Diabetes mellitus is known to be a major risk factor for the development of coronary artery disease (CAD). The aim of this study was to investigate angiographically the coronary arteries of diabetic persons, focusing on the type and distribution of CAD, sex differences in CAD anatomy, and the size of the coronary vessels. This was a randomized study and included two groups of patients with angiographically demonstrated CAD. Group A included 463 diabetics, aged 60.3 years, and Group B 210 nondiabetic patients, aged 58.5 years. The two groups were matched by age, sex, weight, and classic risk factors. The authors evaluated the regional location of CAD, left ventricular (LV) function, and the width of the lumen of coronary arteries. The diabetics had three-vessel disease more frequently (p<0.001) and one-vessel disease less frequently (p<0.001). The CAD was more extensive in Group A (mean 2.2 vessels, compared to 1.8 vessels in Group B, p<0.01). The right coronary artery was affected more often in diabetics (p<0.01), as was the anterior descending artery in three-vessel disease (p<0.05). The male diabetics had the same angiographic CAD severity as the females, although the latter had a better LV ejection fraction (p<0.05). The female diabetics < 55 years old had CAD findings comparable with those from women 4 years older in Group B. Diabetics show more diffuse and severe CAD than the general population. There are no sex-related differences in the severity of CAD.

BACKGROUND AND HYPOTHESIS: Although it is well established that diabetes mellitus (DM) induces more severe coronary artery disease (CAD), it is not known whether it contributes to the development of coronary collateral circulation. The present study examines coronary collateral circulation in diabetic and nondiabetic patients with angiographically verified CAD. METHODS: The study group consisted of 463 diabetic patients (382 men, 81 women) with a mean age of 60.3 +/- 8.8 years, and 227 nondiabetic subjects (159 men, 68 women) with a mean age of 59.2 +/- 9 years. The extension and functional capacity of coronary collateral circulation was assessed according to the Cohen and Rentrop grading system of 0 to III. RESULTS: We found that diabetic patients had grade III collateral circulation more frequently than nondiabetic subjects (13.2 vs. 8.5%, p < 0.01). This finding was even more pronounced in diabetic men aged < 55 years compared with both nondiabetic men (20 vs. 3.4%, p < 0.001) and diabetic women (20 vs. 2.2%, p < 0.001). Grade III collateral circulation was found to develop mainly at the left anterior descending (LAD) coronary artery and the right coronary artery (RCA), where complete occlusions of coronary arteries usually occur. CONCLUSIONS: Diabetic patients with CAD develop more extensive coronary collateral circulation than nondiabetic subjects, especially men aged < 55 years. The collateral circulation mainly develops at the LAD and RCA.

We compared the angiographic findings, coronary risk factors and five years prognosis in 200 patients < or =45, and 260 patients >45 years old who where admitted with an acute myocardial infarction. We found that family history and smoking were the most common risk factors in patients < or =45 years old P<0.04, P<0.0001, respectively, and hypertension and diabetes mellitus were more prevalent in patients >45 years, P<0.00001 for both. Young patients had a higher incidence of normal coronary arteries and a lesser one of triple vessel disease in comparison with old ones P<0.001 and P<0.04, respectively. There was also a tendency for young patients to have a higher frequency of single vessel disease. The long-term prognosis was favourable in the younger age group since the survival rate was much better, as well as the quality of life. Death in the young patients seems to be very often electrical owing to sudden ventricular fibrillation, whereas death in the elderly is more often associated with congestive heart failure.

Spontaneous coronary artery dissection is a rare incident occurring usually in young patients, predominantly in females. It is usually fatal and found postmortem. We present the case of a middle aged man with spontaneous left anterior descending coronary artery dissection found angiographically which caused an anterior wall myocardial infarction. We also briefly review the relevant literature.

Vasospasm of the saphenous vein and internal mammary grafts may develop spontaneously under several conditions. We present for the first time spasm of a left internal mammary artery bypass graft during coronary arteriography. A patient who underwent coronary artery bypass operation 4 years ago was recatheterized because he developed chest pain. Selective catheterization of the left internal mammary artery graft showed disappearance of its lumen at its distal part during systole, whereas the patient developed angina. These phenomena disappeared after intravenous nitroglycerin administration.

We describe the case of a 32-year-old man with lung cancer involving the pericardium on which we performed pericardiotomy, using a balloon dilating catheter, to create a non-surgical pericardial window. For the percutaneous creation of pericardial window we advanced into the pericardium by subxiphoid approach a 0.035 inch guide wire through a 7f. pig-tail catheter. Subsequently a 22 mm diameter, 4 cm long balloon dilating catheter was advanced to the parietal pericardium and inflated for about 60 seconds until a tear in the pericardium was formed. We believe that percutaneous balloon pericardiotomy is helpful in the management of large pericardial effusions particularly in patients with malignancies and poor condition.

We describe the case of a man aged 42 who, five years before, had undergone aortocoronary bypass surgery using the internal mammary artery for the anterior and saphenous vein graft for the posterior descending arteries. Over the last one and a half years he had started to present angina pectoris as well as symptoms of vertebrobasilar insufficiency during exertion of the left upper extremity (recently during simple writing), whereas a full treadmill test was normal. Clinically, obstruction of the left subclavian artery was suspected with both coronary and subclavian steals. This suspicion was confirmed with triplex of the vessels of the aortic arch, coronary arteriography and carotid arteriography which demonstrated severe obstruction of the left subclavian artery at its origin and reversal of blood flow through the ipsilateral vertebral artery and the internal mammary artery graft. Angina subsided after balloon angioplasty of the subclavian artery. This combined steal, termed coronary-subclavian syndrome, is rare (our case is probably the 20th reported), but an increase of its incidence is anticipated due to the widespread use of internal mammary artery grafts. The prevention and treatment of this syndrome are discussed.

In order to clarify possible links between mitral valve leaflet prolapse and cerebral ischaemic events we carried out a study prospectively over a period of two years on 66 patients (35 men and 31 women) under the age of 50 who suffered from transient cerebral ischaemic attacks or completed strokes. Twenty-three (34.8 per cent) of the 66 patients were found to have mitral valve leaflet prolapse syndrome. In 16 (24.2 per cent) of those, the only abnormality found was mitral valve leaflet prolapse, suggesting that the mitral valve leaflet prolapse syndrome may be a potential cause of cerebral ischaemic events. Therapeutic approaches for preventing further similar events are discussed.

The inhospital clinical course and early prognosis were studied prospectively in 500 patients who suffered their first transmural or subendocardial myocardial infarction, and were admitted in the coronary care unit of our hospital over the last four years. The coronary arteriogram and left ventriculogram of 300 patients out of the 500 was also compared. 434 patients developed transmural and 66 subendocardial infarction, as judged by electrocardiographic criteria. Both groups of patients had the same range of sex, age, coronary risk factors and history of previous angina. There was no statistical difference in in-hospital prognosis and early clinical course. There was no difference in prevalence of single, double or triple vessel coronary artery disease. The hemodynamic parameters (ejection fraction, left ventricular end-diastolic pressure), as well as the number of hypokinetic, akinetic or dyskinetic segments did not show any significant statistical difference between the two categories of patients. The same extent of coronary artery lesions and degree of left ventricular dysfunction may explain the similarity of early clinical course. 12% of patients who were admitted with subendocardial infarction developed transmural infarction during their hospitalization.

40 patients with acute inferior myocardial infarction (MI) associated with persistent precordial ST segment depression greater than or equal to 0.1 mV underwent coronary arteriography and left ventriculography within 5-6 days of their admission. The inferior MI was the result of complete occlusion of the right coronary artery (RCA) in 38 patients and the result of complete occlusion of the posterior descending artery (PDA) coming off the circumflex artery (Cx) in two patients. 36 (90%) of the 40 patients showed one or more severe stenoses in the left anterior descending artery (LAD). 12 of the 36 patients had severe triple vessel disease. The 36 patients whose coronary arteriograms showed significant LAD stenosis had an emergency coronary artery by pass graft (CABG) operation. Soon afterwards the precordial leads were normal and the patients free of angina till their discharge from hospital. We conclude that a persistent precordial ST segment greater than or equal to 0.1 mV depression in acute inferior MI is highly predictive of significant LAD disease.