Circulation, Vol 81, 850-859, Copyright © 1990 by American Heart Association
EG Nabel, AP Selwyn and P Ganz
Vasodilation in normal and vasoconstriction in atherosclerotic coronary
arteries have been observed in response to complex stimuli such as exercise
and the cold pressor test. To study a single parameter that changes during
these activities, and to better understand the pathophysiology of ischemia
associated with increases in heart rate, we studied coronary vasomotion and
blood flow response to increasing heart rate alone, produced by atrial
pacing, with quantitative angiographic and Doppler flow-velocity
measurements in 15 patients. In five patients with angiographically smooth
coronary arteries (group 1), tachycardia produced progressive dilation of
the epicardial artery with increases in cross-sectional area (CSA) of +15.5
+/- 3.4%, +22.4 +/- 2.1%, +28.5 +/- 3.3%, and +30.6 +/- 2.2% at 90, 110,
130, and 150 beats/min, respectively. In contrast, in five patients with
mild angiographic narrowings (group 2), coronary segments failed to dilate
with progressive tachycardia (-6.3 +/- 2.0%, -8.3 +/- 2.0%, -12.5 +/- 2.0%,
and -11.4% at 90, 110, 130, and 150 beats/min, respectively), and
progressive loss of luminal area was observed in five patients with severe
angiographic narrowings (group 3) (-34.4 +/- 3.4%, -49.6 +/- 2.2%, -59.2%,
and -72.8% at 90, 110, 130, and 150 beats/min, respectively). Coronary
blood flow increased significantly with tachycardia in group 1 (+44.5 +/-
10.2%, +86.0 +/- 24.6%, +105.8 +/- 29.3%, and +137.5 +/- 46.0%), increased
slightly in group 2 (+7.8 +/- 3.2%, +9.4 +/- 4.4%, +8.4 +/- 3.9%, and
+10.0%), and decreased significantly in group 3 (-31.8 +/- 6%, -42.6 +/-
10.7%, -61.0%, and - 70.0%). We conclude that an isolated increase in heart
rate in patients with normal coronary arteries results in a modest increase
in flow and vasodilation. In early atherosclerosis, the flow increase is
blunted and dilation is replaced with paradoxical loss in luminal size. In
patients with stenoses, further loss in luminal size occurs accompanied by
a decrease in coronary blood flow. Thus, increasing heart rate alone in the
setting of coronary stenoses could produce myocardial ischemia by a
reduction in coronary supply, as well as by an increase in oxygen demand.
ARTICLES
Paradoxical narrowing of atherosclerotic coronary arteries induced by increases in heart rate
Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
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