Circulation, Vol 86, 828-838, Copyright © 1992 by American Heart Association
PR Lichtlen, P Nikutta, S Jost, J Deckers, B Wiese and W Rafflenbeul
BACKGROUND. At present, there is extensive knowledge on the clinical course
of coronary artery disease (CAD), whereas data on the underlying anatomical
changes and their relation to clinical events are still limited. METHODS
AND RESULTS. We investigated progression and regression of CAD
prospectively over 3 years in 230 patients (average age, 53.2 years) with
mild to moderate disease by applying quantitated, repeated coronary
angiography. Minimal stenotic diameters, segment diameters, and percent
stenosis were analyzed by the computer-assisted Coronary Angiography
Analysis System (CAAS). Progression was defined either as an increase in
percent stenosis of preexisting stenoses by greater than or equal to 20%
including occlusions or as formation of new stenoses greater than or equal
to 20% and new occlusions in previously angiographically "normal" segments.
At first angiography, we found 838 stenoses greater than or equal to 20%
(average degree, 39.3%) and 135 occlusions in the four major coronary
branches (4.23 lesions per patient). At second angiography, 82 (9.8%) of
the preexisting stenoses had progressed, 15 of them up to occlusion (1.8%;
preocclusion degree averaging 46.6%; 29.7-65.6%). In addition, there were
144 newly formed stenoses (average degree, 39.2%) and 10 new occlusions.
Hence, 25 (2.6%) of all stenoses had become occluded. Altogether, 129
patients (56.1%) showed progression: 68 (29.6%) with new lesions only, 27
(11.7%) with preexisting lesions, and 34 (14.8%) with both types.
Regression (decrease in degree of stenoses greater than or equal to 20%)
was present in 29 stenoses (3.6%) and 28 patients (12%). The incidence of
new myocardial infarctions was low, with three originating from occluding
preexisting stenoses and one from new stenoses; hence, only four (16%) of
the 25 new occlusions led to myocardial infarctions. Risk factor analysis
showed that cigarette smoking correlated significantly with the formation
of new lesions (p = 0.001), whereas total cholesterol correlated with the
further progression of preexisting stenoses (p = 0.017) but not with the
incidence of new lesions. CONCLUSIONS. In patients with mild to moderate
CAD, the angiographic progression is slow (in this study 18.7% of patients
and 7% of stenoses per year) but exceeds regression (4.1% of patients and
1.2% of stenoses per year). Progression is predominantly seen in the
formation of new coronary stenoses and less in growth of preexisting ones.
Most of the stenoses were of a low degree (less than 50%), clinically not
manifest including those going into occlusion and leading to myocardial
infarction. Progression was influenced by risk factors, especially
cigarette smoking (formation of new lesions) and high cholesterol levels
(progression of preexisting stenoses).
ARTICLES
Anatomical progression of coronary artery disease in humans as seen by prospective, repeated, quantitated coronary angiography. Relation to clinical events and risk factors. The INTACT Study Group
Hannover Medical School, FRG.
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