Br Heart J: first published as 10.1136/hrt.44.6.630 on 1 December 1980. Downloaded from Br Heart J 1980: 44: 630-7 Incidence of coronary artery disease in patients with valvular heart disease G W MORRISON,* R D THOMAS,t S F M GRIMMER, P N SILVERTON4$ D R SMITH From the Department of Cardiology, The General Infirmary, Leeds SUMMARY The case notes, cardiac catheterisation data, and coronary arteriograms of 239 patients investigated for valvular heart disease during a five year period were reviewed. Angina was present in 13 of 95 patients with isolated mitral valve disease, 43 of 90 patients with isolated aortic valve disease, and 18 of54 patients with combined mitral and aortic valve disease. Significant coronary artery disease was present in 85 per cent of patients with mitral valve disease and angina, but in only 33 per cent of patients with aortic valve disease and angina. Patients with no chest pain still had a high incidence of coronary artery disease, significant coronary obstruction being present in 22 per cent with mitral valve disease, 22 per cent with aortic valve disease, and 11 per cent with combined mitral and aortic valve disease. Several possible clinical markers of coronary artery disease were examined but none was found to be of practical help. There was, however, a significant inverse relation between severity of coronary artery disease and severity of valve disease in patients with aortic valve disease. copyright. Asymptomatic coronary artery disease is not uncommon in patients with valvular heart disease and if it is policy to perform coronary artery bypass grafting in such patients, routine coronary arteriography must be part of the preoperative investigation. per- Angina occurs commonly in valvular heart dis- tion, and coronary artery bypass grafting is http://heart.bmj.com/ ease'-" but does not necessarily signify the presence formed for significant lesions whenever feasible, of coronary artery disease,'-3 8 This is particularly even when angina is absent. We have performed a true in patients with aortic valve disease'-8; retrospective study of these patients in order to it also applies in those with mitral valve disease. answer three main questions. First, what is the In addition, there are some patients without incidence of significant coronary artery disease in angina who still have significant coronary obstruc- patients with valve disease with and without angina? tion.3 8-10 In patients being considered for valve Second, are there any clinical features predictive of it is that the presence such disease? Third, how often are such lesions surgery generally accepted on September 27, 2021 by guest. Protected of angina is an indication for coronary arteriography amenable to surgical correction? as part of the preoperative investigations.' 8 l-13 Much less is known of the need for routine coronary Methods arteriography in patients without angina. Patients with coronary artery disease do less well after We reviewed the case notes of all adult patients who surgery,"1 13-17 and this has led to increasing underwent coronary arteriography as part of the interest in the possibility of treating coronary preoperative cardiac catheterisation for valvular artery disease at the time of valve surgery. During heart disease during the period 1 January 1975 to the past five years it has been our policy to perform 31 December 1979. Patients with valvular heart routine coronary arteriography on patients aged 45 disease resulting directly from ischaemic heart years or more as part of the preoperative investiga- disease (for example papillary muscle dysfunction) were excluded. A note was made of each patient's *Present address: St. James's University Hospital, Leeds LS9 7TF age, sex, and smoking history. The clinical history tPresent address: Royal United Hospital, Bath BAl 3NT. was examined for evidence of angina pectoris. *Present address: Department of Cardiovascular Studies, The University, Leeds LS2 9JT. Episodes of typical anterior chest pain, with or with- Received for publication 22 May 1980 out radiation, precipitated by exertion and relieved 630 Br Heart J: first published as 10.1136/hrt.44.6.630 on 1 December 1980. Downloaded from Incidence of coronary artery disease 631 by rest or an oral nitrate, were regarded as "typical least one other experienced operator. In the case of angina". In addition, there were some patients who borderline lesions, or a disparity in reporting, a had chest pain with some, but not all, of these third opinion was obtained. All reporting was done features, and these were classified as "atypical chest without clinical knowledge of the patient. The pain". Patients without pain were classified as "no severity of coronary artery stenosis was assessed chest pain". A record was made of any past cardiac as the maximum percentage reduction in luminal ischaemic events and past or current drug treatment. diameter, seen in any one of at least three different The electrocardiogram was examined for rhythm, projections, as compared with the diameter of the evidence of cardiac ischaemia, and previous myo- vessel proximal to the obstruction. The severity of cardial infarction. Heart size was assessed by the each lesion was graded on a simple scale from 0 to 4 radiological cardiothoracic ratio. as follows: 0 =no obstruction; 1=1 to 49 per cent; The data obtained at cardiac catheterisation were 2=50 to 69 per cent; 3=70 to 99 per cent; 4=total reviewed. Pulmonary hypertension was indicated by occlusion. Obstructions of grade 2 or more were a pulmonary artery mean pressure greater than said to be "significant". The maximum narrowings 20 mmHg. Left ventricular end-diastolic pressure on five major vessels' branches were assessed. The was measured directly. Mitral valve gradients were left main stem; left anterior descending; circumflex; measured indirectly between pulmonary artery obtuse marginal (large lateral) branch of the mean wedge pressure and left ventricular end- circumflex; and right coronary arteries were diastolic pressure. Aortic valve gradients were chosen because of their surgical importance in measured by withdrawal from left ventricle to coronary artery bypass grafting. Major vessel aorta. Pressures were measured at rest using disease was assessed as zero, single, double, or Statham (P23 Gp) strain gauges recording on an triple, and the overall severity of coronary artery ultraviolet light recorder. The zero reference point disease was estimated by summing the grades of was 10 cm above the level of the catheter table. The stenosis in the five vessel branches listed above. This severity of valve obstruction was graded on a total was called the coronary score. copyright. simple scale, from 0 to 4, according to the gradient Finally the decision made at the time of investiga- at rest. For mitral stenosis: 0 =no gradient; 1 =1 to tion regarding surgery was recorded and the opera- 4 mmHg; 2 =5 to 10 mmHg; 3 = 11 to 19 mmHg; tion notes examined to obtain details of the pro- 4=more than 20 mmHg. For aortic stenosis: cedure performed. 0=no gradient; 1=1 to 34mmHg; 2=35 to 49 The significance of differences between groups mmHg; 3=50 to 74mmHg; 4=more than 75 was tested using Student's t test for unpaired data mmHg. Haemodynamically "significant" valve or x2 as appropriate. The significance of correla- http://heart.bmj.com/ obstruction was arbitrarily defined as grade 3 or 4. tions was tested by linear regression analysis. The severity of mitral or aortic valve regurgitation was assessed from the left ventricular or aortic root Results cine angiogram and graded on a simple scale from 0 to 4 according to the criteria of Yang et al.'8 During the study period, 239 patients with valvular Haemodynamically "significant" regurgitation was heart disease underwent routine coronary arterio- said to be present with a grade of 3 or 4. The overall graphy as part of their preoperative cardiac cathe- severity ofvalvular disease was assessed by summing terisation. Isolated mitral valve disease was present on September 27, 2021 by guest. Protected all the grades of stenosis and regurgitation, this then in 95 (40%) with isolated stenosis in 35 and isolated being called the valve score. On the basis of the data regurgitation in 10, the remaining 50 having mixed obtained from cardiac catheterisation and angio- lesions. Isolated aortic valve disease was present in graphy the patients were assigned to one of three 90 (38%) with isolated stenosis in 37, isolated groups, depending upon the presence of "signi- regurgitation in 28, and mixed lesions in 25. There ficant" disease as defined above: isolated mitral were 54 (23%) patients with combined mitral and valve disease; isolated aortic valve disease; combined aortic valve disease. A few patients also had tricuspid mitral and aortic valve disease. valve disease but the severity of this was not as- Left ventricular function was assessed from the sessed. The average age of the patients was 51 0 + ejection fraction, calculated from the left ventricular 8-7 years (±SD), with no differences between the volumes obtained from single plane right anterior valve groups. There were 117 men and 122 women. oblique ventriculography.19 Coronary arteriography Typical angina was present in 74 (31%) patients, was performed by the Judkins or Sones technique. atypical chest pain in 34 (14%), and no chest pain Both coronary arteries were injected in at least three in 131 (55%). Coronary arteriography was therefore projections using magnified images. The arterio- performed as a routine screening procedure in more grams were analysed by a cardiac radiologist and at than half the patients. Br Heart J: first published as 10.1136/hrt.44.6.630 on 1 December 1980. Downloaded from 632 Morrison, Thomas, Grimmer, Silverton, Smith Table 1 Relation between angina and coronary artery disease in 239 patients being investigated for valvular heart disease No.