Hypotension accompanying the onset of exertional angina. A sign of evere compromise of left ventricular blood supply

Serious obstructive coronary artery disease was found in all patients who developed hypotension accompanying the onset of angina during multistage exercise testing. Seventeen exercising patients demonstrated a fall in systolic pressure to below resting levels as chest pain and ST segment depression appeared. Two patients died suddenly six weeks after treadmill testing and prior to arteriography. The remaining fifteen were studied with coronary arteriography and all except one exhibited ≥90% stenosis of the left anterior descending artery (LAD). The remaining patient demonstrated two 75% LAD stenoses in series. Five exhibited significant (≥75%) narrowing of the main left coronary artery (MLCA) and thirteen of fifteen had significant stenosis of proximal LAD and circumflex arteries. The two patients without significant circumflex disease exhibited ≥90% stenosis of the dominant right coronary artery (RCA) circulation. Six of six patients had restoration of a normal blood pressure response following coronary bypass surgery, which also relieved angina and reversed ST segment depression. Conditions essential for proper interpretation of this sign are discussed. If these conditions are met, then a fall in systolic pressure during treadmill induced angina pectoris is a reliable sign of severe compromise of left ventricular blood supply.