Angina Pectoris Before and After Myocardial Infarction: Angiographic Correlations

doi:10.1378/chest.81.6.681

Chest

Volume 81, Issue 6, June 1982, Pages 681-686

https://doi.org/10.1378/chest.81.6.681 Get rights and content

Clinical, hemodynamic, and angiographic data were examined in 97 consecutive patients who underwent catheterization within two years of documented acute transmural myocardial infarction. The patients were divided according to the absence or presence of angina pectoris prior to myocardial infarction (groups 1 and 2). Group 1 had more females, was younger, and had a greater prevalence of one-vessel coronary artery disease. Of the patients surviving the myocardial infarction until hospital discharge, group 1 had fewer cases of postinfarction angina pectoris. The following were not statistically different for the two groups: mean time from infarction to catheterization, location of infarction, heart failure, coronary risk factors, mean left ventricular end-diastolic pressure, and mean ejection fraction. The angiographic significance of angina following infarction was analyzed in the 94 survivors. Patients with angina after infarction had a greater prevalence of two- and three-vessel coronary artery disease compared with patients without angina following infarction. Group 1 patients who had developed angina after infarction also had a greater prevalence of two- and three-vessel disease than patients who had no postinfarction angina. One-vessel disease was found in 82 percent of patients who had no angina before and after infarction. Infarction as the first manifestation of coronary artery disease (group 1) is often associated with one-vessel disease, especially if angina does not appear after infarction. Angina before or after infarction suggests two- and three-vessel disease.

Section snippets

MATERIALS AND METHODS

Reports from all patients undergoing selective coronary angiography at the Mount Sinai Medical Center were reviewed for the period from Jan 1, 1977, to June 30, 197 Patients who had a history of a single myocardial infarction were selected only if their infarction was within two years of catheterization. This time limit was used in an attempt to minimize angiographic changes from the postinfarction period to coronary angiography.¹⁸ We excluded patients with associated congenital or valvular

RESULTS

Of the 627 reports reviewed, 97 consecutive patients met the entrance criteria and comprised the study population. Reliable data for coronary risk factors were obtained in only 87 patients.

The patients were divided into two groups (Fig 1), determined by the absence (group 1, n = 63) or presence (group 2, n = 34) of angina pectoris prior to infarction. The 61 survivors of infarction from group 1 (two of the 63 patients died within two weeks of catheterization and were excluded from analysis)

DISCUSSION

Since the presence of infarction may not necessarily be predictive of the extent of coronary artery disease,⁶ in this study we investigated the angiographic correlations of a history of angina pectoris in relationship to the presence of a previous myocardial infarction.

REFERENCES (29)

KT Weber et al.
Identification of high risk subsets of acute myocardial infarction
Am J Cardiol
(1978)
JS Webster et al.
Natural history of severe proximal coronary artery disease as documented by coronary cineangiography
Am J Cardiol
(1974)
RA Williams et al.
Electrocardiographic, arteriographic, and ventriculographic correlations in transmural myocardial infarction
Am J Cardiol
(1973)
WB Kannel et al.
Natural history or angina pectoris in the Framingham study
Am J Cardiol
(1972)
H Sandler et al.
The use of single plane angiograms for the calculation of left ventricular volumes in man
Am Heart J
(1968)
SV Savran et al.
Clinical correlates of coronary cineangiography in young males with myocardial infarction
Am Heart J
(1976)
RR Miller et al.
Chronic stable inferior myocardial infarction; unsuspected harbinger of high risk proximal left coronary arterial obstruction amenable to surgical revascularization
Am J Cardiol
(1977)
TD Paine et al.
Relation of graded exercise test findings after myocardial infarction to extent of coronary artery disease and left ventricular dysfunction
Am J Cardiol
(1978)
RM Norris et al.
Prognosis after myocardial infarction; six-year follow-up
Br Heart J
(1974)
AVG Bruschke et al.
Progress study of 590 consecutive non-surgical cases or coronary disease followed 5-9 years
Circulation
(1973)

GW Burggraf et al.

Prognosis in coronary artery disease

Circulation

(1974)

NJ Fortuin et al.

Exercise stress testing

Circulation

(1977)

JL Ritchie et al.

Myocardial imaging with thallium-201 at rest and during exercise

Circulation

(1977)

JS Borer et al.

Limitations of the electrocardiographic response to exercise on predicting coronary artery disease

N Engl J Med

(1975)

Cited by (35)

Effect of preinfarction angina pectoris on outcome in patients with acute myocardial infarction treated with primary angioplasty (results from the Myocardial Infarction Registry [MIR])
2001, American Journal of Cardiology
Preinfarction angina is associated with better clinical outcome in patients with acute myocardial infarction (AMI) who receive intravenous thrombolysis. This has not been proved in patients with AMI treated with primary angioplasty. We analyzed the data of the prospective multicenter Myocardial Infarction Registry (MIR). Of 14,440 patients with AMI, 774 with a prehospital delay of ≤12 hours were treated with primary angioplasty. Five hundred thirty-two patients (68.7%) had preinfarction angina. Patients with preinfarction angina were slightly older than patients without (63 vs 62 years, p = 0.042), prehospital delay was 1 hour longer (180 vs 120 minutes, p = 0.001), and arterial hypertension was more prevalent (47.6% vs 32.2%, odds ratio [OR] 1.91, 95% confidence intervals [CI] 1.39 to 2.62). There was no significant difference in hospital mortality (5.6% vs 3.3%, OR 1.75, 95% CI 0.79 to 3.87), reinfarction, stroke, or the combined end point of death, reinfarction, or stroke between the 2 groups. Logistic regression analysis showed no association of preinfarction angina with the occurrence of either death (OR 2.21, 95% CI 0.91 to 6.08) or the combined end points (OR 1.10, 95% CI 0.55 to 2.31). There was also no significant difference in mortality (6% vs 5.1%, OR 1.19, 95% CI 0.56 to 2.52), reinfarction, stroke, postinfarction angina, or the combined end points between patients with preinfarction angina within 48 hours compared with patients with preinfarction angina between 49 hours and 4 weeks before the AMI. Thus, the MIR data showed no protective effects of preinfarction angina in patients with AMI treated with primary angioplasty.
Prognostic significance of angina pectoris ≤30 days before acute myocardial infarction in patients ≤ 75 years of age
1997, American Journal of Cardiology
Assessing the significance of preinfarction angina [3]
1996, Journal of the American College of Cardiology
Comparison of coronary angiographic narrowing in stable angina pectoris, unstable angina pectoris, and in acute myocardial infarction
1995, The American Journal of Cardiology
Coronary angiographic findings were compared in patients who presented with acute myocardial infarction (AMI, n = 75), unstable angina pectoris (UAP, n = 36), or stable angina pectoris (SAP, n = 36) for ≥2 years without evidence of any previous acute event and with an angiogram within 2 years of the initial symptoms. Angiograms were evaluated blindly for severity, extent (depending on the percentage of each coronary segment showing atherosclerosis), and pattern (discrete, <3 loci of narrowings involving <50% of any segment; diffuse, anything exceeding this). Patients in the SAP group had more narrowed arteries (2.4 ± 0.7 vs 1.3 ± 0.6 [p <0.021 and 1.4 ± 0.6 [p <0.021), more stenoses (6.0 ± 3.3 vs 2.1 ± 1.5 [p <0.01] and 2.6 ± 1.7 <0.05]) and occlusions (1.3 ± 1.1 vs 0.7 ± 0.6 [p = 0.05] and 0.3 ± 0.5 [p <0.02]), and a greater extent index (0.9 ± 0.5 vs 0.5 ± 0.3 [p <0.02] and 0.5 ± 0.3 [p <0.02]) than those in the AMI and UAP groups. Furthermore, a discrete pattern was less prevalent in patients with UAP than in those with SAP or AMI (3% vs 40% <0.02] and 25% [p <0.05], respectively). In conclusion, patients who present with acute coronary syndromes have less extensive atherosclerosis than those who present with chronic stable angina. Therefore, in the former group, coronary atherosclerosis appears to be more susceptible to ischemic stimuli responsible for acute coronary syndromes. Conversely, whether acute ischemic stimuli result in AMI or in UAP does not appear to depend on the severity of coronary atherosclerosis.
Preinfarction angina as a major predictor of left ventricular function and long-term prognosis after a first Q wave myocardial infarction
1995, Journal of the American College of Cardiology
Objectives. The purpose of this study was to assess the prognostic significance of preinfarction angina after a first Q wave myocardial infarction. Patients with anterior or inferior myocardial infarction were compared.
Background. The effect of preinfarction angina on prognosis after anterior and inferior myocardial infarction remains unclear.
Methods. A total of 291 patients with a first Q wave anterior (n = 171) or inferior (n = 120) myocardial infarction were examined to assess the effect of preinfarction angina on short- and long-term prognosis. The relation between predischarge left ventriculographic findings and preinfarction angina was also examined.
Results. The presence of preinfarction angina was associated with lower peak creatine kinase activity, a lower in-hospital incidence of sustained ventricular tachycardia and fibrillation and a lower incidence of pump failure and cardiac mortality in patients with either anterior or inferior infarction. Among patients with anterior infarction, preinfarction angina was associated with a lower incidence of cardiac rupture and less need for readmission for heart failure within 1 year after the onset of infarction. In this subgroup it was also associated with a higher ejection fraction, a smaller end-diastolic volume and a lower incidence of aneurysm formation noted on ventriculography during convalescence. In patients with inferior infarction, these variables did not differ significantly in the presence or absence of preinfarction angina. Multivariate analysis confirmed that the presence of preinfarction angina was an independent predictor of development of ventricular aneurysm, late phase heart failure and 1-year cardiac mortality.
Conclusions. The presence of preinfarction angina has a favorable effect on infarct expansion and late phase left ventricular function, especially in patients with anterior myocardial infarction. The mechanisms responsible for this phenomenon are not known but may be secondary to limitations of infarct size through unidentified mechanisms other than collateralization (e.g., ischemic preconditioning).
Effects of antecedent anginal episodes and coronary artery stenosis on left ventricular function during coronary occlusion
1995, American Heart Journal
We evaluated the effects of antecedent anginal episodes and coronary artery stenosis on left ventricular function during coronary occlusion and the role of collateral filling in 33 patients with angina pectoris who underwent angioplasty. Wall motion abnormalities were investigated by echocardiography and classified into hypokinesia and akinesia. Collateral filling during angioplasty was evaluated by using a second artery catheter. Akinesia was observed as follows: 24% of the patients had >30 anginal episodes, 38% had 5 to 30, and 87% of the patients had <5 (p < 0.01); 12% of patients had a lesion of 99%, 47% had a lesion of 90%, and 83% had a lesion of 75% (p < 0.05). Akinesia was observed in none of the patients with grade 3 collaterals, 57% with grade 2, and 67% with grade 1 or 0 (p < 0.01). These observations suggest that the patients with antecedent frequent anginal episodes and severe coronary stenosis have less left ventricular dysfunction during coronary occlusion. This finding may be the result of more extensive collateral development.

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: Manuscript received August 31; revision accepted October 15.

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Chest

Clinical InvestigationsAngina Pectoris Before and After Myocardial Infarction: Angiographic Correlations

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am Heart J

Am Heart J

Am J Cardiol

Am J Cardiol

Prognosis after myocardial infarction; six-year follow-up

Br Heart J

Progress study of 590 consecutive non-surgical cases or coronary disease followed 5-9 years

Circulation

Prognosis in coronary artery disease

Circulation

Exercise stress testing

Circulation

Myocardial imaging with thallium-201 at rest and during exercise

Circulation

Limitations of the electrocardiographic response to exercise on predicting coronary artery disease

N Engl J Med

Clinical Investigations
Angina Pectoris Before and After Myocardial Infarction: Angiographic Correlations