characteristics and feasibility of prehospital initiation of thrombolytic therapy. J Am fact Gze. I. Specificity and observer agreement. Circularion 1982;65:342-347. Cd Cardiol 1990; 15:925-93 1. 6. Clemmensen P, Ohman EM, Sevilla IX, Peck S, Wagner NB, Quigley PS, Lee 4. Weaver WD, Cerqueira M, Hallstrom AP, Litwin PE, Martin JS, Kudenchuk PJ, KL, Wagner GS. Changes in standard electrocardiographic ST-segment elevation Eisenberg M, for the Myocardial Infarction Triage and Intervention Project Group. predictive of successful repafusion in evolving acute myocardial infarction. Am ./ Prehospital-initiated vs. hospital-initiated thrombolytic therapy: The Myocardial In- Cardiol 1990:66:1407-1411. farction Triage and Intervention trial. JAMA 1993:270:1211-1216. 7. Hackett D, Davies G, Chierchia S, Masai A. Intermittent coronary occlusion in 5. Wagner GS, Freye CJ, Palmeri ST, Roark SF, Stack NC, Ideker RE, Hare11 FE, acute myocardial infarction: value of combined thrombolytic and vasodilator ther- Selvester RH. Evaluation of a QRS scoring system for estimating myocardial in- spy. N Enfil J Med 1987;317:1055-1059. Association Between Plasma Insulin and Angiographically Documented Significant Coronary Artery Disease Paolo Spallarossa, MD, Renzo Cordera, MD, Gabriella Andraghetti, BSc, Giovanni Bertero, MD, Claudio’Brunelli, MD, and Salvatore Caponnetto, MD F ew data are available on the relation between plasma insulin and angiographic evidence of coronary ath- erosclerosis.1,2 If hyperinsulinemia is associated with the clinical end points of coronary atherosclerosis-myo- cardial infarction or cardiac deathS5--then a similar as- sociation should also be found between hyperinsuline- mia and angiographic evidence of coronary artery disease (CAD). The present study in nondiabetic men examines whether plasma insulin levels, both fasting and after an oral glucose load, are correlated with angio- graphically documented significant CAD. One hundred thirty-six consecutive men undergoing elective coronary angiography formed the study popu- lation. Eligible patients met the following criteria: (1) no history of diabetes; (2) normalfasting blood glucose; (3) no treatment with lipid-lowering drugs; and (4) no antecedent history of myocardial infarction, coronary artery bypass, or angioplasty. The study was approved by the local ethics committee and each patient gave in- formed consent. Cardiovascular medications including B blockers, calcium antagonists, nitrates, aspirin, an- giotensin-converting enzyme inhibitors, and diuretics were not discontinued before the study.Both current and former smokers were included. Selective coronary angiography was performed by standard techniques with multiple injections of 4 to 8 ml of iohexol(647 mglml) in the anteroposterior, right, and left oblique views with various cranial and caudal an- gulations. Angiograms were examined by 3 observers unaware of the results of plasma insulin, glucose, and lipoprotein determinations. The luminal percent diame- ter narrowings were estimatedby a consensus of the ob- servers or by the mean of different measurements. Di- ameter stenoses 250% were considered significant, and thesepatients were assigned to the CAD+ group. Over- all severity of CAD was assessed according to the 15- segmentcoding system of the American Heart Associa- tion6 Each segment was given a numerical value corresponding to the percent diameter reduction, from 0 From the Departments of Internal Medicine, and Endocrinology and Metabolism, University of Genoa, Viale Bendetto XV, 6, 16124 Genoa, Italy. This work was supported in part by the Association for the Progress of Cardiology, Genoa, and by P. F. Ingegneria Genetica-CNR, Rome. Manuscript received August 19, 1993; revised manuscript re- ceived and accepted December 20, 1993. in the case of a normal segmentto 100 in the case of a total occlusion. Segments with <2.5%stenosiswere con- sidered normal. The total CAD score was obtained by summation of each segmentvalue. A standard oral glucose tolerance test wasperformed within 3 days of coronary angiogruphy. After 12-hour fasting, venous blood was drawn for measurements of glucose, insulin, triglycerides, and lipoproteins. A 75 g glucose load was subsequently administered and blood specimens for insulin and glucose determinations were collected after 1 and 2 hours. Normal glucose tolerance, impaired glucose tolerance, and non-insulin-dependent diabetes mellitus were diagnosed according to World Health Organization criteria.7 Results are expressed as mean f. SEM. Between- group comparisons of mean values were per$ormedus- ing the unpaired 2-tailed Student’s t test. Differences among >2 groups were assessed by analysis of variance; multiple comparisons were then made with Duncan’s method.Differencesbetween proportions were compared by chi-square test. Univariate correlations betweenvari- ables were analyzed using the Spearmancorrelation co- TABLE I Characteristics of Study Population by Coronary Angiography Significant Coronary Artery Disease Absent Present Number of subjects 29 (21%) 107 (79%) Age (years) 53.6 f 1.8 59.7 f 0.9* Body mass index (kg/m*) 25.0 + 0.6 26.3 I? 0.3 Total cholesterol (mmol/L) 4.62 k 0.03 4.82 f 0.09 LDL cholesterol (mmol/L) 3.13*0.12 3.33 f 0.10 HDL cholesterol (mmol/L) 0.97 f 0.06 0.93 f 0.04 Triglycerides (mmol/L) 1.10~0.12 1.32 f 0.07 Number of smokers 22 (75%) 74 (69%) Number of hypertensives 17 (59%) 50 (47%) Treatment 8 blockers 7 (24%) 40 (37%) Calcium antagonists IO (34%) 63 (59%)t Nitrates 13 (45%) 67 (63%) Aspirin 15 (52%) 83 (78%)t Angiotensin-converting 8 (29%) 34 (32%) enzyme inhibitors Diuretics 3 (10%) 15 (14%) ‘p <0.001; tp co.05. Data are expressed as mean f SEM. BRIEF REPORTS 177