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Randomly selected cine arteriographic films of 30 diseased patients were read twice by each of three experienced observers. The intrareader variability was less than one-half of the interreader variability in reading the stenosis of segments of the coronary anatomy - a statistically significant difference (p less than 0.001). When extent of disease was evaluated by the number of diseased vessels, interreader variability was larger than intrareader variability (p less than 0.01). One reader read considerably less disease than the other two readers. The films were rated as to quality of the arteriographic films and the completeness of the study. In each case there was a greater interreader than intrareader variability (p less than 0.01). The films were rated good, acceptable, or poor. One of the three interpreters consistently gave worse ratings than the other two readers. It was particularly noteworthy that a larger amount of interreader variability was observed in both the left main coronary artery and the proximal left anterior descending artery.

The Collaborative Study in Coronary Artery Surgery (CASS) is a large multi-institutional study of the medical and surgical treatment of coronary artery disease (CAD). Fifteen cooperating institutes have carried out isolated coronary artery bypass grafting (CABG) on 6,176 patients from August, 1975, through December, 1978. The operative mortality (OM) was 2.3%. In an effort to better understand the clinical and angiographic characteristics predictive of OM, we have done a multivariate discriminant analysis of variables associated with OM. Numerous clinical and angiographic variables were selected from the CASS data file and evaluated in a univariate manner for their relationship to OM. Twenty of these variables were then selected for multivariate discriminant analysis. Clinical variables of most predictive value were age, female sex, increased heart size, and congestive heart failure (CHF). Angiographic variables of importance included left ventricular wall motion abnormalities, and left main coronary disease (LMCD). The priority of operation (elective, urgent, or emergent) was also associated with OM. Six variables that contained the most predictive information were selected by discriminant analysis for a group of 6,176 patients who had isolated bypass operations. In descending order of importance they were age, left main coronary artery stenosis greater than or equal to 90%, female sex, left ventricular wall motion score, left ventricular end-diastolic pressure (LVEDP), and râles. Five other groups or subgroups of patients were also analyzed in a similar manner. There is a strong association of OM with advanced age, female sex, and variables associated with left ventricular dysfunction. The risk of OM for an individual patient may be estimated with the use of these clinical and angiographic characteristics.

Data were collected prospectively on 7553 consecutive patients undergoing coronary arteriography. The studies were performed at 13 clinics of the Collaborative Study of Coronary Artery Surgery (CASS) using brachial and femoral techniques. There were eight deaths 0--24 hours and seven deaths 24--48 hours after arteriography (2/1000). There were 15 non-fatal myocardial infarctions (MIs) 0--24 hours and four MIs 24--48 hours after arteriography (2.5/1000). Of 657 cases with left main stenosis greater than or equal to 50%, five died and three had MI. Left main disease increased risk of death by 6.8 times (p less than 0.001). Other factors increasing risk were unstable angina, congestive heart failure, multiple premature ventricular contractions, and hypertension. Of the 1187 patients studied from the brachial artery, six died (0.51%) and five had MIs (0.42%). In 6328 patients studied from the femoral artery, nine died (0.14%) and 14 had MIs (0.22%). The brachial artery technique increased the risk of death 3.6 times compared with the femoral approach (p less than 0.05). This result did not apply when analysis was restricted to laboratories with 80% or more brachial procedures. Risk was not altered by heparin. Thus, a prospective, multicenter analysis of complications reveals low risk of coronary arteriography but significant difference between two techniques.

During a 14-month period, 75 deaths occurring in relation to 53,581 cardiac catheterizations were consecutively and prospectively reported to the Registry Committee of the Society for Cardiac Angiography. Three of the patients died several days after their catheterization from an unrelated cause and are excluded from this analysis. There were 21 patients (group I) who arrived at the laboratory in extremis and whose deaths were expected irrespective of the catheterization. Most of these patients suffered from recent myocardial infarctions and cardiogenic shock, or had complex congenital malformations. In 35 patients (group II), a cardiovascular complication occurring during the catheterization resulted in death. In 16 patients (group III) catheterization seemed uneventful, but death occurred suddenly 10 min to 10 h after the procedure. Of these 16 patients, eight had left main coronary artery obstruction greater than or equal to 90%, five had three-vessel disease all with 90% obstructions, one had 2-vessel disease both with 90% obstructions, and who had critical aortic stenosis. The 51 unexpected deaths (groups II and III) were considered to be causally related to the procedure, a mortality rate of 0.10%. Subsets with an increased mortality rate (M), were patients with: a) left main disease greater than 50% (M = 0.94%); b) ejection fraction less than 30% (M = 0.54%); c) NYHA class III or IV (m = 0.24%); d) age over 60 years (M = 0.23%); or e) three-vessel disease (M = 0.13%). In conclusion, catheterization related mortality occurs mostly in patients with far advanced cardiac disease. Nearly 1/3 of the unexpected deaths occurred suddenly after a seemingly uneventful procedure. Close monitoring after catheterization of patients with similar characteristics (left main disease greater than or equal to 90%, or three-vessel disease all greater than or equal to 90%) might disclose avenues for reducing mortality occurring after catheterization.