Congestive Heart Failure, No Prior MI
10/29/98 (Lubin)

Question: Has congestive heart failure resulting from small-vessel ischemia, but in the absence of any prior myocardial infarction, been reported?

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Unique Identifier 92166895
Authors: Strauer BE.
Institution: Medical Clinic and Policlinic B, University of Dusseldorf, Germany.
Title: Development of cardiac failure by coronary small vessel disease in hypertensive heart disease?
Source: Journal of Hypertension - Supplement. 9(2)S11-20; discussion S20-1, 1991 Dec.
Abstract: In essential hypertension, ventricular function is determined primarily by the degree of hypertrophy (myocardial factor) and by organic complications in the coronary artery (coronary factor). Ventricular function is inversely correlated with ventricular size and systolic wall stress, inasmuch as ventricular function diminishes when these two variables increase. Even the young hypertensive heart of normal size with no angiographic abnormalities appears to be prone to ischemia, because the coronary reserve is seriously limited even in the absence of coronary stenosis. Unlike ventricular distensibility, myocardial compliance may be normal, even in the presence of pronounced myocardial hypertrophy. As myocardial compliance decreases, systolic wall stress increases and ventricular function is reduced. The hypertensive heart, the most common form of an irregular hypertrophy of the ventricular wall, is found in 14% of such cases. Analysis of the degree of hypertrophy shows that the hypertrophy can be inappropriately high (high mass-to-volume ratio, reduced wall stress), appropriate, or inappropriately low (normal mass-to-volume ratio, increased wall stress). One of the profound mechanisms influencing both myocardial and coronary function in hypertensive heart disease is the pressure-dependent development of smooth vascular hypertrophy (media) or coronary resistance vessels. Consequently, the oxygen supply to the myocardium is impaired and secondary lesions occur such as fibrosis, increased myocardial and perivascular collagen content and scars within the heart muscle. Diastolic dysfunction develops, as well as an increase in myocardial stiffness, thus promoting the transition from the concentric (compensated) to the eccentric or dilated (decompensated) state, with the consequence of the occurrence of cardiac failure. On the basis of both functional and morphological criteria, evidence is presented in this report that coronary small vessel disease is one of the underlying mechanism for the development of cardiac failure in hypertensive heart disease.

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Unique Identifier 90077389
Authors: Atkinson JB. Virmani R.
Institution: Department of Pathology, Vanderbilt University, Nashville, TN 37232.
Title: Congestive heart failure due to coronary artery disease without myocardial infarction: clinicopathologic description of an unusual cardiomyopathy.
Source: Human Pathology. 20(12)1155-62, 1989 Dec.
Abstract: Cardiomyopathies (CMs) can be classified as idiopathic dilated, hypertrophic, restrictive/obliterative, and so-called "ischemic cardiomyopathy." We have observed a subgroup of patients with congestive heart failure, dilated hearts, and severe coronary artery disease in the absence of myocardial infarction and therefore not fulfilling the criteria for ischemic CM. To better elucidate this group, which we called "coronary" CM, 54 consecutive necropsy patients who had congestive heart failure were retrospectively studied. Nineteen patients had idiopathic dilated CM, 26 had ischemic CM, and nine had coronary CM. The mean age of the patients with coronary CM and ischemic CM was significantly greater than that of the patients with idiopathic dilated CM (62 +/- 10 and 64 +/- 10 years versus 47 +/- 19 years, respectively). The duration of congestive heart failure was longest in the coronary CM group (4.1 +/- 3.4 years); half of these patients died suddenly or from arrhythmias. Hearts from patients with coronary CM had marked biventricular dilatation and severe coronary artery disease (mean number of coronary arteries with more than 75% narrowing, 2.2). No acute or healed infarcts were grossly visible, but interstitial and focal perivascular fibrosis were present in the myocardium of all coronary CM hearts. Although coronary CM may comprise a subset of so-called "ischemic cardiomyopathy," these cases may also represent idiopathic dilated CM with coincidental coronary artery disease.

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Unique Identifier 89211997
Authors: Regan TJ.
Institution: Division of Cardiovascular Diseases, UMDNJ-New Jersey Medical School.
Title: Cardiac disease in the older diabetic: management considerations. [Review] [22 refs]
Source: Geriatrics. 44(5)91-4, 96, 1989 May.
Abstract: A number of experimental and clinical studies have indicated that the process of aging and diabetes mellitus may result in alterations of cardiac function and composition. These appear to be independent of myocardial ischemia. Left ventricular diastolic compliance is diminished in both situations associated with interstitial collagen accumulation. There is also a reduction in the relaxation rate of the ventricle. In the subclinical state, the aged heart cell undergoes enlargement, but this has not been described in diabetes. In an unknown portion of patients with subclinical abnormalities, the process may advance to abnormalities of systolic function, heart failure, and arrhythmias. There is no convincing evidence that intramural small vessel disease can account for the diffuse cardiomyopathy of these two states. Management requires a particularly cautious use of cardioactive agents. [References: 22]

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