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Background: A low level of HDL cholesterol has been identified as a risk factor for stroke in observational studies., Methods and Results: Our objective was to determine whether treatment aimed at raising HDL cholesterol and lowering triglycerides reduces stroke in men with coronary heart disease and low levels of both HDL and LDL cholesterol. The study was a placebo-controlled, randomized trial conducted in 20 Veterans Affairs medical centers. A total of 2531 men with coronary heart disease, with mean HDL cholesterol 0.82 mmol/L (31.5 mg/dL) and mean LDL cholesterol 2.9 mmol/L (111 mg/dL), were randomized to gemfibrozil 1200 mg/d or placebo and were followed up for 5 years. Strokes were confirmed by a blinded adjudication committee. Relative risks were derived from Cox proportional hazards models. There were 134 confirmed strokes, 90% of which were ischemic. Seventy-six occurred in the placebo group (9 fatal) and 58 in the gemfibrozil group (3 fatal), for a relative risk reduction, adjusted for baseline variables, of 31% (95% CI, 2% to 52%, P=0.036). The reduction in risk was evident after 6 to 12 months. Patients with baseline HDL cholesterol below the median may have been more likely to benefit from treatment than those with higher HDL cholesterol., Conclusions: In men with coronary heart disease, low HDL cholesterol, and low LDL cholesterol, gemfibrozil reduces stroke incidence.

Context: A low plasma level of high-density lipoprotein cholesterol (HDL-C) is a major risk factor for coronary heart disease (CHD). A secondary prevention study, the Veterans Affairs High-Density Lipoprotein Intervention Trial (VA-HIT), demonstrated that CHD events were significantly reduced during a median follow-up of 5.1 years by treating patients with the fibric acid derivative gemfibrozil when the predominant lipid abnormality was low HDL-C., Objective: To determine if the reduction in major CHD events with gemfibrozil in VA-HIT could be attributed to changes in major plasma lipid levels., Design: Multicenter, randomized, double-blind, placebo-controlled trial conducted from September 1991 to August 1998., Setting: The Department of Veterans Affairs Cooperative Studies Program, in which 20 VA medical centers were participating sites., Participants: A total of 2531 men with a history of CHD who had low HDL-C levels (mean, 32 mg/dL [0.83 mmol/L] ) and low low-density lipoprotein cholesterol (LDL-C) levels (mean, 111 mg/dL [2.88 mmol/L])., Intervention: Participants were randomly assigned to receive gemfibrozil, 1200 mg/d (n = 1264), or matching placebo (n = 1267)., Main Outcome Measure: Relation of lipid levels at baseline and averaged during the first 18 months of gemfibrozil treatment with the combined incidence of nonfatal myocardial infarction and CHD death., Results: Concentrations of HDL-C were inversely related to CHD events. Multivariable Cox proportional hazards analysis showed that CHD events were reduced by 11% with gemfibrozil for every 5-mg/dL (0.13-mmol/L) increase in HDL-C (P =.02). Events were reduced even further with gemfibrozil beyond that explained by increases in HDL-C values, particularly in the second through fourth quintiles of HDL-C values during treatment. During gemfibrozil treatment, only the increase in HDL-C significantly predicted a lower risk of CHD events; by multivariable analysis, neither triglyceride nor LDL-C levels at baseline or during the trial predicted CHD events., Conclusions: Concentrations of HDL-C achieved with gemfibrozil treatment predicted a significant reduction in CHD events in patients with low HDL-C levels. However, the change in HDL-C levels only partially explained the beneficial effect of gemfibrozil.

Isolated single coronary artery is a rare congenital anomaly occuring in approximately 0.024% of the population. This entity can be diagnosed during life only by coronary angiography. Ten patients with isolated single coronary artery are reported. Based on angiographic analysis, a new classification is proposed, according to the site of origin and anatomical distribution of the branches. Typical angina did not occur with single coronary artery in the absence of coexisting coronary artery disease or aortic stenosis. No correlation was apparent between the type of anomalous patterns and the symptoms of angina.

Eight hundred seventy arteriograms from the Coronary Artery Surgery Study (CASS) were independently read by readers at two different clinics to evaluate the reproducibility of the interpretation of coronary arteriograms. Among proximal segments, the interpretation of lesions of the left main coronary artery were the least reproducible, P less than .02. When one angiographer reads a stenosis of 50% or more in the left main coronary artery, it is estimated that a second reader will report no lesion 18.6% of the time. In 94.7% of the films, the number of significantly (greater than or equal to 70% stenosis) diseased vessels was the same for both readers (72.1%) or differed by one vessel (22.6%). The reproducibility of interpretation of films of good or acceptable quality or completeness was better than the reproducibility of readings of arteriograms judged to be of poor quality or incomplete studies. The mean absolute difference between readings of the percent stenosis decreased over the time of the patient enrollment, 1975 to 1978. This may have resulted from major collaborative efforts made during the course of the study to improve the quality of angiography and to standardize the reading of the cine films.

Randomly selected left ventricular cineangiograms performed by 14 medical centers (clinical sites) participating in a large multicenter study of medical and surgical treatment of coronary artery disease (CASS) were systematically recalled and reread by one of four designated quality control centers. The end diastolic volume (EDV), end systolic volume (ESV), and ejection fraction (EF) calculated by the quality control center were compared with those calculated by the clinical site, and correlation coefficients of 0.71, 0.84, and 0.79, respectively, were obtained. Regional left ventricular (LV) wall motion abnormalities were assessed by dividing the LV wall as viewed in the right anterior oblique (RAO) and left anterior oblique (LAO) views into five segments each and grading the motion of each segment according to six categories of increasing abnormalities from normal to aneurysm. When discrepancies based on "nearest neighbor" differences in naming adjacent segments were eliminated and only marked differences of more than one degree of severity of wall motion abnormality were considered, interobserver differences were 7% and 10% for RAO and LAO segments, respectively. Agreement was less frequent in designating a segment "aneurysmal." When each LV segment was assigned a numerical score based on increasing severity of wall motion abnormality and a total LV score for each ventriculogram computed, the quality control and clinical site readings were in good agreement with a correlation coefficient of 0.83.

Reliability of angiographic assessment of the left main coronary artery segment was evaluated by review of 106 coronary cineangiograms from the Coronary Artery Surgery Study. The films were interpreted by three groups of angiographers: those at a clinical site, those at a quality control site, and those on a study census panel. Among the readings of these three groups, there was 41% to 59% agreement on the severity of the lesion, with 80% agreement on whether the lesion was greater or less than 50%. The severity of lesion, its location, or presence of ectasia or calcium did not affect the discrepancy rate, whereas segments that were unusually short, diffusely diseased, or obscured by overlapping vessels were especially difficult to interpret.

Changes in coronary arterial size due to ergonovine maleate are described and quantitated in 90 patients--18 with typical angina pectoris, 56 with atypical chest pain, nine with variant angina pectoris, and seven heart transplant (allograft) recipients. We observed two angiographic changes in the diameter of coronary arteries: 1) spasm, which was characterized by occlusion or marked (greater than 85%) focal or diffuse vessel narrowing, or 2) relatively mild and diffuse vessel narrowing, which was interpreted as the normal pharmacologic response to the drug. Serial bolus injections of 0.05 mg, 0.10 mg and 0.25 mg of ergonovine maleate produced diffuse narrowing of the diameter of coronary arteries of 10 +/- 1.5%, 16 +/- 1.4% and 20 +/- 1.3% (mean +/- SEM), respectively, in the 72 patients with anginal syndromes who did not develop coronary spasm. The degree of coronary arterial narrowing was the same in heart transplant recipients and in patients with normally innervated hearts who did not develop coronary spasm. We believe the normal pharmacologic response to ergonovine maleate was due to a direct vasoconstrictor action of the drug; this action was independent of neural control extrinsic to the heart.

A patient with Takayasu's aortitis and angina pectoris due to severe narrowing of the right and left coronary arterial ostia is described. Takayasu's arteritis produces a panaortitis, with thickening of the adventitia predominating, and an inflammatory cell infiltrate involving the adventitia, outer media and vasa vasorum. Narrowing of the coronary arteries in this disease is due to extension into these arteries of the processes of proliferation of the intima and contraction of the fibrotic media and adventitia that occur in the aorta. The distal coronary arteries usually do not manifest arteritis and are normal in caliber. Angina pectoris may be the first symptom of the disease if the coronary arteries are the initial site of severe arterial narrowing. The coronary arterial bypass graft operation is effective therapy for treating coronary arterial narrowing due to Takayasu's arteritis.