A Detailed Angiographic Analysis of Patients With Ambulatory
Electrocardiographic Ischemia: Results From the Asymptomatic
Cardiac Ischemia Pilot (ACIP) Study Angiographic Core Laboratory
BARRY L. SHARAF, MD, FACC,* DAVID O. WILLIAMS, MD, FACC, NICHOLAS J. MIELE,
ROBERT P. M
C
MAHON, P
H
D,* PETER H. STONE, MD, FACC,†
PREBEN BJERREGAARD, MD, FACC,‡ RICHARD DAVIES, MD, FACC,§
A. DAVID GOLDBERG, MD, FACC, MICHAEL PARKS, MD,¶ CARL J. PEPINE, MD, FACC,#
GEORGE SOPKO, MD,** C. RICHARD CONTI, MD, FACC,#
FOR THE
ACIP I
NVESTIGATORS
Providence, Rhode Island; Baltimore and Bethesda, Maryland; Boston, Massachusetts; Saint Louis, Missouri;
Ottawa, Ontario, Canada; Detroit, Michigan; Birmingham, Alabama; and Gainesville, Florida
Objectives. The purpose of this Asymptomatic Cardiac Ischemia
Pilot (ACIP) data bank study was to characterize angiographic
features of coronary pathology of patients enrolled in the ACIP study.
Background. Ischemia during ambulatory electrocardiographic
(AECG) monitoring is associated with increased morbidity and
mortality. Reports relating AECG ischemia to severity or com-
plexity of coronary artery disease are few in number and small in
size and have produced conflicting results.
Methods. Coronary angiograms from patients with asymptom-
atic AECG ischemia enrolled in the ACIP study were reviewed at
a central core laboratory. Quantitative measurement of percent
stenosis and Thrombolysis in Myocardial Infarction flow grades
were used to assess the severity of coronary artery disease. Lesions
were also evaluated for the presence of intracoronary thrombus,
ulceration and lumen contour as indicators of stenosis complexity.
In addition, comparisons were made with 27 patients screened for
the ACIP study, but who were found ineligible because they did
not have AECG ischemia on 48-h Holter monitoring.
Results. A total of 329 (75%) of 439 patients with AECG
ischemia had multivessel coronary artery disease. Proximal ste-
noses
>
؊
50% diameter reduction were common in patients with
AECG ischemia (62.2%), as were proximal stenoses
>
؊
70%
(38.7%). Features suggesting complex plaque were found in 50.1%
of patients with AECG ischemia.
Conclusions. Multivessel coronary artery disease, severe prox-
imal stenoses and features of complex plaque were observed
frequently in patients who exhibited AECG ischemia. The pres-
ence of severe and complex coronary artery disease may explain,
in part, the increased risk for adverse outcome associated with
ischemia during activities of daily life.
(J Am Coll Cardiol 1997;29:78 – 84)
᭧1997 by the American College of Cardiology
Asymptomatic myocardial ischemic episodes detected by am-
bulatory ECG (AECG) monitoring are common events in
patients with coronary artery disease (CAD). Recent reports
have suggested a relation between asymptomatic ischemia
recorded by AECG monitoring and adverse clinical outcomes
(1–14).
Little is known about the details of the angiographic
coronary pathology of patients with AECG ischemia. Reports
relating AECG ischemia to the severity of CAD are few in
number and small in size and have produced conflicting results
(14–19). None of these studies has used central core laboratory
quantitative angiographic review.
Recent pathologic data suggest that plaque rupture and
thrombosis are common events leading not only to unstable
clinical syndromes but also to progression of CAD in asymp-
From the Maryland Medical Research Institute, Baltimore, Maryland;
*Rhode Island Hospital, Brown University, Providence, Rhode Island; †Brigham
and Women’s Hospital, Boston, Massachusetts; ‡Saint Louis University Medical
Center, Saint Louis, Missouri; §Ottawa Heart Institute, Ottawa, Ontario,
Canada; Henry Ford Hospital, Detroit, Michigan; ¶University of Alabama at
Birmingham, Birmingham, Alabama; #University of Florida, Gainesville, Flor-
ida; **National Heart, Lung, and Blood Institute, Bethesda, Maryland. This
study was funded by the National Heart, Lung, and Blood Institute, Cardiac
Diseases Branch, Division of Heart and Vascular Diseases, National Institutes of
Health, Bethesda, Maryland, by Research Contracts HV-90-07, HV-90-08,
HV-91-05 to HV-91-14. Study medications and placebo were donated by Zeneca
Pharmaceuticals Group, Wilmington, Delaware; Marion-Merrell Dow, Kansas
City, Missouri; and Pfizer, New York, New York. Support for electrocardio-
graphic data collection was provided in part by Applied Cardiac Systems, Laguna
Hills, California; Marquette Electronics and Mortara Instrument, Milwaukee,
Wisconsin; and Quinton Instruments, Seattle, Washington. Some centers had
partial support from General Clinical Research Center grants. A complete list of
participating centers and investigators for the ACIP study appears in reference 30.
Manuscript received April 17, 1996; revised manuscript received August 14,
1996, accepted September 20, 1996.
Address for reprints: ACIP Clinical Coordinating Center, Maryland Medical
Research Institute, 600 Wyndhurst Avenue, Baltimore, Maryland 21210.
Address for correspondence: Dr. Barry L. Sharaf, Rhode Island Hospital,
Division of Cardiology/APC 434A, 593 Eddy Street, Providence, Rhode Island
02903.
JACC Vol. 29, No. 1
January 1997:78–84
78
᭧1997 by the American College of Cardiology 0735-1097/97/$17.00
Published by Elsevier Science Inc. PII S0735-1097(96)00444-5