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The study of mitral flow and pulmonary venous flow by Doppler provides a non-invasive method of assessing diastolic function. But there are difficulties in differentiating normal pattern from "pseudo-normal" (Appleton Type II) (E/A Mitral > 1). Phonocardiography enables the recording of early (B3) and late (B4) diastolic gallops. The apexogramme enables calculation of the a/H and D/H ratios (amplitude of the "D" wave resulting from rapid early diastolic filling to the total amplitude of the apexogramme). These two techniques record pulsatile phenomena ("pulse waves") arising from variations in intra-left ventricular pressure. They may complete the interpretation of Doppler recordings of velocities of blood flow ("flow waves"). To evaluate the value of each technique, the authors studied left ventricular diastolic function by Doppler phonocardiography and apexography in 60 subjects (38 patients of which 30 with ischaemic heart disease, and 22 healthy subjects). The results showed that increase in velocity and deceleration slope of the Doppler mitral E wave was associated with the presence of a B3 and correlated (r = 0.60; p = 0.0001) with the D/H ratio of the apexogramme. On the other hand, the absence of correlation between the mitral A wave velocity and a B4 associated with an increased a/H ratio enables the differentiation of normal Doppler mitral flow (absence of B4, Doppler a/H ratio < 12%) from pseudo-normal appearances (B4, a/H ratio > 12%). Therefore, the evaluation of diastolic function by Doppler mitral and pulmonary venous flow analysis may be usefully completed by phonocardiography and apexography.

The present study was designed to prospectively evaluate whether reinjection thallium-201 single-photon emission computed tomography (SPECT) has a significant additive predictive value for occurrence of perioperative cardiac events in clinically selected patients at high cardiac risk undergoing abdominal aortic surgery. Of a group of 517 consecutive patients referred, 134 had > or = 2 of the following clinical or electrocardiographic cardiac risk variables: age > 70 years; history of myocardial infarction, angina, or congestive heart failure; diabetes mellitus; hypertension with severe left ventricular hypertrophy; and Q waves or ischemic ST-segment abnormalities on electrocardiogram at rest. Operation was performed after thallium SPECT study. Twelve patients (9%) had major perioperative events (cardiac death or nonfatal myocardial infarction) and 18 patients had other cardiac events (unstable angina, congestive heart failure, or severe ventricular tachyarrhythmia). Variables correlated with the occurrence of major events were history of myocardial infarction (p < 0.05) and the presence (p < 0.001) and number of segments with thallium reversible defects (p < 0.001). In multivariate analysis, history of myocardial infarction (p < 0.05) and the number of segments with reversible thallium defects (p < 0.001) were independent predictors. When all the cardiac events were taken into consideration, all the previous variables, as well as Q waves and ischemic ST abnormalities on the electrocardiogram, showed significant predictive value in both univariate and multivariate analyses. Furthermore, thallium SPECT imaging has an additive predictive value for major cardiac events over clinical and electrocardiographic risk factors. When performed on clinically selected patients at high cardiac risk undergoing abdominal aortic surgery, thallium SPECT demonstrates significant prognostic value for cardiac events over that provided by clinical variables alone.

Numerous experimental and clinical studies have reported a role of radical forms of oxygen in the etiology of the manifestations of reperfusion of the ischemic myocardium. However, clinical results remain controversial. The aim of this study was to ascertain the existence of reperfusion-related radical stress after thrombolysis with a marker that is easy to use and reliable. Thirty patients hospitalized for acute myocardial infarction were involved in the study. Of these, 18 had been subjected to intravenous thrombolysis (Group I) and 12 had not (Group II). They were compared to two control groups who had no history of myocardial infarction. Of these, 16 were patients with coronary heart disease hospitalized for stable angina (Group III) and 17 were patients free of any known cardiovascular disease (Group IV). Radical activity was assessed in plasma samples taken from a peripheral vein over a 10-day period of hospitalization by measuring (1) malondialdehydes (MDA) concentrations using fluorometry techniques or HPLC, (2) the antioxidant activity of glutathione peroxidase (GPx) and (3) the concentration of various antiradical compounds (beta-carotene, vitamins A and E, uric acid). All patients in Group I had a patent artery on coronary angiography and showed a significant increase in plasma MDA when compared to those who had not been subjected to thrombolysis (3.15 +/- 0.62 and 2.70 +/- 0.40 mole/l of plasma, respectively). Furthermore, GPx plasma activity was also significantly increased following thrombolysis. By contrast, there was no significant alteration in the antiradical compounds measured. These data suggest that MDA measurements (an early measurement 1-2 days and a late measurement 5-7 days after reperfusion) by fluorometry is a good marker of radical stress during reperfusion in man. The assessment of this marker in patients might represent a simple and reliable test of reperfusion efficacy following thrombolysis, and it might enable one to test the effect of various antioxidant therapies associated with thrombolytic treatment.

Many doppler echocardiographic indices have been described for quantifying aortic regurgitation, posing the problem of the relative value of each. Therefore, the authors assessed the severity of aortic regurgitation in 60 consecutive patients (16 women and 44 men, mean age 56.7 years, range 7 to 84 years) by the four grades of Seller's classification with selective aortography. These results were compared with Doppler echocardiographic measurement of anterograde cardiac output (Qao), the pressure half time (PHT), diameter of the jet at its origin in M mode colour Doppler (DTM) and calculation of the regurgitant fraction (RF) by comparison of flow at the different cardiac orifices by a method previously described and validated in the author's laboratory with an interorifice correlation of 0.91 to 0.96 and confidence intervals at 95% of the order of 12%. The feasibility of doppler echocardiographic methods was good: 87.8% for PHT (58/66 patients), 90% for DTM (36/40 patients), 90.9% for Qao and RF (60/66 patients). The correlation with aortography was -0.65 (p < 0.01) for PHT; 0.91 (p < 0.01) for DTM, 0.80 (p < 0.01) for Qao and 0.92 (p < 0.005) for RF. However, there was a number of overlaps between Grades I and II and Grades III and IV.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic total coronary occlusion remains one of the limitations of percutaneous transluminal coronary angioplasty, and few therapeutic devices are specifically designed to address this problem. Among such devices, low-speed rotational angioplasty could improve the primary success rate of the procedure but has never been studied in a controlled trial. One hundred consecutive patients with total coronary occlusion (duration 10 days to 1 year) and an indication for myocardial revascularization were randomized to either rotational or conventional angioplasty if the occlusion morphology was judged suitable for either technique. All baseline variables were evenly distributed among the 2 groups. The primary success rate in the rotational angioplasty groupø was 66% (33 of 50) compared with 52% (26 of 50) in the conventional angioplasty group before crossover to the rotational technique (p=NS). According to lesion morphology, the respective primary success rates were 77% (10 of 13) versus 92% (11 of 12) for tapered occlusions (p=NS), and 61% (22 of 36) versus 38% (14 of 37) for "stump-like" occlusions (p < 0.05). After taking into account the crossovers after failed conventional angioplasty, there was no benefit in performing rotational angioplasty first versus conventional angioplasty first (primary success rates 66% vs 60%, p=NS). Thus, in chronic coronary occlusions of tapered morphology, rotational angioplasty is not superior to conventional angioplasty. In stump-like occlusions, the primary success rate is higher with the rotational angioplasty technique; however ther is a disadvantage in using rotational angioplasty as a second-line device if the conventional technique is unsuccessful.

It has been suggested that the injury induced by reperfusion of the ischemic myocardium could result, in part, from the cytotoxic effects of oxygen free radicals. Since various trace elements are involved in several of the reactions leading to free radical production, we have measured plasma levels of copper, zinc, selenium, and iron: 1. In 18 patients (mean age 60 yr old) subjected to thrombolytic therapy within 6 h after the onset of a myocardial infarction (G1); 2. In 16 patients with coronary artery disease, but without a history of a previous myocardial infarction (MI) (mean age 50 yr old, G2); and 3. In 50 healthy volunteers divided into two subgroups according to age (mean age 33 yr old, G3 and 55 yr old, G4). Plasma myosin levels were used to estimate quantitatively the extent of the infarcted mass. Plasma trace element levels were measured in blood samples following centrifugation and storage at -80 degrees C. The main results were as followed: In G1 patients who have been subjected to thrombolysis, an important release of myosin was measured in plasma, with a peak at D6 (1678 vs 95 microU/L at H0). In those G1 patients after MI: 1. A significant increase in plasma copper levels was observed from day 4 to day 10 postinfarction (x1.15 in reference to the baseline data at H0); 2. A decrease in plasma zinc levels was observed and was maximum 12 h after the onset of the thrombolytic treatment; 3. A decrease in selenium concentration was observed in G1, as well as in G2 patients, compared to the control groups (80% of G3 and G4 values); and 4. A significant decrease in plasma iron levels was observed in G1 (67.8% of G3 and G4 control values) and was significant from H0 to day 7 (p < 0.01). In conclusion, this study underlined the time-course evolution of plasma trace element levels in the followup of patients who have been subjected to thrombolysis following a MI and the potential prognostic implication of such variations.

Objectives: The purpose of this study was to determine whether early qualitative or quantitative angiographic features can predict reocclusion after initially successful coronary thrombolysis., Background: Although both the benefits of early reperfusion and the consequences of subsequent reocclusion after thrombolysis for acute myocardial infarction have been well described, efforts to describe angiographic markers of lesions at high risk for reocclusion have produced conflicting results. The Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) angiographic trial provides the opportunity to examine these relations in the largest single, prospective patient cohort studied to date., Methods: We studied 559 patients undergoing follow-up angiography at 90 min and 5 to 7 days after thrombolysis in the GUSTO trial. Patients received one of four thrombolytic regimens: 1) streptokinase with intravenous heparin; 2) streptokinase with subcutaneous heparin; 3) accelerated-dose recombinant tissue-type plasminogen activator (rt-PA) with intravenous heparin; or 4) a combination of streptokinase and conventionally dosed rt-PA with intravenous heparin. Qualitative variables examined at 90-min angiography included Thrombolysis in Myocardial Infarction (TIMI) flow grade, visible thrombus and lesion morphology. Quantitative variables included percent diameter stenosis, percent area stenosis, minimal lumen diameter and lesion length. The study contained a power > 0.85 to detect clinically important differences in percent diameter stenosis, percent area stenosis and minimal lumen diameter between the groups with subsequent reocclusion and sustained patency at the p = 0.05 level., Results: At follow-up, 33 patients (5.9%) had reocclusion. The reocclusion rate for patients with early TIMI grade 2 flow was 6.3% versus 5.6% for TIMI grade 3 flow (p = NS). When the group with reocclusion was compared with the group with continued patency, there were no differences in presence of early visible thrombus, complex lesion morphology, percent diameter stenosis, percent area stenosis, minimal lumen diameter or lesion length., Conclusions: Our findings demonstrate that neither qualitative nor quantitative angiographic variables at 90 min after initiation of thrombolytic therapy can be used to predict subsequent coronary reocclusion.

Objectives: This study was designed to assess the prognostic value of thallium-201 single-photon emission computed tomographic (thallium SPECT) perfusion imaging in patients evaluated for stable angina pectoris and to examine the relation, if any, between the presence and extent of myocardial defect and future fatal or nonfatal cardiovascular events (revascularization, secondary myocardial infarction)., Background: Compared with planar scintigraphy, thallium SPECT enables better evaluation of the extent of myocardial perfusion defect. However, its prognostic value has not yet been studied in a large population of patients., Methods: Between 1987 and 1989 we studied 3,193 patients. After exclusion of patients with unstable angina, myocardial infarction during the previous month or earlier revascularization, 1,926 patients were followed up for 33 +/- 10 (mean +/- SD) months after stress thallium SPECT imaging (performed after exercise in 1,121 patients or during dipyridamole infusion in 805 patients). Thallium SPECT imaging of the left ventricle was divided into six segments., Results: After normal thallium SPECT imaging (715 patients), the annual total and cardiovascular mortality rates were, respectively, 0.42%/year and 0.10%/year and were significantly higher after abnormal thallium SPECT imaging (respectively, 2.1%, relative risk 5, p = 0.012; 1.5%, relative risk 15, p < 0.0001 [log-rank test]). There was a significant relation between the number of abnormal segments and cardiovascular mortality during follow-up (p < 0.02) or the occurrence of nonfatal events (p < 0.001). The extent of defect on the initial scan provided the best SPECT variable for long-term prognosis. Thallium SPECT imaging provided additive prognostic information compared with other clinical variables (gender, previous myocardial infarction) and exercise electrocardiogram., Conclusions: In patients with stable angina, normal thallium SPECT imaging indicates a low risk patient, and the extent of myocardial defect is an important prognostic predictive factor.

One of the main advantages of Doppler echocardiography is the possibility of non-invasive measurement of blood flow at each valvular orifice. This method enables quantification of valvular regurgitation, the measurement of Qp/Qs in cardiac disease with atrial or ventricular shunts, and the interpretation of gradients and functional surface areas in valvular stenosis or prosthesis with respect to the underlying haemodynamics. In each of these application, the measurement of pulmonary blood flow is valuable as the reference blood flow, and even indispensible in cases of shunts. The authors' objective was to study the feasibility and accuracy of pulmonary flow measurement in 100 consecutive patients (40 women and 60 men, average age 56.7 +/- 17.5 years) with cardiac disease (82%) or healthy hearts (18%). A grading from A to D was accorded depending on the technical difficulty of the examination, each grade having three degrees: 1) difficulty of recording and poor quality Doppler spectrum, 2) difficulty of measuring orifice diameter by 2D echocardiography, 3) necessity of analysis of color coded anterograde flow to measure the pulmonary valvular orifice. Grade A was distributed to easily recordable measurements with no difficulty; grade B for measurements with one difficulty; grade C for measurements with 2 difficulties and grade D for investigations judged to be impossible or unreliable (3/3 criteria). The feasibility of measurement of the cardiac output at the pulmonary orifice was 88% (A:55%, B:25%, C:8%). The correlation between the pulmonary flow and reference measurements at the aortic and/or mitral valve and/or mitral annulus was 0.96. The average difference between the pulmonary and reference flow was 51 +/- 273 cc/min.(ABSTRACT TRUNCATED AT 250 WORDS)

Non-invasive quantification of mitral regurgitation remains a clinical problem. The aim of this study was to assess a new methodology of Doppler echocardiographic assessment of the mitral regurgitant fraction. The study included 60 patients (average age 61 years) in sinus rhythm with mitral regurgitation. The cardiac output was measured by Doppler echocardiography at four sites: the aortic, pulmonary and mitral rings and at the tips of the mitral leaflets by a method previously validated and published. Using the average of the aortic and pulmonary cardiac outputs on the hand and the mitral cardiac output on the other, it was possible to calculate the regurgitant fraction: (mean mitral flow-mean aortic/pulmonary flow)/mean mitral flow. This was correlated with the Sellers angiographic grades of regurgitation. The results confirm this validated procedure: the correlation of aortic and pulmonary flows was good: r = 0.94. This also held true for mitral flow at the two sites: r = 0.96. The correlation between the Doppler echocardiographic regurgitant fraction and the angiographic estimation of the severity of mitral regurgitation was good: r = 0.89. There was a statistically significant difference between the Doppler echocardiographic regurgitant fractions corresponding to Sellers Grades I, II and III mitral regurgitation (p = 0.0001). This study shows that Doppler echocardiographic measurements of blood flow at different orifices of the heart applied to the quantification of mitral regurgitation is a reliable method, the use of which, with strict methodological criteria, may be proposed in everyday clinical practice.

Thirty patients with recent myocardial infarction were intravenously injected with the modified fatty acid [123I]16-iodo-3R,S-methyl hexadecanoic acid (MIHA) at peak exercise to quantify viable myocardium after infarction. The results were analysed visually and quantitatively and compared with those obtained after injection of thallium 201 at peak exercise with single-photon emission computed tomography (SPECT) imaging immediately and 4 hours later. Ventriculography was used to study regional wall motion in all patients. In the visual comparison of 201Tl- and MIHA-SPECT scintigrams, 98.8% of normal segments (N) and 96% of temporary thallium-defect segments (T) were N or T on MIHA-SPECT scintigrams (91.3% and 70.5%, respectively, in the quantitative analyses). In contrast, 47.2% of permanent thallium-defect segments (P) were N or T on the MIHA-SPECT scintigrams (20.6% in the quantitative analysis). Revascularization therapy could only be recommended on the basis of MIHA-SPECTs in 5 to 8 of the 30 patients. To confirm the superiority of MIHA over 201Tl to evaluate myocardial viability, one must compare their uptake with myocardial contractility after revascularization.

Thallium scintigraphy holds a unique position amongst the methods available for evaluating the prognosis of coronary patients: it enables quantification of underperfused myocardium and evaluates already constituted ventricular damage (irreversible necrosis) and areas at risk of future coronary events (viable but ischemic myocardium). In a series of 1,926 patients who underwent exercise stress or dipyridamole Thallium myocardial scintigraphy for angina pectoris and followed up fort an average of 34 months, the following features were observed: the long-term prognosis in patients with normal myocardial scintigraphy (715 patients) was identical to that of a normal population of the same age (0.11% cardiovascular deaths per year) whereas the cardiovascular mortality was 15 times higher in cases with a pathological scintigraphy: finally, the long-term prognosis (cardiovascular deaths, infarcts or secondary revascularisation) was directly related to the severity of the initial lack of Thallium uptake. This method was used to assess the prognosis and evaluate the myocardial ischaemia in 75 patients who underwent complete surgical revascularisation fort ischaemia, 50 of whom had previous myocardial infarction: all patients had at least one arterial bypass graft: 39% of the myocardium was underperfused before revascularisation; this procedure reduced by 80% (p < 0.0001) the zones of reversible underperfusion but also zones of irreversible underperfusion by 17% (p = 0.04). The results were particularly impressive in patients who underwent revascularisation with an arterial pedicle (left and right internal mammary, gastroepiploic alone or in association) as 91% of the ischemic territories recovered on average 13 days after revascularisation.(ABSTRACT TRUNCATED AT 250 WORDS)

Fainting (short loss of consciousness) is a frequent reason for a consultation in a general practitioner's or cardiologist's office. Four main causes are recognized commonly: cardial with auriculo-ventricular block and arrhythmias, vascular in particular vaso-vagal syncopes, neurologic and other causes. In 38 to 47% of the patients no etiology is found: these are syncopal attacks of unknown origin. The first diagnostic step comprises noninvasive investigations. A 24-hour recording of the ECG or a 'long strip' improve the diagnostic rate by 10%. They are particularly useful for sick sinus syndromes. The head-up tilt-test has been developed recently. It is very useful for detection of vagovasal syncope and permits to understand the pathophysiology and the therapeutic consequences of these disorders. This test plays a particular role for the diagnosis of syncopes of unknown causes and shows in 24 to 75% of the cases pathologic results. Patients at high risk for ventricular arrhythmia can be recognized by ECG with high amplification. Doppler investigation of the neck vessels, however, seems to be of low diagnostic value in syncopes. Invasive measures are the last line resort. Electrophysiologic studies provide criteria that are well defined. They are useful for detection of ventricular dysrhythmias and conduction disorders. This latter approach is reserved to patients with negative noninvasive tests and in particular with cardiopathy. The approach to syncope and the power of noninvasive and invasive tests is thus well established. However, in a certain number of patients the cause for fainting is not disclosed. Fortunately mortality is low in this particular group.

Two hundred and seventy patients under 71 years of age with myocardial infarction less than 4 hours old, defined by clinical and electrocardiographic criteria, were included in this trial and followed up for 1 year: two groups of 89 and 92 patients were randomised to receive APSAC (30 mg i.v. over 5 minutes) or rt-PA (10 mg bolus + 5000 IU of heparin as a bolus, followed by 90 mg rt-PA over 3 hours) and compared with a control series of 89 consecutive patients treated with streptokinase (1.5 MU in 1 hour). Heparin and aspirin (250 mg/day) were prescribed systematically. A score of efficacy was established from the following 4 parameters: patency of the infarct-related artery on coronary angiography at day 6 +/- 2 (N = 252), dyssynergic score on radiological ventriculography, infarct size on resting Thallium myocardial scintigraphy performed between day 15 and 21 (N = 242) and radionuclide ejection fraction performed at the same time. This score (0-24) was respectively 17.8 +/- 6.4 for rt-PA, 17.7 +/- 6.0 for APSAC and 18.1 +/- 6.0 for streptokinase (NS). The costs of hospital treatment were assessed by including: the cost of thrombolytic therapy (ranging from 1.7% of total cost for streptokinase to 16% for rt-PA), the cost of other treatments and biological investigations (10% of total cost); the cost of followed coronary angiography, in 33% of patients, by an angioplasty (21% of total cost), the cost of hospital stay averaging 17 days (49% of total cost in the rt-PA and APSAC groups and 56% in the streptokinase group NS).(ABSTRACT TRUNCATED AT 250 WORDS)

The aim of this study was evaluation of mid-term results, with a mean follow-up of 23 months (range: 6 months to 6 years), in 449 patients undergoing 500 consecutive angioplasty procedures before 1989. All of these 449 patients underwent primary angioplasty, and not dilatation after restenosis. Data processing of information, based upon a questionnaire filled out by the patient's own cardiologist, enabled 100 per cent follow-up. In these patients with a mean age of 56 (range: 32-83), angioplasty was single in 93 per cent of cases. The indication was unstable angina (45%), following a myocardial infarction (44%) or, more rarely, stable angina (10%). The anterior interventricular was dilated more often than the right coronary and circumflex (56%, 31% and 22% respectively). The cardiac survival rate of 41 months was 94.3 per cent, 78 per cent of patients not having experienced any serious coronary events at the time of last available information. 65 (sixty five) per cent of patients were asymptomatic and the Thallium stress test was normal in 67 per cent of them. Angina recurred in 17 per cent of patients, twice as often in women (p < 0.02). 14 (fourteen) per cent had undergone a bypass procedure and 14 per cent had been redilated. Comparisons by the Kaplan-Meier method showed less good results after the age of 57: higher mortality (p < 0.01), more frequent recurrences of angina (p < 0.05), more frequent aorto-coronary bypasses (p < 0.001). Aorto-coronary bypasses were commoner after dilatation of the anterior interventricular (p < 0.005), after multiple dilatations (p < 0.03) or after unstable angina (p < 0.05).

Nuclear Cardiology has seen many advances in the past few years: new indications for tracers already known, but also the appearance of new markers, by single photon imaging or by position emission (PET). With regard to the investigation of myocardial perfusion, thallium remains the most widely used isotope. Its sensitivity in the diagnosis of coronary disease is improved by the use of scintigraphic CT scan (SPECT) and excellent predictive value in terms of the onset of coronary events or mortality has been confirmed in particular. At the same time, the sensitivity and specificity of new technetium markers have been better defined. The investigation of myocardial metabolism, accessible up to now only via PET and confined, in France, to the domain of clinical research, is in the process of becoming a tool suitable for use by clinicians as a result of new SPECT-Thallium protocols (reinjection, late redistribution and rest), but also because of the development of single photon markers of myocardial viability, e.g. iodinated fatty acids. A functional approach to coronary disease, indispensable adjuvant to the anatomical approach, is now possible on a routine basis.

A hundred and eighty three patients with a primary myocardial infarction less than 4 hours old were included in a double blind trial versus placebo comparing an isolated plasminogen streptokinase activator complex (APSAC: 30 mu in 5 mn) and tissue type plasminogen activator (rt PA: 10 mg bolus followed by 90 mg in 130 mn). Clinical evolution, side effects, patency of the artery responsible for infarction, left ventricular contractile function (contrast angiography on the 7th day and angioscintigraphy on the 21st day) and infarct size were studied. The two groups were comparable in age (54 +/- 11 years), delay in randomisation (170 +/- 50 mn), infarct site and severity of cardiac failure. There was no significant difference in hospital mortality (7 in the rt PA group and 5 in the APSAC group) or in adverse effects (haemorrhage: rt PA: 9 patients, APSAC: 11 patients). The patency was 72% in the APSAC and 76% in the rt PA group. Left ventricular function and infarct size were comparable in the two groups: angiographic EF (0.50 +/- 0.1 in the APSAC and 0.52 +/- 0.1 in the rt PA group: NS); asynergic score (11.3 +/- 1.7 in the APSAC and 10.5 +/- 1.8 in the rt PA group: NS); infarct size (10.9 +/- 8.0 in the APSAC and 9.4 +/- 7.2 in the rt PA group: NS). This trial shows that these two thrombolytic agents have the same efficacy. The authors recommend adaptation of the dosage of rt PA to body weight.

Although global mortality in the year following myocardial infarction is about 10%, this figure varies from less than 1% to more than 50% in some very high risk cases. The principal objective of clinical evaluation during the acute phase is to establish a prognosis and propose a rational strategy for myocardial revascularisation (by bypass grafting or angioplasty) in patients with a poor prognosis. An essential feature of this evaluation is to reduce health care costs and hospital stay to a minimum. Coronary angiography is the only investigation which allows assessment of the coronary circulation and is probably the best method of evaluating global and regional left ventricular function, two essential prognostic factors: on the other hand, it does not provide information about the presence of residual ischaemia or persistent myocardial viability in the infarcted territory. Some very high risk patients should undergo systematic coronary angiography to determine the possibilities for myocardial revascularisation: early post-infarction angina, left ventricular failure, chronic angina, elderly but valid patients... The indications of coronary angiography should also extend to patients with non-Q wave infarction, to young patients with myocardial infarction on thrombolysed infarcts: results of coronary angiography should then be compared with those of standard exercise stress testing. It is only in other situations, concerning a minority of patients, in which two attitudes may be considered: the first, to perform coronary angiography very early (within 24-48 hours of admission) allowing early discharge from hospital of many cases, completed later by standard exercise stress testing: any revascularisation procedure is considered at that time and requires a second hospital admission. The second attitude consists in performing coronary angiography between the 7th and 10th day only if some paraclinical changes are present: exercise stress testing then has an essential role; to improve its negative predictive value for absence of long-term coronary events it should be associated with radionuclide investigation of myocardial perfusion (thallium, MIBI) or with an evaluation or residual myocardial viability (labelled fatty acids, cyclotron). This attitude also allows early identification of "good candidates" for myocardial revascularisation.

Invasive techniques for the measurement of cardiac output include the Fick method, the marker dilution method and radiological ventriculography. The principles, methods and accuracy of these techniques are described. The reference method remains that of Fick, despite its being less widely used now because of its complicated nature and its technical limitations (need for strict baseline conditions, precision of sampling). The thermodilution method is often performed. It is easy and provides reliable results, except in conditions of low cardiac output or when there is severe tricuspid insufficiency. Radiological ventriculography is used less for the measurement of cardiac output, since it is heavily dependent upon heart rate and theoretical geometrical models. It remains valuable for the quantification of mitral and aortic regurgitation.

Fifteen patients with an ostium secundum type atrial septal defect, aged between 5 and 68 (mean = 31) underwent Doppler-echocardiographic evaluation of the ratio of pulmonary and systemic flow rates. Systemic flow was evaluated at the aortic orifice, as well as at the mitral ring and at the extremities of the mitral cusps, based upon the measurement of valve diameters by 2D or TM echocardiography, pulsed Doppler velocity curve and hear rate. Pulmonary flow was measured by the same technique at the site of insertion of the pulmonary cusps. The values obtained were compared with cardiac catheterisation findings, the reference method being an oxymetric measurement of the shunt ratio. Feasibility of the Doppler investigation was 100 per cent. Correlation between the two techniques was r = 0.85 when the Doppler measurement was at the aorta, r = 0.81 for the mitral ring and r = 0.71 at the extremity of the mitral cusps. Doppler-echocardiography thus appears to be a reliable and reproducible method for the evaluation of left-right shunts, confirming data from the literature.

In recent acute myocardial infarction, early reperfusion of the infarct-related artery by intracoronary or intravenous thrombolytic therapy induces a significant limitation of infarct size, provided reperfusion occurs within a time frame that myocardial salvage can still be expected. Limitation of infarct size reduces scar tissue formation, aneurysm formation, infarct zone expansion, left ventricular volume enlargement, and eventually results in higher left ventricular ejection fraction. Infarct size limitation and left ventricular function preservation occur with all thrombolytic agents currently in clinical use: streptokinase, alteplase and, more recently, anistreplase. When anistreplase is compared with conventional heparin therapy, a 31% reduction in infarct size is found (estimated from single photon emission computed tomography, or SPECT). This translates into a significant preservation of left ventricular ejection fraction as observed in anistreplase-treated patients compared with heparin-treated patients (0.53 +/- 0.13 vs 0.47 +/- 0.12, p less than 0.002). In comparative trials of 2 thrombolytic agents, anistreplase was demonstrated to be as efficient as alteplase on left ventricular ejection fraction preservation and infarct size limitation.

The authors report the case of a 30-year old patient who presented atrioventricular block 12 years after mediastinal radiation treatment of Hodgkin's disease. This patient had been monitored in the service for 3 years after the insertion of a pacemaker. A review of the literature, identified 15 cases of post-radiation AV block. The AV block was subnodal in the 7 cases which were subjected to endocavitary recording.

Two hundred and thirty-one patients admitted to hospital within 5 hours of the onset of symptoms of a primary myocardial infarction were randomised into 2 groups: one received thrombolytic therapy [anisoylated plasminogen streptokinase activator complex (APSAC): 30 IU in 5 minutes] and the other was given conventional heparin therapy (5,000 IU). Heparin was given to both groups 4 hours later (500 IU/kg/day); the APSAC (N = 119) was identical with respect to age, location of infarct, Killip classification, delay before randomisation (188 +/- 62 minutes). Coronary angiography and ventriculography were performed after 3.4 +/- 1.2 days, and angioscintigraphy and myocardial scintigraphy after 19 +/- 2.5 days to determine the size of the infarct and the quality of left ventricular function. Coronary patency was much higher in the APSAC group (77%) than the heparin group (37%) (p less than 0.001). The angiographic ejection fraction was significantly greater in the thrombolytic group than in the heparin group (53 +/- 13% vs 47 +/- 12%, p less than 0.002), the difference being statistically significant in the anterior and inferior infarct subgroups. At the third week, the difference remained significant in the anterior infarct subgroup: a 31 per cent reduction in necrosed myocardial mass was observed in the APSAC group (33% in anterior infarcts: p less than 0.05 and 16% in inferior infarcts: NS). The limitation of infarct size explained the smaller reduction in left ventricular systolic function (r = 0.73; p less than 0.01). The hospital and one year mortality was comparable in the two groups which was not surprising given the small number of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The early intravenous administration of thrombolytic agents in the acute phase of myocardial infarction induces reperfusion of the artery responsible for the necrosis, thereby limiting the size of the infarct and preserving the left ventricular systolic function with consequent reduction of short- or long-term mortality. With the exception of urokinase, these effects have been demonstrated with all thrombolytic agents used so far, including streptokinase, plasminogen tissue activator and anistreplase. Owing to its special pharmacokinetic properties, the latest thrombolytic agent, formerly known as APSAC (anisoylated plasminogen streptokinase activator complex), provides a high arterial reperfusion rate with a low percentage of reocclusion. As a result, the mean size of the infarct is reduced by 31 per cent (36% in the case of anterior infarct), and the left ventricular systolic function is highly significantly preserved.

Endoscopic sclerotherapy is widely employed for esophageal variceal hemorrhage. However it has side effects and can aggravate portal hypertension by suppression of portosystemic shunt. The purpose of the present investigation was to study the effect of variceal thrombosis on hepatic venous pressure gradient and azygos blood flow. Eight alcoholic cirrhotic patients with a first variceal hemorrhage were included. According to Child Pugh's classification, 4 patients were group A, 2 group B and 2 group C. At each session 40 to 60 ml of 1 p. 100 polidocanol were injected into the varices. A hemodynamic study was performed in each patient before and about one week after variceal obliteration (mean 3.3 procedures). Mean value of hepatic venous pressure gradient was 16.6 +/- 5.5 mm Hg and 17.0 +/- 3.8, respectively, before sclerotherapy and after eradication of varices; azygos blood flow 663 +/- 506 ml/mn before and 682 +/- 522 after; cardiac, output was 6.5 +/- 0.7 ml/min before and 6.5 +/- 0.8 after. None of these differences were significant. These results suggest that endoscopic sclerotherapy using polidocanol does not change hepatic venous pressure gradient and azygos blood flow, and does not lower blood flow through the gastroesophageal collaterals draining into the azygos vein. This is consistent with the hypothesis that thrombosis remains localized.

In cases of acute myocardial infarction (MI), it has been shown that preserving left ventricular function and limiting infarct size with early reperfusion of the occluded artery by means of a thrombolytic agent could eventually result in a reduced mortality rate. The aim of the APSIM study (anisoylated plasminogen streptokinase activator complex [APSAC] dans l'infarctus du Myocarde) was to demonstrate that early administration of APSAC in patients with recent acute MI could limit the infarct size and preserve left ventricular systolic function. In all, 231 patients with a first acute MI were randomly allocated to either APSAC (30 U over 5 minutes) or to conventional heparin therapy (5,000 IU in bolus injection) within 5 hours of the onset of symptoms. Of these patients, 112 received APSAC and 119 received heparin within a mean period of 188 +/- 62 minutes after the onset of symptoms. The patency rate of the infarct-related artery was 77% in the APSAC group and 36% in the heparin group (p less than 0.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the APSAC than in the heparin group. This was true for the entire population (0.53 +/- 0.13 vs 0.47 +/- 0.13, p = 0.002) as well as for the subgroups of anterior and inferior wall infarctions (0.47 +/- 0.13 vs 0.4 +/- 0.16, p = 0.004 and 0.56 +/- 0.11 vs 0.51 +/- 0.09, p = 0.02). At 3 weeks, the difference remained significant for patients with anterior MI.(ABSTRACT TRUNCATED AT 250 WORDS)

This study was based on a series of 486 patients with acute myocardial infarction. All were treated with heparin and nitrite derivatives. 320 patients received 600 mg/24 h Potassium Canrenoate for 5 days (long duration); 90 patients received 1000 mg of Potassium for the first 36 hours only. 76 patients did not receive the drug and served as controls. The biochemical changes due to Potassium Canrenoate are discussed with special emphasis on the serum and intraerythrocytic potassium levels. The antiarrhythmic action of the potassium was assessed directly (the number of ventricular extra systoles decreased significantly) and indirectly (the amount of antiarrhythmic therapy required in association was three times less in patients treated by Potassium Canrenoate). The mortality rate changed from 17 to 12%. The beneficial effect of Potassium Canrenoate is attributed to the maintenance or the restoration normal potassium levels of ischaemic myocardial tissue.

Many metabolic and hormonal changes are observed during the acute phase of myocardial infarction (glucose metabolism, lipoproteins...). Mineralocorticoid function may also be disturbed but there have been few studies of this problem. The aim of this study was to confirm the elevation of serum aldosterone during the acute phase of myocardial infarction and to determine the effects of antialdosterone treatment in these patients. Hyperaldosteronism was confirmed in 74% of 72 consecutive patients admitted for acute myocardial infarction, in 85% if patients previously treated by an antialdosterone drug or admitted after the acute phase are excluded, and in 96% if patients with cardiac failure are included. One thousand consecutive patients admitted for myocardial infarction were given an antialdosterone agent systematically (intravenous potassium canrenoate , 600 mg daily for 5 days). The serum and red blood cell potassium concentrations rose, the number of ventricular extrasystoles and the administration of anti-arrhythmic drugs fell, and, above all, the prevalence of ventricular fibrillation decreased significantly: 0,8% (p less than 0,001), compared with comparable previously reported series.

Report and comments on one case of cerebral malaria with myocardial infarction, icterus and renal insufficiency, and of another one with a black-water-like syndrome with complete recovery under quinine treatment.

Idiopathic mitral valve prolapse due to severe myxoid degeneration may be associated with aortic and/or tricuspid valve disease of the same aetiology. These localisations, which usually give rise few symptoms, can be detected by echocardiography. Sometimes, however, they may give rise to serious valvular regurgitation requiring surgical correction at each diseased valve. The authors report two cases of "floppy" mitral valve prolapse, the first requiring mitral and tricuspid, and the second, mitral and aortic, valve replacement. These cases underline the value of especially by echocardiography, in view of their serious complications.

In patients with posterior or postero inferior infarction, a limited septal infarction may be detected by vectorcardiography, septal extension being a sign of disease of the left anterior descending artery. In order to confirm this hypothesis, 31 posterior or postero inferior infarction with septal extension were selected by vectorcardiography from more than 500 ECGs recorded after the acute phase of a clinically and biologically documented infarction. The following criteria were chosen: 1. Anterior deviation of the QRS, associated or not with superior deviation of the initial deflection lasting over 25 ms and clockwise rotation of the frontal loop (posterior infarct: 9 cases, postero inferior infarct: 22 cases). 2. Abnormalities of the initial phase of the QRS in the horizontal plane, associated with a reduced amplitude and duration of the initial deflection. The clinical, ECG, vectorcardiographic and angiographic (14 cases) features of these 31 postero septal infarcts were compared with those of 31 posterior septal infarcts were compared with those of 31 posterior or postero inferior infarcts (24 coronary angiographies). 1. From the clinicl point of view, in the acute phase postero septal infarction did not differ from posterior infarction and the early prognosis was favourable. On the other hand, with an average follow-up of 2 years, the outcome of postero septal infarction was statistically more complicated than that of strict posterior infarction (52 p. 100 compared to 19 p. 100, p < 0.01). 2. From the electrocardiographical point of view, septal extension of posterior infarction was only suspected in 25 p. 100 cases. In the acute phase, ST depression in V2 to V5 sometimes associated with reduction of the R wave in the right precordial leads and QS waves in V4R, suggesting a "rudimentary" or "subendocardial" infarct. 3. From the angiographic point of view, although disease of the posterior vessels was equally common in posterior and postero septal infarction (86 p. 100 compared to 92 p. 100 NS), stenosis of the left anterior descending artery was statistically more common in postero septal infarction than in posterior infarction (86 p.100 compared to 29 p. 100, p < 0.001). Thallium myocardial scintigraphy, when performed, showed the double myocardial lesion in the antero septal and postero inferior walls in postero septal infarction. These results validate the vectorcardiographical criteria retained for diagnosis of postero septal infarction and confirmed the superiority of the vectorcardiogramme over the electrocardiogramme in the diagnosis of double infarction. Therefore, the vectorcardiogramme in the diagnosis of double infarction. Therefore, the vectorcardiogramme allows selection of the patients with postero diaphragmatic infarction with a limited septal extension, for whom coronary angiography should be proposed. A "postero septal" infarct diagnosed on vectorcardiogramme has a high probability of stenosis of the left anterior descending artery.

In order to evaluate the usefulness of this new exploratory method in dissection of the aorta, 13 patients (10 men and 3 women, mean age 58 +/- 14 years) were examined by means of an 0.5 Tesla Magniscan 5000 nuclear magnetic resonance machine. Fifteen examinations were performed: 5 in patients with actual aortic dissection (type A 4 including one acute, type B1), 5 in patients previously operated upon for type A dissection and 5 for suspected acute aortic dissection unconfirmed by other examinations. Magnetic resonance imaging (MRI), synchronized with electrocardiography, was carried out using spin-echo techniques with 1 to 3 echoes and multiple contiguous sections along several planes. In the 5 patients with actual dissection the 2 channels separating the membrane could be demonstrated, thus providing a firm diagnosis (MRI proved superior to angiography in 2/5 patients). All 5 patients could be classified as either type A or type B. Extension to the cervical vessels was observed in 3 cases and the portal of entry was seen in one case, but the origin of the coronary arteries was never visualized. In the 5 patients previously operated upon MRI provided detailed analysis of the prosthesis of the supra-coronary ascending aorta implanted in all cases, of the aorta proximal and distal to that segment and of the periaortic mediastinum. By studying the signal from the false channel distal to the prosthesis information was obtained as to the presence in it (2 patients) or absence of circulating blood.(ABSTRACT TRUNCATED AT 250 WORDS)

Unlabelled: Between January 1983 and May 1984, 104 patients with no known cardiac pathology were referred by their cardiologist for diagnosis of chest pain. They all underwent coronary angiography which was used as the reference investigation and the following sequential Bayes' analysis was performed. The percentage probability of coronary artery disease was estimated from clinical date (age, sex, characteristics of the chest pain subdivided into 3 groups); an exercise ECG was performed in all cases (classified as positive, negative or non diagnostic); if the probability of coronary artery disease was greater than 95% (or less than 5%) after exercise stress testing the patients was diagnosed as having (or not having) coronary artery disease. If the probability was between 6 and 94% the patient underwent Thallium myocardial scintigraphy (Thallium dipyridamole; analysis on a colour television screen); the coronary risk probability before Thallium was that calculated after exercise stress testing. If after myocardial scintigraphy the coronary risk remained between 6 and 94%, an exercise angioscintigraphy was performed and interpreted in the same way. The clinical and complementary date was analysed on a mini-computer, the values of the sensitivity and specificity of the tests used for the calculation of the probability of coronary artery disease were those previously published by our group., Results: 31/88 (35%) of patients were classified in the 5% risk groups after exercise stress testing (24 coronary artery disease; 7 normals: no errors of classification). Fifty six out of the 88 patients (65%) were classified in the 5% risk group after myocardial scintigraphy (42 patients with coronary artery disease with 41 abnormal coronary angiographies and 14 normal patients, all of whom had normal coronary angiographies; this represents a 1.8% divergence of classification compared with coronary angiography). Angioscintigraphy only classified 3 of the remaining patients, one wrongly, and did not seem to be useful diagnostically as a third-line investigation after Thallium scintigraphy or as a second-line investigation instead of Thallium scintigraphy. This strategy is less costly than carrying out coronary angiography systematically in these patients: if diagnostic coronary angiography is performed alone in patients with a risk of 6 to 94% the cost is 4 800 FF vs 10 400 FF per patient; if coronary angiography is performed in all patients in whom coronary artery disease is possible or certain (all patients with a risk of over 5%), the cost is 8 400 FF vs 10 400 FF per patient, a saving of 20%.(ABSTRACT TRUNCATED AT 400 WORDS)

Although transluminal coronary angioplasty is now acknowledged as an effective treatment for coronary artery disease, the long-term outcome of patients treated by this method is still under evaluation. A french multicenter trial was set up and the long-term efficacy of transluminal coronary angioplasty was assessed in 546 patients undergoing the procedure before the 31/3/83. 380 initial successes (69 p. 100) were followed up for a period ranging from 6 to 48 months (average 19.9 +/- 10.4 months). A control coronary angiography was carried out in 88 p. 100 of cases. Restenosis (loss of over 50 p. 100 of initial angiographic improvement) was observed in 27 p. 100 of cases. Including the repeat procedures, the patency rate of the dilated vessels was 82 p. 100. Progression of atherosclerosis on another coronary artery was observed in 1.3 p. 100 of cases. After transluminal coronary angioplasty, 72 p. 100 of patients remained improved, 11 p. 100 underwent repeat angioplasty, 8 p. 100 underwent coronary bypass surgery, 1.3 p. 100 suffered myocardial infarction and 1.3 p. 100 died. Restenosis was associated with recurrence of angina pectoris in 90 p. 100 of cases (within 3.3 +/- 1.6 months) and a positive exercise stress test in 87 p. 100 of cases. Recurrence of angina due to progression of disease on the dilated vessel was observed in 24.2 p. 100 of cases; repeat transluminal coronary angioplasty was carried out for this indication in 38 p. 100 of cases, coronary bypass in 34.8 p. 100 and medical treatment was continued in 27.2 p. 100 of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

The electrophysiological effects of the cardiotropic drugs have been studied in man by the agency of endocavitary electrocardiography. The effects of drug combinations, which are often prescribed therapeutically, have been studied less often. The authors report the results of a preliminary study of the combination of deslanoside with ajmaline in 26 patients; its effects were compared with those using each drug separately. This combination seems to have true dromotropic effects; although deslanoside alone, in the doses used, does not modify conduction below the bundle of His, it can still act synergistically with ajmaline at this level. A detailed study of the pharmacological effects as a function of the original status of conduction shows that at the level above the bundle His, the dromotropic action is quantitively less on healthy conducting tissue than on abnormal tissue. The effects of ajmaline on the conduction times below the bundle seem to be similar whether or not there is any conduction defect under basal conditions. The difficulties in obtaining and interpreting such measurements in man are discussed in the hope of arriving at a general protocol for studying drug combinations.

Seven patients with arrhythmogenic right ventricular dysplasia were explored by magnetic resonance imaging (MRI), using the spin-echo technique (TR = the patient's own RR cycle; TE = 28 ms, 56 ms, 84 ms) with multiple, contiguous, 7 to 10 mm thick sections performed in two planes: axial plus sagittal or frontal planes. In 5 out of 7 patients, MRI showed dysplastic lesions in the right ventricular wall presenting typically as fat-like high signals contrasting with the normal myocardium. In 2 patients, no lesion was clearly visualized. The parietal lesions were located in the anterior wall of the right ventricle and conus arteriosus in 5 cases and in the lower wall of the right ventricle in one patient who had two dysplastic areas. In 3 patients the lesions extended up to the tip of the interventricular septum and of the left ventricle. In the 2 patients whose lesions were most extensive, their predominance in the subepicardial region and the concordance between the sites of abnormalities at MRI and angiography were clearly observed. Thus, despite its present technical limitations MRI seems to be one of the first techniques capable of visualizing the parietal lesions in patients with arrhythmogenic right ventricular dysplasia.

The right ventricular ejection fraction is rarely measured, as conventional diagnostic methods (radiology, echocardiography) are confronted with the problem of representing the right ventricle as a simple tridimensional geometrical model. This is not necessary with the radio-isotopic techniques. However, all those used for the measurement of right ventricular ejection fraction lead to important methodological problems. We have therefore developed a technique of measuring this parameter with an infusion of 81 m Kr. This radioactive gas is pure gamma-ray emitter with a 13 second period. Dissolved and infused intravenously, it is eliminated during the first passage through the lung. The continuous separation of the generator of 81 m Kr is performed with isotonic dextrose solution which is then infused for a period of 7 minutes. During this time, the activity detected by the scintillation camera inclined in the 30 degrees RAO projection is stored, together with the electrocardiogram in a computer. The precordial radioactivity of the retrocardiac lung tissue is subtracted after injection of 74 MBq of 99 mTc microspheres. A graph of right ventricular activity can then be reconstructed and the right ventricular ejection fraction calculated. The left ventricular ejection fraction is then measured with 99 mTc--labelled RBCs. This method allows the right ventricular ejection fraction to be measured in the RAO projection, the best incidence for the separation of the right atrial from the right ventricular activity without interference from left ventricular activity because of the pulmonary elimination of the Krypton radioactivity. The measurement performed on a large number of cardiac cycles allows a continuous study of the right ventricular ejection fraction. At the end of the infusion there is no circulating radioactivity so that the measurement can be repeated. This technique was used in 17 patients with acute myocardial infarction. In the 7 patients with anterior infarcts reduction of the left ventricular ejection fraction was the predominant finding (21,6 +/- 6,8%). The right ventricular ejection fraction was 34,2 +/- 6,4%. On the other hand, patients with a postero-inferior infarction had little change in left ventricular ejection fraction (59,2 +/- 12%) but those with right ventricular extension of their infarcts had very reduced right ventricular ejection fractions (less than 23%). The measurement of right ventricular ejection fraction with 81 m Kr is a reliable atraumatic method for diagnosing right ventricular infarction by the quantification of its functional impairment.

The aims of this comparative study by vectorcardiography and myocardial scintigraphy in the topographical analysis of primary inferior and/or posterior wall infarction, were: to obtain data confirming the value of identifying true posterior wall infarction; to confirm the diagnostic value of vectorcardiography in this condition. The patients in this retrospective study were admitted to hospital for primary inferior and/or posterior wall infarction and underwent vectorcardiography and myocardial scintigraphy either with Thallium 201 (137 patients) or 99m Technetium (88 patients) in the acute phase. The scintigraphies of all patients included showed hypofixation compatible with inferior and/or posterior infarction as this was used as the topographical reference. The results of vectorcardiography and myocardial scintigraphy were concordant in 164 of the 225 patients (72.8%), 18 with true posterior infarction [%), 110 with inferior wall infarction (48.8%) and 36 with postero-inferior wall infarction (16%). The results were discordant in 61 patients (27.1%); infarcts of the inferior or posterior walls according to one technique, were observed on the posterior or inferior walls with the other. The majority of these cases had postero-inferior wall changes on vectorcardiography and inferior wall infarction alone on scintigraphy (35 patients: 15.5%). The specificity of the vectorcardiographic signs of true posterior wall infarction remained satisfactory.(ABSTRACT TRUNCATED AT 250 WORDS)

Two coronary pulmonary fistulae were demonstrated between the right coronary and left anterior descending arteries and the main pulmonary artery at coronary angiography, in a 66 year old woman with a continuous murmur in the third left intercostal space. This double malformation, though uncommon is not rare (18 previously published cases). It is usually diagnosed late (17 to 76 years) and the presentation is limited in half the cases to a localised continuous murmur, the localisation of which may simulate a patent ductus arteriosus. The hypothesis of a supernumerary coronary artery arising from the main pulmonary artery is suggested by the constancy of the anatomical characteristics of the reported cases. Eight patients presented typical attacks of angina which were due to severe coronary atherosclerosis, affecting two or three main vessels except in one case. Therefore, it is unlikely that these fistulae cause coronary insufficiency by a coronary steal syndrome. However, this mechanism may aggravate symptoms in patients with coronary artery disease and necessitate surgical cure of the fistulae at the same time as coronary bypass surgery. On the other hand, surgery does not seem to be indicated in asymptomatic patients.

154 patients investigated for chest pain underwent 12 lead exercise electrocardiography and also exercise 201-Thallium myocardial scintigraphy performed at coronary angiography. 92 patients had typical angina; in this group the sensitivity and specificity of exercise electrocardiography was good (91% and 86% respectively) and exercise myocardial scintigraphy did not give significantly better results. On the other hand, in cases when exercise electrocardiography was negative (27%) exercise myocardial scintigraphy was positive in 75%. 201-Thallium did not discriminate between ischaemia and necrosis in patients with previous myocardial infarction, ischaemia alone causing hypofixation on basal myocardial scintigraphy. 62 patients had atypical chest pain. The low incidence of coronary artery disease in this group (30%) increases the value of exercise 201-Thallium scintigraphy as it is both more sensitive (59% compared to 21%, p less than 0,05) and more specific than exercise electrocardiography (43% compared to 85%, p less than 0,1). 29% monotruncular lesions had negative exercise electrocardiography and myocardial scintigraphy. However, multivessel and left main coronary disease may be excluded with great probability by a negative exercise 201-Thallium scintigraphy.