Circulation 1966 PROUDFIT 901 10

Selective Cine Coronary ArteriographyCorrelation with Clinical Findings in 1,000 Patients

By WILLIAM L. PROUDFIT, M.D., EARL K. SHIREY, M.D.,AND F. MASON SONES, JR., M.D.

SYMPTOMS of coronary arterial diseasegenerally occur in association with ob-

struction of the coronary arteries in the ab-sence of valvular defects. Until recent yearsaccurate information relative to obstructivelesions in the coronary arteries could notbe obtained from the living patient.

In the absence of definite electrocardio-graphic evidence of myocardial infarction,clinical diagnosis of coronary disease hasbeen dependent principally on the elicitationand proper evaluation of the history, andtherefore, the accuracy has varied with thecare, ability, and experience of the physician.In other fields of medicine in which clinicaldiagnoses can be compared with those basedon objective criteria, it is evident that errorsin clinical diagnoses are common. The devel-opment of selective cine coronary arteriogra-phyl has made possible the correlation ofclinical syndromes and evidence of arterial ob-struction during life. If this method of studyis valid, there should be a close relationshipbetween the typical clinical syndromes (an-gina pectoris and myocardial infarction) andthe presence of significant arteriographic ab-normality.

Group Studied and Methods of StudyThe clinical records of 1,001 patients who had

selective cine coronary arteriography betweenJanuary 1, 1961, and March 31, 1964, werereviewed. One patient was excluded from theseries because the arteriographic study was con-sidered to be technically inadequate; the leftcoronary artery could not be catheterized. About1,000 patients examined before 1961 were notconsidered because of the possibility of technical

From the Department of Cardiovascular Diseaseand the Department of Pediatric Cardiology andCardiac Laboratory, The Cleveland Clinic Founda-tion, Cleveland, Ohio.Circulation, Volume XXXIII, June 1966

or interpretive errors in early experience. Patientswho had primary valvular disease were not in-cluded. In almost all of the 1,000 patients inthis series coronary disease had been suspected ordiagnosed by one or more physicians beforethis study. Exceptions were 37 patients studiedbecause of electrocardiographic abnormalitiesonly, unexplained cardiomegaly, congestive heartfailure, pericarditis, embolus, or extreme hyper-cholesterolemia. In most patients chest pain wasthe presenting symptom.Clinical Diagnosis

All clinical records were evaluated by onephysician (W.L.P.) without knowledge of thearteriographic findings. Diagnoses were basedupon data from the clinical history, the physicalexamination, and the electrocardiogram. In somepatients more than one diagnosis was made, sothat the total number of diagnoses exceeded thetotal number of patients. For example, anginapectoris and myocardial infarction may occur inthe same patient.Clinical ClassesThe following clinical classes were used:1. Normal: Chest pain had no features of

coronary disease.2. Probably Normal. Pain that did not seem

to be of coronary artery origin, but some featureswere suggestive.

3. Atypical Angina Pectoris. Pain that wasthought to be due to angina pectoris but theprecipitating factors were unusual or inconstant.

4. Angina Pectoris (Class I, II, or III, Func-tional Classification2). Pain somewhere in the up-per half of the body which was precipitated bywalking and relieved promptly (within 15minutes) by rest. Other precipitating or potentiat-ing factors were common in this group but allhad exertional pain. None had rest pain.

5. Angina Pectoris (Class IV, Functional Clas-sification2). Pain at rest as well as on physicalexertion.

6. Rest Pain Only. Pain that appeared to becharacteristic of angina but was not precipitatedby exertion; pain lasted less than 15 minutes.

7. Coronary Failure.3 Pain that occurred withor without apparent precipitation and persisted 15

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PROUDFIT ET AL.

minutes to several hours (coronary insufficiency,premonitory pain, intermediate syndrome).

8. Myocardial Infarction. QRS abnormalitiesthat were considered characteristic at the time ofarteriographic study. Most patients in this grouphad typical histories of prior infarction.

9. Possible Myocardial Infarction. BorderlineQRS abnormalities or sharp inversion of T-waveswhich was consistent with intramural infarction.

10. Congestive Failure. Either clear evidenceof congestive failure on examination or a historystrongly suggestive of it in the recent past. Insome cases there was no clinical evidence of coro-nary disease.

11. Embolus. The presenting clinical manifes-tation without apparent source.

12. Pericarditis. Possibly due to prior myo-cardial infarction.

13. Abnormal Electrocardiographic Findings.S-T or T-wave abnormalities or conduction defectsin the absence of coronary symptoms.

14. Cardiac Enlargement of Unknown Etiology.Cardiac enlargement demonstrated roentgeno-graphically.

15. Arrhythmia. Cardiac arrhythmia withoutapparent clinical basis.

16. Hypercholesterolemia. Extreme elevation ofthe serum cholesterol without clinical heart dis-ease.

Electrocardiograms and Exercise TestsThe electrocardiograms (standard and unipolar

limb leads and eight precordial leads) were re-corded almost exclusively on high-sensitivity pho-tographic electrocardiographs (Sanborn TwinBeam). Exercise tolerance tests were done on di-rect-writing electrocardiographs. Routinely, threelimb leads and one precordial lead were ob-tained immediately and 3 and 6 minutes afterexercise, consisting of 50 trips over a two-stepstaircase in about 3 minutes, unless the test hadto be terminated because of the development ofpain. In a few instances more than one precordiallead was recorded after exercise. Exercise testsin 107 patients were reviewed without knowledgeof arteriographic findings. Few tests were donein patients who had abnormal electrocardiogramsat rest. Mattingly's4 criteria were used in evalua-tion of exercise tests.

Arteriographic DiagnosesAn arbitrary classification of the arteriographic

obstruction was employed. Obstructions of themajor arteries or major branches of these ar-teries were considered. For the purpose of thisstudy, obstructions of the lumen estimated to be30% or less were considered slight. They weretabulated separately from the strictly normal stud-ies. The degree of estimated obstruction in each

instance in this study refers to the maximal in-volvement in any major vessel. Often multiplevessels were involved. The following classificationwas used:

1. None. Smooth-walled vessels showing novariations in lumen diameter.

2. Slight. Barely perceptible to 30% narrowingof lumen diameter.

3. Moderate. Narrowing of lumen diameter ofbetween 30 and 50%.

4. Severe. Narrowing of lumen diameter ofbetween 50 and 90%.

5. Subtotal. Almost complete (90% or more) ob-struction of lumen.

6. Total. Complete obstruction of lumen.Repeated injections of contrast mediums were

employed in multiple roentgenographic projec-tions before and after the use of nitroglycerin orisosorbide dinitrate (Isordil), to minimize mis-interpretation of functional constriction or artifactsarising from the plane of projection. There wereonly two known false-positive arteriographic diag-noses in this series. In these two patients, con-strictions were encountered in the proximal rightcoronary artery which were considered to be or-ganic because they did not completely disappearwithin 2 to 4 minutes after sublingual adminis-tration of nitroglycerin, 1/150 grain. Repeatedstudy demonstrated the segmental narrowing tobe absent in one case. In the other case the seg-ment of narrowing disappeared completely afteroral administration of 10 mg of isosorbide dini-trate. Obvious functional constrictions due to ar-terial spasm in the proximal right coronary arterywere encountered in more than 50 patients. Ex-cept for the two instances mentioned, these con-strictions were abolished within 2 to 4 minutesafter administration of nitroglycerin or isosorbidedinitrate. Systolic constrictions of the anteriordescending branch of the left coronary artery dueto myocardial bridges did not appear to be as-sociated with symptoms.From the standpoint of left ventriculograms,

ventricular aneurysm was considered to be presentwhen there was paradoxical motion of a segmentof the myocardium as contrasted to failure ofnormal contraction without bulging.

Results and DiscussionIn this type of clinical investigation it is

essential that the clinical diagnosis be madewithout knowledge of the findings on the ar-teriographic studies. If selective cine coro-nary arteriography is useful as a diagnosticmeasure, there must be a close correlationbetween the clinical diagnosis of typical an-gina pectoris and the arteriographic evidence

Circulation, Volune XXXIII, June 1966

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CORONARY ARTERIOGRAPHY

of obstruction, unless functional constrictionin normal vessels or obstruction limited tominute peripheral coronary arteries is impor-tant. Poor correlation could be explained byinadequacy of clinical records, incompetentclinical evaluation, technical or interpretiveerrors, or lack of relationship between clinicalsymptoms and arteriographically demonstrat-ed obstructions. If perfect correlation werereported, one could question the integrity ofthe investigators.The degree of arterial obstruction deter-

mined by arteriography, in relation to the ageand sex of the patients is shown in table 1.The youngest man who had a significant ar-terial obstruction was 27 years of age and theyoungest woman, 32. The striking predomin-ance of men over women (786 to 214) evenin the older age groups suggests that theeconomic implications of coronary disease in-fluenced the patient's and the physician's de-cisions to have diagnostic studies.

In 207 patients a clinical diagnosis of an-gina pectoris, functional class I, II, or III,was made, and in 194 (93.7%) of these pa-tients there was evidence of moderate orsevere obstruction of one or more major ves-sels (table 2). The clinical records of the 13patients in whom no significant abnormalitywas found were reviewed. In two instancessevere arterial hypertension was present. Inone of these, administration of angiotensinresulted in reproduction of the pain coincidentwith rise in arterial blood pressure. Anginapectoris has been reported to occur in patientshaving severe arterial hypertension in the ab-sence of evidence of coronary disease.5 Athird patient had left bundle-branch block, aventricular aneurysm, mitral insufficiency, andcongestive heart failure due to primary myo-cardial disease without demonstrable arterialobstruction. Angina may have resulted fromreduced coronary perfusion secondary todiminished cardiac output. If these three cases

Table 1Severity of Arterial Obstruction Determined by Arteriography, Related to Age and Sex

Severity of obstructionAge, Minimal Significantrange No. of None (< 30%) (30-100%)

yr Sex patients No. of patients

20-29 M 19 16 0 3F 3 3 0 0

30-39 M 156 72 13 71F 35 30 0 5

40-49 M 307 52 31 224F 76 36 16 24

50-59 M 221 19 21 181F 76 38 7 31

60+ M 83 5 7 71F 24 3 4 17

Total 1000 274 99 627

Table 2Correlation of Clinical Diagnosis with Arteriographic Evidence of Moderate or SevereObstruction

Abnormal findingson arteriograms;

Clinical diagnosis Total no. of patients no. of patients (%)Angina pectoris, class I, II, or III 207

Uncorrected classification 207 194 (93.7)Corrected classification* 198 194 (98.0)

Myocardial infarction 196 174 (98.9)*See text for explanation.

Circulation, Volume XXXIII, June 1966

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PROUDFIT ET AL.

are excluded, significant coronary obstructionwas demonstrated in 95% of patients who hadangina pectoris. On careful review of therecords of the remaining 10 patients, it wasthought that six should have been classifiedoriginally as having atypical angina pectoris.If this reclassification is permitted, signifi-cant coronary obstruction was demonstratedin about 98% of patients who had anginapectoris (table 2). In most instances the ar-terial obstruction was severe (tables 3 and4). It appears, therefore, that functionalconstriction in the absence of obstructivelesions or arterial disease affecting only min-ute arteries causes angina rarely if ever. It ispossible that some condition outside the heartcould be responsible for occasional instancesof exertional pain relieved promptly by rest.The close correlation of the clinical diag-

nosis of angina pectoris, classes I, II, and III,with arteriographic evidence of significantobstruction does not necessarily establish thismethod of study as a diagnostic technique.

Conversely, severe arterial obstructions shouldnot be the majority encountered in personsthought to be normal clinically. Table 5 showsthe correlation of clinical diagnoses with ar-teriographic findings in the 1,000 patients. In95.6% of patients thought to be free fromcoronary arterial diseases, the arteriogramswere normal; and in 80.6% of patients thoughtprobably to be free from coronary arterialdisease, the arteriograms were normal. Somecoronary disease must be expected in the agegroups studied, even in the absence of clinicalsymptoms.

Atypical angina pectoris is a vague term,and it has a different meaning for each clini-cian. In this study the term was applied tocases in which the pain had some of thecharacteristics and precipitating factors ofangina pectoris, but there were unusual orinconstant features in the history. Unusuallocation of the pain alone was not consideredto be an atypical symptom. An incidenceof arteriographic abnormalities of only 64.5%

Table 3Incidence of Severe Involvement* in Arteriographically Demonstrated Significant Ob-struction

Extent of obstruction

Clinical diagnosis

Angina pectoris,class I, II, or III

Myocardial infarction

Totalno.

of cases

194174

.More than 50%,% of cases

98.5100.0

More than 90%,% of cases

75.383.9

*Classified in the text as severe, subtotal and total obstruction.

Table 4Distribution of Patients Related to Extent of Arterial Obstruction and to Clinical Diagnosis

Extent of maximal obstruction

Clinical diagnosis

NormalProbably normalAtypical angina pectorisAngina pectoris, class I, II, or IIIAngina pectoris, class IVRest pain onlyCoronary failureMyocardial infarctionPossible myocardial infarctionCongestive failure

None or slight Moderate(0-30%) (30-50%)

65 2163 1350 913 322 59 4

37 42 013 38 2

Severe Subtotal(50-90%) (90% +)

No. of patients

113

34453011272847

0

51736341035436

16

Total Total no.Of patients

0 687 201

31 141110 20782 1738 42

71 174103 17624 5030 63


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Table 5Correlation of Clinical Diagnosis with Arteriographic Findings in 1,000 Patients

No. of % ArteriographicClinical diagnosis patients correlation evidence

Normal 68 95.6 No significantProbably normal 201 80.6 obstructionAtypical angina pectoris 141 64.5Angina pectoris, class I, II, or III 207 93.7Angina pectoris, class IV 173 87.3Rest pain only 42 78.6 SignificantCoronary failure 174 78.7 obstructionMyocardial infarction 176 98.9Possible myocardial infarction 50 74.0Congestive failure 63 87.3Other* 37

*Embolus, pericarditis, arrhythmias, abnormal electrocardiograms, abnormal roentgeno-grams, and xanthoma tuberosum.

(table 5) might be expected in this group.The high incidence of atypical angina in thisseries is at least partly a result of the largenumber of patients included in the series whowere referred for study because of confusingclinical features. The inclusion of patientshaving any deviation from the history ofexertionally induced pain relieved promptlyby enforced rest will result in an increasedincidence of normal arteriographic findings,because many of these patients have normalhearts. Often physicians speak of "typical an-gina pectoris" when the history is atypicalupon careful scrutiny.The high incidence of patients who had

experienced pain at rest as well as on exer-tion (angina pectoris, class IV) is out ofproportion to the incidence encountered inordinary clinical practice (table 5). Many ofthese patients were referred to us becauseof the difficult therapeutic problems presented.There may have been no objective clinicalevidence of disease. Emotional coloring of theillness was frequent in this group even whenobstructive lesions were demonstrable, andthis added to diagnostic confusion. An intel-ligent patient could give a precise history onthe basis of common knowledge or readingof lay literature. The neurotic with convulsionobtains secondary gain only by having themost severe and disabling symptoms. The useof narcotics was not uncommon in patientswho had symptoms at rest (eight persons).Circulation, Volume XXXIII, June 1966

Most of the patients having angina pectoris,class IV, had been hospitalized on numerousoccasions and by a number of physicians, andhad received various forms of medical andsurgical therapy. It is not surprising, therefore,that the incidence of normal arteriographicfindings in patients having angina pectoris,class IV, was about double that encounteredin persons having milder symptoms of anginapectoris (table 5). Conversion neurosis was acommon problem among those in whom thearteriographic findings proved to be normal.

Patients who had pain of anginal type andduration but which occurred only at rest (42patients) presented a difficult diagnostic prob-lem, as did patients (174) who had prolongedpain with or without additional typical ex-ertional pain (coronary failure, coronary in-sufficiency, intermediate syndrome). The largenumber (216) of such patients in this series isagain the result of prior selection for referralby the patient's physicians. Arteriographic ab-normalities were observed in almost 80% ofeach of these two groups of patients (table5). The need for caution in drawing con-clusions concerning the therapeutic claimsin the treatment of patients having prolongedpain is obvious, since more than 20% of suchpatients had no disease.

Early in this study it was decided to dis-regard prior diagnosis of myocardial infarc-tion unless there was sufficient residual evi-dence in the QRS complexes to support this

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PROUDFIT ET AL.

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diagnosis at the time of arteriographic study.Many patients had a history of myocardialinfarction, but the electrocardiogram beforearteriographic study showed no diagnostic evi-dence of infarction; often normal arteriogramswere found. The possibility of myocardial in-farction in the absence of coronary athero-sclerosis is well known but its frequency isdebatable. In this series arteriographic evi-dence of obstruction was found in 98.9% ofthe cases of myocardial infarction (tables 2,4, and 5). The distribution of patients inrelation to the degree of the maximal ob-struction is shown in table 4. All patientshaving myocardial infarction who had arterio-graphic abnormalities had severe obstruction,and in most there was almost total or totalocclusion. In general, the correlation was goodbetween the location of the myocardial in-farction and the location of the severely ob-structed vessel supplying the affected areas.The clinical records of the two patients whohad QRS changes consistent with myocardialinfarction and normal arteriograms were re-viewed. Neither had a history of prolongedsevere chest pain. One record interpreted asshowing remote posterior myocardial infarc-tion should have been considered possible,rather than definite, infarction. The other hadQRS changes of anteroseptal and posteriorinfarction, but the electrocardiogram wasnormal 1 month later. In this series there wereno instances of hypertrophic subaortic stenosisresulting in electrocardiographic abnormali-ties similar to those of myocardial infarction,though cases of this type have been en-countered outside this series.

Clinically, it appeared that congestive heartfailure was due to coronary disease in somecases and in others it was of unknown etiology.Whenever there was no complicating condi-tion, severe arterial obstruction of multiplevessels was the rule. Frequently another etio-logical factor placed an additional burden onthe heart. Ventricular aneurysm, mitral in-sufficiency, cardiac arrhythmias, and arterialhypertension were common conditions (table6). In one case an arteriovenous fistula dueto a Beck-II operation was an additional stress.


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Table 7Other Indications for Arteriographic Study

AbnormalNo. of arteriograms,

Condition cases cases

Embolus 1 0Pericarditis 8 0Electrocardiographic abnormalities 19 6Arrhythmia 2 1Roentgenographic abnormalities 4 1Xanthomatosis 3 2

In 60.4% (32 of 53) of those having severecoronary disease, there was electrocardio-graphic evidence of myocardial infarction, andan additional 13.2% (7 of 53) had left bundle-branch block that might have obscuredchanges due to infarction. In eight no signif-icant obstructions were found.

Other indications for study were encount-ered occasionally (table 7). In eight cases ofpericarditis features were suggestive of coro-nary disease, but no obstructive lesions werewere found. Electrocardiographic abnor-malities without clinical symptoms, cardiacenlargement of unknown cause, and cardiacarrhythmias were indications for study insome cases. The source of an embolus wassought in one study.

Left ventriculography was carried out inmost patients who had obstructive arteriallesions. Evidence consistent with ventricularaneurysm was found in 80 cases. In manythere was no obvious evidence of aneurysm

Table 8Serum Cholesterol Levels as Related to Arterio-graphic Findings in 147 Men Less than 40 Yearsof Age

Arteriographic findingsSerum cholesterol Normal* Abnormallevel, mg/ 100 ml No. of patients

< 200 23 5200-224 15 7225-249 13 8250-274 9 10275-299 9 13300-349 4 17350 + 1 13

Total 74 73

*No arteriographic evidence of obstruction.Circulation, Volume XXXIII, June 1966

in roentgenograms of the chest. The incidenceof aneurysm was higher than expected by us.The serum cholesterol levels were tabulated

for 147 men less than 40 years of age andcorrelated with arteriographic findings (table8). In general, the incidence of normal find-ings was high when the level was less than225 mg per 100 ml and the frequency ofabnormal findings was high when the levelexceeded 300 mg. However, the level was oflimited diagnostic value in the individual pa-tient.One of the difficulties encountered in the

correlation of clinical and arteriographic find-ings is the necessarily arbitrary separationof degrees of estimated arterial obstruction.It is apparent that mild degrees of obstruc-tion rarely cause angina pectoris or myo-cardial infarction. Arteriographic evidence ofobstruction is almost always severe in symp-tomatic patients. Therefore, precise classifi-cation of relatively minor degrees of obstruc-tion does not seem to be so important as itwas considered to be during early progressof the study.The frequency of diagnosis of coronary

atherosclerosis in the absence of satisfactoryclinical evidence is recognized by cardiolo-gists. Such a diagnosis, however, may alarmthe anxious patient. In the present study al-most all patients were told by some physiciansthat coronary disease was present or sus-pected. Actually about 37% of the 1,000 pa-tients had no significant obstruction, and thearteriograms of more than 27% were entirelynormal (tables 1 and 9). A diagnosis of coro-nary disease had been made in 700 of the1,000 patients in this review of clinical rec-

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PROUDFIT ET AL.

Table 9Correlation of Clinical and Arteriographic Diagnosis in 1,000 Patients

Clinicaldiagnosis

NormalCoronary

atherosclerosisTotal

Arteriographic obstruction, extent0-30% 30-1O(X Total

-No. of patients no. of patients

250

123373

ords; in about 17% of the 700 there were noarteriographic abnormalities. It would bedifficult significantly to increase the percen-tage of correlation on the basis of clinicalinformation that is available at this time.Rigid definition of typical angina pectoriskept the percentage of correlation high inthis group, and restriction of diagnosis ofmyocardial infarction to those who had de-finite QRS abnormalities was necessary. How-ever, atypical symptoms occur in a significantnumber of patients with coronary athero-sclerosis. Some improvement in correlationmight result if each patient had been inter-viewed personally by the evaluating physician.However, consistent histories written by sev-eral physicians were available; experience andappraisal of the recorded data were respon-sible for the higher percentage of correlationwith the abnormal arteriograms than the cor-relation on the basis of the referral diagnosis.In this study about 17% of the 300 patientswho were thought to have noncoronarysymptoms had significant abnormalities in thearteriograms. It is difficult, of course, to becertain that the symptoms were related tothe obstructions demonstrated. The percent-age of patients in whom false-negative diag-noses were made by referring physicianscould not be estimated because there wasno referral for study in most of these cases.The value of Venn diagrams in statistical

studies have been demonstrated by Feinstein.6Figure 1 shows the primary clinicalmanifestations in the majority of 627 patientswho had abnormal arteriographic findings.Pain was the most common manifestation.Included in the group with pain are 91 pa-tients who were thought to have atypical

50

577627

300

7001000

Correlationi83.3%

82.4%

angina pectoris. Myocardial infarction of un-complicated nature was unusual becauseactively symptomatic patients are more likelyto be referred for study.The distribution of patients having what

was considered typical pain is shown in figure2. The number of patients who had myo-cardial infaretion without additional pain syn-drome is larger in figure 2 than in figure 1because some patients who had congestivefailure and myocardial infarction are in-cluded in figure 2.The reactions of the patients to the report

of normal arteriographic findings vary. In

Figure 1Common presenting conditions in patients havingmore than 30% obstruction of a major coronary artery.Patients who were thought to have noncoronary pain,electrocardiographic evidence of possible myocardialinfarction without pain or congestive heart failure,or miscellaneous indications for arteriography (table7) are omitted. Myocardial infarction refers to elec-trocardiographic diagnosis only. The numbers in-dicate the number of patients in each group.


908



Figure 2Pain spectrum. Myocardial infarction refers to ahistory of typical pain in addition to electrocardio-graphic evidence in this diagram. In 26 additionalpatients there was electrocardiographic but no clinicalevidence of myocardial infarction: 16 of these hadsome other type of pain of coronary origin and areincluded in appropriate sections of the diagram.Atypical angina pectoris, included in figure 1, isomitted here.

most instances, the patients were visibly re-lieved; some of these patients had led a lifeof invalidism, and it is remarkable that theyreturned to a normal life. On the other hand,some patients showed an immediate trans-ference of symptoms to some other organsystem-sometimes while the physician wasstill giving them the report. The outlook ispoor in this group. Patients did not insistthat there must be something wrong with theheart which has not been found. Those whohave abnormal studies accepted a candid re-port well. Perhaps those who most feared thedocumentation of obstructive lesions refusedto have arteriography.

SummaryThe clinical records of 1,000 patients who

had adequate selective cine coronary arteriog-raphy were reviewed. The clinical diagnoseswere made by a physician who had no knowl-edge of the arteriographic findings. Correla-tion of the clinical diagnoses with the ar-teriographic findings was made subsequently.Symptomatic coronary disease was accom-

panied by arteriographic evidence of signifi-Circulation, Volume XXXIII, June 1966

cant obstruction of major coronary arteriesin most instances. A close correlation existedbetween the clinical diagnosis of angina pec-toris without rest pain and significant arterialobstruction (95%). A similar correlation wasfound between QRS evidence of myocardialinfarction and severe arterial obstruction(99%). The demonstrated arterial obstructionin patients who had angina pectoris almostalways was severe and usually almost total ortotal in one or more major vessels. In myo-cardial infarction the demonstrated obstruc-tion was always severe and generally almosttotal or total.The correlation between clinical and ar-

teriographic findings was moderately close inpatients who had angina with symptoms atrest. The correlation between the arterio-graphic findings and less characteristic clinicalsyndromes (rest pain only, 79%, coronary fail-ure, 78%, and especially atypical angina pec-toris, 65%) was not so close. In congestivefailure secondary to coronary disease, arterialobstruction was extensive unless ventricularaneurysm, mitral insufficiency, arrhythmia, ar-terial hypotension, or some other complicationwas present. Most patients thought to havenoncoronary symptoms had no significant ob-structive lesions.

In 37% of the entire group of patients, al-most all of whom had been suspected ofhaving coronary disease by some physicians,no significant arteriographic obstruction wasdemonstrated; in 27% the arteriograms werenormal.

Diagnoses, based on appraisal of the clinicalrecords without knowledge of the arterio-graphic findings, yielded 83% correlation withabnormal arteriographic findings in 700 pa-tients thought to have coronary disease.

References1. SONES, F. M., JR., AND SHIREY, E. K.: Cine

coronary arteriography. Mod Con Cardiov Dis31: 735, 1962.

2. The Criteria Committee of the New York HeartAssociation, Kossman, C. E. (Chairman): Dis-eases of the Heart and Blood Vessels: Nom-enclature and Criteria for Diagnosis, ed. 6.Boston, Little, Brown & Co., 1964, 463 pp.

3. BLUMGART, H. L., SCHLESINGER, M. J., ANDZOLL, P. M.: Angina pectoris, coronary fail-

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ure and acute myocardial infarction: Role of 5. ZOLL, P. M., WESSLER, S., AND BLUMGART, H. L.:coronary occlusions and collateral circulation. Angina pectoris: Clinical and pathologic cor-JAMA 116: 91, 1941. relation. Amer J Med 11: 331, 1951.

4. MATTINGLY, T. W.: Postexercise electrocardio- 6. FEINSTEIN, A. R.: Scientific methodology in clin-gram: Its value in the diagnosis and prog- ical medicine: II. Classification of human dis-nosis of coronary arterial disease. Amer J ease by clinical behavior. Ann Intern MedCardiol 9: 395, 1962. 61: 757, 1964.

A Problem of Retrograde Vertebral Flow, 100 Years AgoSuccessful Operation for Subelavian Aneurism.-The first No. of the New Orleans

Medical Record, edited by the well-known indefatigable Dr. Bennet Dowler, containsan interesting account, by Dr. A. W. SMYTH, of a case of a mulatto man, thirty-twoyears of age, admitted into the Charity Hospital, New Orleans, May 9, 1864, withaneurism of the right subclavian artery. The tumour was of the size of a small orange,"was circumscribed and round in shape, filling up the posterior inferior triangle of theneck; strong pulsatory movement was visible even at some distance, and on applyingthe ear to its surface, a loud bellows sound was heard accompanying the arterialbeat......The patient was seen by a number of surgeons, and among others Dr. D. L. Rogers, of

New York, who strongly urged the ligature of the innominate and carotid arteries at thesame time.... "no difficulty was experienced in placing a ligature on the innominateartery a quarter of an inch below its bifurcation, and another on the carotid, an inchabove its origin. On tying the former all pulsation stopped in the tumour. The tempera-ture of the arm and hand was immediately increased, and in about forty-eight hoursafter the operation a perceptible undulatory motion was discovered in the arteries ofthe wrist...."On the 29th of May, fourteen days from the time of operating, a severe hemorrhage

occurred, causing syncope rapidly, and ceasing of its own accord.... "After studying the subject, Dr. S. concluded that the vertebral carries on almost the

entire anastomosing circulation into the subclavian artery, and he therefore decided toligate the former vessel.... A marked decrease in the circulation of the arm was nowapparent, the slight pulsation at the wrist disappearing. . . . No further hemorrhagehaving taken place after the second operation, the new wound healed rapidly; the lig-ature coming away on the tenth day. "-American Intelligence: Domestic Summary.Amer J Med Sc 52: 280, 1866.


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WILLIAM L. PROUDFIT, EARL K. SHIREY and F. MASON SONES, JR.1,000 Patients

Selective Cine Coronary Arteriography: Correlation with Clinical Findings in

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