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OVERVIEW

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Low coronary blood flow causes acute coronary syndromes, angina pectoris, myocardial infarction, impaired left ventricular function, heart failure, arrhythmia, and death. High coronary blood flow capacity associates with cardiovascular health with its variations, reflecting our emotional states, lifestyles, and food, even the postprandial lipid surge of the last meal, all documented to alter coronary blood flow and risk factors, symptoms, and outcomes of coronary artery disease. The mammalian heart evolving from 200 million years ago—coronary blood flow, human gender evolution, fluid dynamic equations, coronary pressure flow measurements, quantitative perfusion imaging, diagnostic tests, coronary artery disease in women versus men, and how poor coronary flow is optimally treated—constitutes a highly integrated conceptual continuum, a syncytium of knowledge immediately relevant to current cardiovascular medicine and patient well-being.

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Resurgent interest in coronary blood flow related to myocardial “ischemia” derives in part from substantial disconnects in cardiovascular medicine. Immediate percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS) reduces myocardial infarction and cardiovascular mortality.1 However, all elective revascularization trials driven by “ischemia” on diagnostic testing fail to reduce myocardial infarction or cardiovascular deaths despite relief of angina2,3,4,5,6,7,8,9 (Fig. 34–1).

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FIGURE 34–1.

Outcomes after coronary revascularization in (A) acute coronary syndromes (ACS), stable coronary artery disease at 12-year follow-up of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial (B), cardiovascular mortality (C) and all-cause mortality or cardiovascular hospitalization (D) in the Surgical Treatment for Ischemic Heart Failure (STICH) trial with (red line) and without (blue line) ischemia by single-photon emission tomographic perfusion imaging. CI, confidence interval; PCI, percutaneous coronary intervention. (A) reproduced with permission from Fox KA, Clayton TC, Damman P, et al: Reproduced from Fox KA, Clayton TC, Damman P, et al. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol. 2010 Jun 1;55(22):2435-2445. (B) reproduced with permission from Sedlis SP, Hartigan PM, Teo KK: Effect of PCI on Long-Term Survival in Patients with Stable Ischemic Heart Disease. N Engl J Med. 2015 Nov 12;373(20):1937-1946. C, data from Velazquez EJ, Lee KL, Deja MA, et al: Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med. 2011 Apr 28;364(17):1607-1616. D, reproduced with permission from Panza JA, Holly TA, Asch FM, et al: Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction. J Am Coll Cardiol. 2013 May 7;61(18):1860-1870.

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This disconnect even reaches into the legality of fully informed consent wherein “cardiologists (95%) in this sample did not inform the patient that PCI would not lower the risk of death or MI [myocardial infarction], or ...

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