e s c e n d i n g
w a s
a d d i t i o n a l l y
i n v o l v e d .
A m o n g t h e
1 4 c a s e s w i t h
s i g n i f i c a n t
i n v o l v e m e n t o f
t h e m a i n
l e f t
c o r o n a r y
a r t e r y , t h e
d i s t r i b u t i o n a s t o
t h e
t y p e s
o f a n g i n a
w a s a s f o l l o w s :
s t a b l e
m o d e r a t e ,
s i x
c a s e s ;
s t a b l e s e v e r e ,
s i x
c a s e s ;
a n d
u n s t a b l e , t w o
c a s e s .
C o r o n a r y t h r o m b i
w e r e o b s e r v e d
i n
1 7
c a s e s ; 1 5
o f
t h e s e
a l s o e x h i b i t e d
a c u t e m y o c a r d i a l i n f a r c t i o n .
S i n c e
h i s t o l o g i c d e s i g n a t i o n
o f a g e o f
a
c o r o n a r y
t h r o m b u s
i s
d i f f i c u l t , t h e
a s s o c i a t e d i n f a r c t i o n ,
w h e n p r e s e n t , w a s
u s e d
t o
d e t e r m i n e
t h e
a g e
o f
t h e
i n j u r y .
We
w a n t e d
t o
d e t e r m i n e w h e t h e r
t h e a c u t e
p r o c e s s w a s p r e s e n t
o r
i m m i n e n t
w h e n t h e
c l i n i c a l s t u d y
w a s d o n e ,
o r
w h e t h e r
t h e i n f a r c t i o n
d e v e l o p e d
a t s o m e
t i m e
a f t e r
t h e
c l i n i c a l
s t u d y , f o r
e x a m p l e ,
p o s t o p e r a t i v e l y .
S i x
o f t h e
1 2
c a s e s w i t h u n s t a b l e
a n g i n a
e x h i b i t e d
c o r o n a r y
t h r o m b o s i s
a n d
f i v e
o f
t h e s e h a d
a s s o c i a t e d
a c u t e m y o c a r d i a l i n f a r c t i o n .
I n f o u r
o f
t h e l a t t e r ,
t h e
h i s t o l o g i c a g e
o f a t
l e a s t
s o m e
o f t h e i n f a r c t e d
t i s s u e
c l e a r l y a n t e d a t e d
t h e t i m e
o f o p e r a t i o n a n d
t h u s
i n
e a c h o f t h e s e
t h e
i n f a r c t
m a y
h a v e b e e n p r e s e n t
a t
t h e
t i m e
o f o r s h o r t l y a f t e r t h e b a s i c
c l i n i c a l
s t u d y .
A m o n g
s u b j e c t s
w i t h
s t a b l e
a n g i n a ,
e i t h e r
s e v e r e
o r
m o d e r a t e ,
t h e r e w e r e 1 1 c a s e s
w i t h
c o r o n a r y
t h r o m -
b o s i s ,
t e n
o f
w h i c h
a l s o
e x h i b i t e d
a c u t e
m y o c a r d i a l
i n -
I n t e r m e d i a t e
P r o x i m a l
A n t e r i o r
ENE
P r o x i m a l
C i r c .
D i s t a l
R . C .
M a i n
L . C .
D i s t a l
L . A D .
P o s t e r i o r
D e s c .
of
C a s e s
2 0
3 0
40 5 0 6 0
7 0 80 9 0
i d 0
F i g u r e
2
A v e r a g e s o f
g r a d e s o f
a t h e r o s c l e r o s i s
( g r a d e
3 o r
m o r e )
b y
a r t e r i e s
o f
a l l
t h r e e
t y p e s
o f
a n g i n a
s t u d i e d
( 4 7 c a s e s ) .
D e s c .
=
d e s c e n d i n g ;
s e e
f i g u r e
1
f o r
o t h e r a b b r e v i a t i o n s .
1 0 6 1
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G U T H R I E ,
V L O D A V E R , N I C O L O F F ,
EDWARDS
f a r c t i o n .
H o w e v e r ,
i n
c o n s t r a s t t o t h e
g r o u p
w i t h u n -
s t a b l e
a n g i n a ,
e a c h
o f
t h e
i n f a r c t s
a p p e a r e d
t o h a v e
o c c u r r e d
p o s t o p e r a t i v e l y
a n d
c o u l d
n o t
b e
r e l a t e d
t o
t h e
p r e o p e r a t i v e
s t a t e .
F o r
p u r p o s e s
o f
t a b u l a t i n g s c a r s ,
t h e
m y o c a r d i u m
w a s d i v i d e d
i n t o t h e
p o s t e r i o r i n f e r i o r , l a t e r a l ,
a n t e r o s e p t a l ,
a n d
s e p t a l
w a l l s .
S c a r s
i n v o l v i n g
o n e
o r
m o r e o f t h e s e r e g i o n s
o f
t h e
l e f t v e n t r i c u l a r
w a l l w e r e
o b s e r v e d i n
3 6 o f t h e 4 7 p a t i e n t s
6 7 ) ( t a b l e 3 .
T h e
s c a r s
w e r e r e s t r i c t e d
t o o n e
a s p e c t
i n
1 7 c a s e s
a n d
i n -
v o l v e d t w o
o r m o r e
i n
1 9 .
T h e r e
w a s n o
s i g n i f i c a n t
d i f f e r e n c e
b e t w e e n t h e
p r e s e n c e
o r a b s e n c e o f
s c a r r i n g
a n d t h e e x t e n t
o f
s c a r r i n g a m o n g
s u b j e c t s
w i t h
t h r e e
d i f f e r e n t c a t e g o r i e s
o f
a n g i n a .
S c a r s
w e r e m o s t
c o m m o n l y
l o c a t e d
i n t h e
p o s t e r i o r
( i n f e r i o r )
w a l l
o f
t h e l e f t v e n t r i c l e
( t e n
a l o n e a n d
1 3
w i t h
a n o t h e r
z o n e , u s u a l l y
t h e
a n t e r o s e p t a l ) .
L e s s
c o m m o n l y ,
t h e
a n t e r o s e p t a l
r e g i o n
w a s i n v o l v e d
( 1 6
c a s e s ) ( t h r e e
a l o n e
a n d
1 3
w i t h a n o t h e r
z o n e ,
u s u a l l y
t h e
p o s t e r i o r ) .
S c a r s
o f t h e l a t e r a l
w a l l
w e r e
s e e n
i n
1 1 c a s e s
( t h r e e
a l o n e ,
f o u r w i t h
s c a r r i n g
o f t h e
a n t e r o s e p t a l w a l l ,
a n d
f o u r
o t h e r s w i t h s c a r s o f
t h e
p o s t e r i o r
w a l l ) .
L e f t v e n t r i c u l a r h y p e r t r o p h y ,
a s
j u d g e d b y
t h i c k n e s s
o f t h e l e f t
v e n t r i c u l a r
w a l l
e x c e e d i n g
1 . 5
cm
a n d
c a r d i a c w e i g h t
i n e x c e s s
o f 3 5 0
g r a m s
f o r women
a n d
4 5 0
g r a m s
f o r
m e n ,
w a s
p r e s e n t
i n
3 8
o f
t h e
4 7
p a t i e n t s
( 8 1 ) .
T h e r e
w a s
n o
s i g n i f i c a n t
d i f f e r e n c e a s
t o t h e
i n c i d e n c e
o f
l e f t
v e n t r i c u l a r
h y p e r t r o p h y
i n
o n e
c l a s s o f
a n g i n a
a s
c o m p a r e d
w i t h a n o t h e r .
T h e
p e r c e n t a g e
w i t h
l e f t
v e n t r i c u l a r
h y p e r t r o p h y
i n
e a c h
o f t h e c l a s s e s o f
a n g i n a
w a s
a s f o l l o w s : s t a b l e
m o d e r a t e , 5 3 ;
s t a b l e
s e v e r e ,
7 0 ;
a n d
u n s t a b l e ,
5 0 .
T h r e e
p a t i e n t s
h a d a o r t i c
v a l v u l a r
d i s e a s e .
Two
w e r e
f r o m
t h e s t a b l e s e v e r e
g r o u p
a n d o n e f r o m t h e
s t a b l e
m o d e r a t e g r o u p .
N i n e
p a t i e n t s
h a d
e v i d e n c e
o f
m i t r a l r e g u r g i t a t i o n a s s o c i a t e d w i t h
s c a r r i n g
o f t h e
p o s t e r o m e d i a l
p a p i l l a r y
m u s c l e
a n d
p o s t e r i o r
l e f t v e n -
t r i c u l a r w a l l . T h r e e
w e r e f r o m
t h e
g r o u p
w i t h u n -
s t a b l e
a n g i n a ,
t h r e e
f r o m
t h e s t a b l e s e v e r e a n d t h r e e
f r o m t h e s t a b l e
m o d e r a t e g r o u p s .
T a b l e
3
L o c a t i o n
o f
S c a r s
o f
H e a l e d
M y o c a r d i a l
I n f a r c t i o n
i n
P a t i e n t s w i t h
T h r e e C a t e g o r i e s o f A n g i n a P e c t o r i s
L e f t
v e n t r i c u l a r
s c a r r i n g
b y
w a l l s
( a n t e r i o r ,
s e p t a l ,
p o s t e r i o r ,
A n g i n a l a t e r a l )
Type
N o . c a s e s None
On e T wo A l l t h r e e
U n s t a b l e 1 2
4
4
3
1
S t a b l e
s e v e r e 2 0
4
7
8
1
S t a b l e
m i l d
t o m o d e r a t e
1 5
3 6
6
T o t a l
4 7 1 1 1 7
1 7
2
Comment
T o
t h e
b e s t
o f
o u r
k n o w l e d g e ,
t h i s i s t h e
f i r s t
s t u d y
i n w h i c h t h e c l i n i c a l a n d
p a t h o l o g i c
f e a t u r e s o f
p a t i e n t s
w i t h
a n g i n a
p e c t o r i s h a v e b e e n e xa m i ne d
w i t h i n
a t i m e f r a m e t h a t a l l o w s c o r r e l a t i o n s
t o
b e m a d e
b e t w e e n t h e
p a t h o l o g i c
a n d
t h e
c l i n i c a l
f i n d i n g s
n e a r
t h e
t i m e
t h a t
t h e
a n g i n a
w a s
c a t e g o r i z e d .
S e v e r a l
o t h e r s t u d i e s 2 h a v e
i n c l u d e d
p a t i e n t s w h o
d i e d
f r o m
u n r e l a t e d c a u s e s
( c a r c i n o m a ,
h e a r t
f a i l u r e , e t c . )
s e v e r a l
y e a r s f o l l o w i n g
c l i n i c a l
e v a l u a t i o n
o f a n g i n a , a
t i m e s p a n m a k i n g p r e c i s e c o r r e l a t i o n i m p o s s i b l e .
I n o u r s e r i e s ,
t h e
s e x
a n d
a g e d i s t r i b u t i o n c o r -
r e s p o n d s w i t h t h e u s u a l d i s t r i b u t i o n a m o n g p a t i e n t s
w i t h
c l i n i c a l l y e v i d e n t c o r o n a r y d i s e a s e .
I n c o n t r a s t
t o
t h e
s t u d y
o n
a n g i n a b y
Z o l l a n d
a s s o c i a t e s , '
i n
w h i c h a
h i g h
i n c i d e n c e
o f
h y p e r t e n s i o n
w a s
p r e s e n t ( 6 0 ) ,
o u r
s t u d y
r e v e a l e d
a
h i s t o r y o f h y p e r t e n s i o n
i n
o n l y
3 1 .
H o w e v e r , t h e
m u c h h i g h e r
i n c i d e n c e o f l e f t
v e n -
t r i c u l a r
h y p e r t r o p h y
5 8 )
t h a n h y p e r t e n s i o n
i n o u r
s e r i e s
s u g g e s t s
t h a t s o m e
o f
t h e c a s e s
c l a s s i f i e d
a s n o r -
m o t e n s i v e m a y
h a v e b e e n
h y p e r t e n s i v e
f o r
s o m e
p e r i o d p r i o r
t o
t h e t i m e
o f
c l i n i c a l e v a l u a t i o n .
A
h i g h p r o p o r t i o n o f p a t i e n t s
7 7 )
h a d
m y o c a r d i a l
s c a r s .
S i n c e
o n l y
6 0 h a d a
p r e v i o u s
h i s t o r y o f m y o -
c a r d i a l i n f a r c t i o n ,
1 7
o f
t h e
p a t i e n t s
m o s t
l i k e l y h a d
s u f f e r e d
s i l e n t a c u t e m y o c a r d i a l
i n f a r c t i o n i n
t h e p a s t .
T h e h e a r t s
o f
o u r a n g i n a l p a t i e n t s
g e n e r a l l y
s h o w e d
m u l t i f o c a l
s e v e r e
c o r o n a r y
d i s e a s e i n v o l v i n g
a l l
t h r e e
v e s s e l s .
S i n g l e
v e s s e l
d i s e a s e
w a s p r e s e n t
i n
o n l y o n e
c a s e a n d t w o
v e s s e l d i s e a s e i n
o n l y n i n e
o f 4 7 c a s e s .
T h e
d i s t r i b u t i o n o f l e s i o n s
i n
t h e
c o r o n a r y
a r t e r i e s
a m o n g o u r
a n g i n a l p a t i e n t s w a s e s s e n t i a l l y
t h e
s a m e
a s t h a t f o u n d
e a r l i e r i n
a
g r o u p
o f p a t i e n t s
w i t h
s i g n i f i -
c a n t
c o r o n a r y a t h e r o s c l e r o s i s b u t
u n s e l e c t e d a s
t o t h e
c l i n i c a l m a n i f e s t a t i o n s . 3 O t h e r s t u d i e s f r o m
t h i s
l a b o r a t o r y h a v e d e m o n s t r a t e d t h a t a n g i o g r a p h y
m a y
u n d e r e s t i m a t e
t h e
d e g r e e
o f a t h e r o s c l e r o t i c n a r r o w i n g
a n d m a y
m i s s s i g n i f i c a n t l e s i o n s
a l t o g e t h e r . 4
We a c k n o w l e d g e
t h a t s i n c e
a l l e x c e p t o n e
o f
o u r
p a t i e n t s
d i e d
f o l l o w i n g o p e r a t i o n
w e
a r e d e a l i n g w i t h
a
s e l e c t e d s e r i e s . I t m i g h t b e
c l a i m e d
t h a t f a t a l
c o m -
p l i c a t i o n s
w o u l d b e
m o r e
l i k e l y
i n
s u b j e c t s w i t h s e v e r e
d i s e a s e
t h a n
i n
t h o s e
w i t h
l e s s e r
d e g r e e s .
B e c a u s e
m a n y
o f
o u r
p a t i e n t s d i e d o f n o n c a r d i a c c a u s e s , w e
f e e l
t h a t
t h e
g r o u p o f p a t i e n t s
i s
a v a l i d r e p r e s e n t a t i o n
o f
t h e
p a t i e n t s u n d e r g o i n g b y p a s s s u r g e r y b u t
w e c a n -
n o t
d e n y
t h a t
a m o n g
o p e r a t e d
p a t i e n t s
w h o s u r v i v e d
t h e r e
w a s
l e s s
e x t e n s i v e
d i s e a s e
t h a n
i n t h o s e i n c l u d e d
i n
t h i s
s t u d y . H o w e v e r i t i s i m p o r t a n t
t o
p o i n t o u t t h a t
t h e
p a t h o l o g i c a l p r o f i l e i n c l u d i n g d i s t r i b u t i o n a n d
s e v e r i t y
o f
c o r o n a r y
d i s e a s e ,
l e f t
v e n t r i c u l a r
h y p e r -
t r o p h y ,
a n d
a n t e c e d e n t m y o c a r d i a l i n f a r c t i o n
d i d
n o t
d i f f e r
a p p r e c i a b l y
a m o n g t h e c l a s s e s
o f a n g i n a .
D i f f e r e n c e s ,
h o w e v e r ,
w e r e n o t e d w i t h
r e g a r d t o
c o r o n a r y t h r o m b o s i s
a n d / o r
a c u t e
m y o c a r d i a l
i n f a r c -
C i r c u l a t i o n ,
V o l u m e
5 1 ,
J u n e 1 9 7 5
1 0 6 2
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STABLE
AND
UNSTABLE
ANGINA
t i o n . I n
f o u r
o f
t h e
1 2
c a s e s
w i t h u n s t a b l e a n g i n a ,
t h e s e
c h a n g e s a p p e a r e d
t o h a v e
b e e n c o e x i s t e n t
w i t h
t h e u n s t a b l e a n g i n a . I n
c o n t r a s t ,
i n n o n e o f
t h e s u b -
j e c t s w i t h s t a b l e
a n g i n a
w a s
c o r o n a r y t h r o m b o s i s
a n d / o r
a c u t e m y o c a r d i a l
i n f a r c t i o n ,
w h e n
p r e s e n t ,
c o n s i d e r e d t o h a v e e x i s t e d p r e o p e r a t i v e l y . T h i s
s u g g e s t s
t h a t
m a n y
c a s e s
c l a s s i f i e d a s
h a v i n g
u n s t a b l e
a n g i n a p e c t o r i s m a y a c t u a l l y b e s u f f e r i n g a n a c u t e
m y o c a r d i a l
i n f a r c t i o n w h i c h i s u n d e t e c t e d
b y
u s u a l
c l i n i c a l t e s t s .
Two
p o i n t s
n e e d t o b e e m p h a s i z e d w i t h
r e g a r d
t o
s i g n i f i c a n t
a t h e r o s c l e r o s i s
o f
t h e m a i n l e f t
c o r o n a r y
a r t e r y . F i r s t , i n
o u r
s e r i e s , t h e r e w e r e
n o c a s e s
i n
w h i c h s i g n i f i c a n t a t h e r o s c l e r o s i s
w a s
r e s t r i c t e d
t o
t h i s
a r t e r y . S e c o n d , a m o n g p a t i e n t s
i n whom
s i g n i f i c a n t
a t h e r o s c l e r o s i s
w a s
p r e s e n t
i n t h e l e f t m a i n
a r t e r y ,
t h e r e w a s n o t
a
s t r o n g t e nd e n c y t o wa r d
a
p a r t i c u l a r
t y p e o f a n g i n a . W h i l e
o u r f i g u r e s
a r e
t o o
s m a l l
f o r
f u r t h e r
g e n e r a l i z a t i o n ,
a n i m p o r t an t f i n d i n g
w a s
t h a t ,
i n o u r s t u d y ,
w h e n
t h e l e f t m a i n
c o r o n a r y
a r t e r y w a s
i n v o l v e d , t h e m o s t p r e v a l e n t t y p e
o f
a n g i n a w a s
s t a b l e , m o d e r a t e .
R e f e r e n c e s
1 .
Z O L L
P M ,
W E S S L E R
S ,
B L U M G A R T
H L :
A n g i n a
p e c t o r i s .
A c l i n i c a l
a n d p a t h o l o g i c
c o r r e l a t i o n . Am
J
Med 1 1 : 3 3 1 ,
1 9 5 1
2 .
L E N E G R E
J ,
H I M B E R T J : C r i t i c a l
s t u d y o f t h e r e l a t i o n s h i p
b e t w e e n
a n g i n a p e c t o r i s
a n d
c o r o n a r y a t h e r o s c l e r o s i s . Am
H e a r t
J 5 8 :
5 3 9 , 1 9 5 9
3 . V L O D A V E R
Z ,
E D W A R D S J E : P a t h o l o g y
o f c o r o n a r y a t h e r o s c l e r o s i s .
P r o g C a r d i o v a s c D i s
1 4 :
2 5 6 ,
1 9 7 1
4 . V L O D A V E R Z , F R E C H R , VAN
T A S S E L R A ,
E D W A R D S
J E :
C o r r e -
l a t i o n o f t h e
a n t e m o r t e m
c o r o n a r y
a r t e r i o g r a m a n d t h e
p o s t -
m o r t e m
s p e c i m e n . C i r c u l a t i o n 4 7 : 1 6 2 , 1 9 7 3
C i r c u l a t i o n ,
V o l u m e
5 1 ,
J u n e 1 9 7 5
1 0 6 3
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R B Guthrie, Z Vlodaver, D M Nicoloff and J E EdwardsPathology of stable and unstable angina pectoris.
Print ISSN: 0009-7322. Online ISSN: 1524-4539Copyright © 1975 American Heart Association, Inc. All rights reserved.
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation
doi: 10.1161/01.CIR.51.6.10591975;51:1059-1063Circulation.
http://circ.ahajournals.org/content/51/6/1059
the World Wide Web at:The online version of this article, along with updated information and services, is located on
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