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OBJECTIVE--To examine how exercise testing on background medical treatment affects the ability of the test to predict prognostically important patterns of coronary anatomy in patients with a high clinical probability of coronary artery disease but who are well controlled on medication. DESIGN--Prospective study. SETTING--Regional cardiothoracic centre and referring district general hospital. PATIENTS--84 patients with a history of typical angina or definite myocardial infarction and mild symptoms who had been placed on the waiting list for prognostic angiography. INTERVENTION--Maximal exercise electrocardiography and radionuclide ventriculography performed off and on medication, followed by angiography within three months. MAIN OUTCOME MEASURE--Prognostically important coronary artery disease for which early surgery might be recommended purely on prognostic grounds, irrespective of symptoms. RESULTS--Coronary artery disease was present in 71/84 (85%) patients; in 28/84 (33%) patients this was prognostically important. When the result was strongly positive, the predictive accuracy for prognostically important disease was 0.46 off and 0.62 on medication for the exercise electrocardiogram and 0.71 off and 0.82 on medication for exercise radionuclide ventriculography. The likelihood ratio was 1.00 off and 1.36 on medication for exercise electrocardiography and 2.54 off and 10.5 on medication for exercise radionuclide ventriculography. In stepwise logistic regression, the test identified as the strongest predictor of prognostically important disease was exercise radionuclide ventriculography on medication for which the improvement chi 2 was 28 (p < 0.0001). With the regression model, the probability of important disease is 92% if exercise radionuclide ventriculography on medication is at least strongly positive, compared with 16% if the result is normal or just positive. CONCLUSION--In patients likely to have coronary disease, exercise testing should be performed without interruption of medication to optimise its ability to identify those with prognostically important disease, and to help to avoid unnecessary or premature angiography in those who are well controlled on medical treatment.

Percutaneous transluminal coronary angioplasty was attempted with elective percutaneous intra-aortic balloon pump support in 21 patients (mean age 60 years, range 40-82; 18 males) with unstable angina (n = 2), multivessel coronary disease requiring multivessel angioplasty (n = 2), severe left ventricular dysfunction (ejection fraction 10-30%; n = 16) or ventricular fibrillation at diagnostic angiography (n = 1). Fourteen patients had 3-vessel disease (1 with vein grafts also diseased), 6 had 2-vessel disease and 1 had isolated left anterior descending disease. Twenty-five procedures were performed (one in 18 patients, two in 2 patients and three in one patient) on 42 lesions in 34 vessels/grafts. There was no angioplasty-related death. Successful dilatation was achieved in 38/42 lesions (90%) in 21/25 procedures (84%) without major complication. Three procedures were complicated: one by major coronary dissection without sequelae, one by haemodynamic deterioration due to distal occlusion and one by an unstable residual stenosis in the attempted vessel necessitating urgent bypass surgery. The only complication related to the intra-aortic balloon pump was local haematoma in 2 patients. In conclusion, elective intra-aortic balloon pump support may be safely used to stabilise high-risk patients undergoing coronary angioplasty, leading to a satisfactory primary success rate.

This study was undertaken to identify the safety of outpatients awaiting coronary bypass surgery. An audit of the outcome of 92 such outpatients at one Regional centre was undertaken by a retrospective review of medical records. Outcome measures were: time on the waiting list, anti-ischaemic medications, readmission for unstable angina, myocardial infarction and death. Almost half of the patients underwent surgery within three months, and three-quarters waited less than six months. No outpatient death occurred. However, 4 of the 7 adverse events occurred within this period. Despite advanced disease, the safety of outpatients awaiting coronary surgery within such a short time frame appeared to be acceptable, the only adverse events being non-fatal and occurring unpredictably.

We examined retrospectively the usefulness of routine clinic visits in preventing adverse cardiac events in 115 patients awaiting coronary surgery or angioplasty. Mean waiting time from angiography to revascularization was 126 days. A total of 126 visits were made by 80 patients. No deaths occurred, but one patient, despite three visits, suffered myocardial infarction at 316 days post-angiography. Eight patients required admission for unstable angina, five having been on the waiting list for less than 5 weeks. The mean number of clinic visits, number of diseased vessels and proportion on triple anti-ischaemic therapy were similar in the patients suffering such events and those remaining stable. In conclusion, the inherent unpredictability of coronary disease greatly limits the role of interim clinic visits in the prevention of adverse cardiac events in patients awaiting revascularization.