Circulation, Vol 89, 2005-2014, Copyright © 1994 by American Heart Association
ED Folland, RA Vogel, P Hartigan, ER Bates, GJ Beauman, T Fortin, C Boucher and AF Parisi
BACKGROUND: Practitioners often assume a close relation between
angiographic coronary artery stenosis and patient functional capacity. To
test this unproven hypothesis, we analyzed the relation between coronary
artery stenosis measured by different methods and maximal treadmill
exercise tolerance in patients with single-vessel disease before and after
intervention by percutaneous transluminal coronary angioplasty (PTCA).
METHODS AND RESULTS: Coronary angiography and maximal exercise testing off
anti-ischemic medication were performed before random assignment of 227
patients with single-vessel coronary artery disease to PTCA or drug
therapy. Six months later, angiography and exercise testing were repeated
with patients assigned to PTCA off anti-ischemic therapy so that the
altered coronary stenosis was the only consistent variable. Patients
assigned to drug therapy were exercised on drug therapy. Coronary stenosis
was assessed visually by the local investigator and quantitatively by
blinded caliper and computer methods in central laboratories. Variabilities
of caliper and computer measurements were established in a subset read
twice. Visually estimated stenosis > or = 90% at baseline was associated
with shorter exercise duration (7.9 versus 9.2 minutes, P < .04).
Similar segregation at baseline was not observed with caliper or computer
methods. Regardless of the method of measurement used, correlation between
changes of lesion severity and exercise duration from baseline to follow-up
was poor. Patients were angiographically classified as "better,"
"unchanged," or "worse" if follow-up stenosis was below, within, or above 2
SD of mean technical variability from baseline (+/- 18.8%, caliper, +/-
14.6%, computer). Exercise duration for PTCA patients improved among those
with better lesions (+2.4 minutes, n = 50, P = .001) but also among those
with unchanged lesions (+1.9 minutes, n = 41, P < or = .001). Unchanged
medically treated patients improved less (+0.5 minutes, n = 86, P = .04).
Results were similar when patients were angiographically classified by
minimum lumen diameter. CONCLUSIONS: Handheld calipers and quantitative
coronary angiography are equivalent techniques for making anatomic
measurements. Neither method identified patients having reduced exercise
capacity at baseline as well as visual estimation. The relation between
changes of coronary stenosis and exercise duration is highly variable, at
least in part because of the insensitivity of angiographic methods for
detecting small but potentially important changes. Minimal anatomic
improvement 6 months after PTCA does not preclude a good functional
outcome. Contrary to common belief, angiographic stenosis does not
correlate well with functional capacity, even in patients with
single-vessel disease.
ARTICLES
Relation between coronary artery stenosis assessed by visual, caliper, and computer methods and exercise capacity in patients with single- vessel coronary artery disease. The Veterans Affairs ACME Investigators
Research Service, Veterans Affairs Medical Centers, West Roxbury, Mass.
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