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PubMed1982

The noninvasive evaluation of the coronary artery disease patient: clinical, economic and social issues.

The patient with chest pain is a common but often challenging diagnostic problem to the physician. Evaluating such a patient for coronary artery disease requires a careful history, physical examination and judicious selection of laboratory procedures. Noninvasive stress tests for cardiac diagnosis need not be applied to every patient who presents with chest pain and, in general, are most likely to be helpful when they are used discriminately for patients who have an intermediate likelihood of coronary artery disease. A further elaboration of one systematic approach to this problem, based on Bayesian analysis of noninvasive testing procedures, is presented.

Aged↗
PubMed1982

Implications of alternative strategies to diagnose coronary artery disease.

Strategies to diagnose coronary artery disease were examined for cost-effectiveness in a hypothetical population of 55-year-old men who, alternatively, are asymptomatic, have atypical angina or have definite angina. Strategies considered include various combinations of noninvasive tests (resting ECG, exercise stress test [ETT]. radionuclide scanning [RNS] and coronary angiography). Benefits are estimated in terms of the detection of multivessel disease and years of life gained from coronary artery bypass graft surgery (CABG). Only the direct costs (charges) for diagnostic or treatment procedures are considered. In asymptomatic persons, the average cost-effectiveness for different strategies ranges from $22,600 per year of life gained (ETT followed in positives by RNS) to $60,000 (angiography as primary screening test). Hence, screening is relatively cost-ineffective and would be extremely expensive if implemented widely. For patients with atypical angina, the cost-effectiveness ratio is about $9300 per year of life gained. Strategies involving use of ETT alone or in combination with the ECG or RNS appear to be preferable. For definite angina, the cost-effectiveness ratio is about $8800. Little difference is noted among various strategies for diagnosing definite angina, and the option to proceed directly to angiography appears reasonable.

Angina Pectoris↗
PubMed1982

Costs and benefits associated with treatment for coronary artery disease.

Direct and indirect costs of medical and of surgical treatment are presented for patients entered into the Birmingham portion of the Coronary Artery Surgery Study. For comparison, similar results are shown for the Birmingham portion of the national Cooperative Unstable Angina Study. In the Unstable Angina Study, mean inpatient costs at the end of 1 year in the study were $6867 for medical therapy, $10,574 for surgical therapy and $23,045 for those who failed medical therapy and required late surgery. A stepwise multiple regression analysis shows that the single best predictor of cost was the number of myocardial infarctions that the patient had while in the study. A discriminant-function analysis identified 85% of the medical patients who required late surgery. A significantly lower proportion of surgical than medical patients returned to work. Total inpatient costs for patients in the Coronary Artery Surgery Study (i.e, patients with stable angina) were $3432, $11,100 and $13,554 for medical, surgical and late surgical patients, respectively, for the first year in the study. There was no significant difference in the percentage of medical and surgical patients who were working at the end of 1 year. According to their own perceptions, the surgical group was in the best and the late surgical group in the worst health.

Aged↗
PubMed1982

[Treatment of Prinzmetal's angina with normal coronary vessels by thoracic sympathectomy].

Two cases of Prinzmetal angina with normal coronary arteries are reported: coronary spasm was demonstrated in the left anterior descending artery in the first, and in the right coronary artery in the second case. Invalidating angina persisted despite maximal medical treatment with nitrite derivatives, nifedipine, verapamil and amiodarone. Homolateral thoracic sympathectomy led to long term remission of symptoms in one case and a short remission in the other, who then had to undergo complete denervation by plexectomy. Two hours after reoperation a refractory spasm of the right coronary artery led to the death of the patient. The possible causes of refractory coronary spasm and possible therapeutic approaches are discussed with reference to these cases.

Adult↗
PubMed1983

[Arrhythmia in unstable angina pectoris].

79 ECGs, recorded during angina pectoris, from 52 patients were studied to determine the relations of arrhythmias and ST-segment changes and to evaluate the relationship between the prevalence of arrhythmias, the severity of coronary artery disease and left ventricular function. Arrhythmias were found in 22% of the ECGs (VPCs in 9, VT in 4, SVPCs in 3, sinus bradycardia in 1). Angina pectoris attacks accompanied by ST-segment elevation, ST-segment depression or unchanged ST-segment showed disturbances of rhythm in 47%, 24% and 0%. If coronary spasm without significant coronary stenoses was the cause for myocardial ischemia, arrhythmias appeared with 75% more often than in myocardial ischemia caused by organic stenoses (19%). Patients with disturbances of rhythm during spontaneous angina pectoris do not have anymore deterioration in left ventricular function than patients without arrhythmias.

Adult↗
PubMed1983

[Diagnosis of angiospastic angina pectoris by coronarography].

Tests with intravenous ergometrin maleate and selective coronarography were performed in 82 coronary patients. In 16 of those, coronary spasm was suspected from ECG findings at preliminary testing and confirmed at repeated pharmacologic tests during coronarography. Episodes of vasospastic angina pectoris accompanied by multiple spasms in branches of the main coronary arterial trunk, and spastic response developing at different levels of one coronary artery were demonstrated. It is suggested that angiographic diagnosis is indispensable, particularly at a cardiosurgical in-patient unit, as a procedure both specifying the diagnosis and localizing the spasm, so that the site of distal anastomosis can be chosen for future aortal-coronary shunting.

Adult↗