Silent myocardial ischemia after percutaneous transluminal coronary angioplasty and its prognostic significance.

A cohort of 175 patients who underwent successful percutaneous transluminal coronary angioplasty (PTCA) were subjected to a treadmill exercise test to determine the prognostic significance of silent and symptomatic myocardial ischemia during the follow-up (average 11.7 months). The cardiac events during the follow-up were defined as cardiac death, nonfatal myocardial infarction, class III angina, and need for repeat angioplasty or coronary artery bypass surgery. During exercise, 39 patients (22%) had abnormal exercise-induced ST depression without chest pain (Group I). A group of 22 patients (13%) had both exercise-induced chest pain and ST-segment depression (Group II), and 114 patients (65%) had normal exercise test and no chest pain (Group III). The groups were similar in sex distribution, history of previous myocardial infarction, distribution of vessel disease, and presence of left ventricular dysfunction. Group III included more patients with complete revascularization. Follow-up data revealed that cardiac event rates in Groups I and II were significantly higher than in Group III (41%, 41%, vs. 16%) (p less than 0.01). The event rates in Groups I and II with multivessel angioplasty also were significantly higher than in Group III (58%, 61%, vs. 21%) (p less than 0.01). Exercise-induced silent myocardial ischemia is frequently seen early after successful PTCA and is more prevalent in patients undergoing multivessel angioplasty and incomplete revascularization. Both silent and symptomatic ischemia early after PTCA are predictors of an unfavorable prognosis.     

Percutaneous transluminal coronary angioplasty in octogenarians

OBJECTIVE: To assess the safety and short- and long-term outcomes of percutaneous transluminal coronary angioplasty in octogenarians. DESIGN: Retrospective chart review of clinical series. SETTING: Referral-based university medical center. PATIENTS: Consecutive series of 54 octogenarian patients (mean age, 82.4 years) who had percutaneous transluminal coronary angioplasty between March 1980 and December 1988. Of these patients, 91% presented with severe angina (Canadian Cardiovascular Society Class III or IV); 59% had unstable angina. Twenty-six patients (48%) had had a previous myocardial infarction and 15 (28%) had had previous coronary artery bypass surgery. Multivessel disease was present in 44 patients (81%). Follow-up ranged from 1 to 50 months (mean, 19 months). INTERVENTION: Percutaneous transluminal coronary angioplasty. MEASUREMENTS and MAIN RESULTS: The angiographic success rate was 50 of 54 (93%; 95% CI, 81% to 98%) and the clinical success rate was 49 of 54 (91%; CI, 79% to 97%). Two patients had procedure-related myocardial infarction. Two patients died in the hospital, 1 from cardiac tamponade because of pacemaker perforation and 1 from cardiogenic shock after a myocardial infarction despite successful angioplasty. During the follow-up period 4 patients required bypass surgery, 2 had myocardial infarction, and 7 died (4 deaths were cardiac). Eleven patients (20%) had re-stenosis, 7 of whom were managed with repeat angioplasty, including 1 patient who had four procedures. At follow-up, 42 of 45 survivors (93%) were asymptomatic or had class II angina. The Kaplan-Meier survival for all patients, including those who died in the hospital, was 87% at 1 year and 80% at 3 years. Cumulative freedom from major cardiac events (death, myocardial infarction, or coronary bypass surgery) was 81% at 1 year and 78% at 3 years. CONCLUSIONS: Percutaneous transluminal coronary angioplasty can be done in octogenarians with a high rate of angiographic and clinical success, low complication rate, and a favorable long-term (3-year) outcome. As such, it is a treatment option in managing advanced coronary artery disease in this fragile group of patients.     

Coronary angioplasty in unstable angina and stable angina: a comparison of success and complications

One hundred and five patients with unstable angina and 175 with chronic stable angina were treated by primary percutaneous transluminal coronary angioplasty. Patients with unstable angina had had symptoms for a shorter time and were more likely to have angiographically complex lesions and lesions less than 10 mm in length than patients with chronic stable angina. Other baseline variables were not significantly different in the two groups. The overall primary success rate was similar in both groups (87% v 86%). Nine of the 14 unsuccessful procedures in those with unstable angina and nine of the 24 unsuccessful procedures in those with stable angina were the result of acute occlusion. These results led to a 9% frequency of procedure related myocardial infarction in patients with unstable angina and a 5% rate in those with stable angina (NS). The procedure related infarct rate tended to be higher in patients with unstable angina who had coronary angioplasty soon after an episode of unstable angina (mean 10 days) than in those in whom it was delayed (mean 35 days) (12% v 3%) (NS). In patients with unstable angina who had had a previous myocardial infarction procedure related infarction was significantly more common (18%) than in patients with no previous myocardial infarction (3%). The difference between those with and without previous infarction was also significant in patients with stable angina (10% v 3%).     

Coronary angioplasty in unstable angina and stable angina: a comparison of success and complications.

One hundred and five patients with unstable angina and 175 with chronic stable angina were treated by primary percutaneous transluminal coronary angioplasty. Patients with unstable angina had had symptoms for a shorter time and were more likely to have angiographically complex lesions and lesions less than 10 mm in length than patients with chronic stable angina. Other baseline variables were not significantly different in the two groups. The overall primary success rate was similar in both groups (87% v 86%). Nine of the 14 unsuccessful procedures in those with unstable angina and nine of the 24 unsuccessful procedures in those with stable angina were the result of acute occlusion. These results led to a 9% frequency of procedure related myocardial infarction in patients with unstable angina and a 5% rate in those with stable angina (NS). The procedure related infarct rate tended to be higher in patients with unstable angina who had coronary angioplasty soon after an episode of unstable angina (mean 10 days) than in those in whom it was delayed (mean 35 days) (12% v 3%) (NS). In patients with unstable angina who had had a previous myocardial infarction procedure related infarction was significantly more common (18%) than in patients with no previous myocardial infarction (3%). The difference between those with and without previous infarction was also significant in patients with stable angina (10% v 3%).     

Percutaneous transluminal coronary angioplasty in unstable and stable angina pectoris: a comparison of immediate success and complications.

To determine the success rate and the safety of percutaneous transluminal coronary angioplasty in patients with unstable angina pectoris (group 1) versus stable angina (group 2), we studied 299 consecutive patients who underwent coronary angioplasty of 373 consecutive lesions. Of these patients, 149 had unstable angina pectoris and dilation of 188 arteries. The success rate was high and similar in both groups (95 and 93%, respectively). The groups did not differ in regard to the lesion characteristics, vessels and number of sites dilated except for an increase in the presence of thrombus in the unstable angina group (p < 0.03). Although there was a higher incidence of coronary thrombus and more acute myocardial infarction in group 1, the major complication rate did not differ from that of group 2 and was low in both of them (3 and 2%, respectively). No deaths occurred. Six patients (3 in each group) needed urgent coronary artery bypass grafting while 3 additional patients developed acute Q-wave myocardial infarction (all of them in group 1). Thus, percutaneous transluminal coronary angioplasty is a safe and successful procedure in patients with unstable angina as well as in patients with stable angina pectoris.     

Coronary angioplasty for unstable angina: immediate and late results in 200 consecutive patients with identification of risk factors for unfavorable early and late outcome

Two hundred patients (mean age 56 years, range 36 to 74) with unstable angina (chest pain at rest, associated with ST-T changes) underwent coronary angioplasty. In 65 patients with multivessel disease, only the "culprit" lesion was dilated. The initial success rate was 89.5% (179 of 200 patients). At least one major procedure-related complication occurred in 21 patients (10.5%): (death in 1, myocardial infarction in 16 and urgent surgery in 18). All patients were followed up for 2 years. Five patients died late; 8 had a late nonfatal myocardial infarction and 52 had recurrence of angina pectoris. The restenosis rate was 32% (51 of 158) in the patients with initial successful angioplasty who had repeat angiography. At the 2 year follow-up, after attempted coronary angioplasty in all 200 patients, the total incidence rate of death was 3% (one procedure related; five late deaths), of nonfatal myocardial infarction 12% (16 procedure related and 8 late after angioplasty), and 13% (26 patients) were still symptomatic although they had improved in functional class. Multivariate analysis showed that variables indicating an increased risk 1) for major procedure-related complications were: ST segment elevation, persistent negative T wave and stenosis greater than or equal to 65% (odds ratio 3.7, 3.7 and 3.3, respectively); 2) for angiographic restenosis were: presence of collateral vessels, ST segment depression, multivessel disease, left anterior descending coronary artery stenosis and history of recent onset of symptoms (odds ratio: 2.2, 2.0, 1.9, 1.9 and 0.54, respectively); and 3) for late coronary events (recurrence of angina, late myocardial infarction or late death) were: multivessel disease, total occluded vessel and ST segment elevation (odds ratio 3.7, 2.8 and 0.44, respectively). Thus, coronary angioplasty for unstable angina can be performed with a high initial success rate, but at an increased risk of major complications. The prognosis is favorable after initial successful coronary angioplasty.     

Triple vessel coronary angioplasty: acute outcome and long-term results

Triple vessel coronary angioplasty, defined as angioplasty of one or more lesions in each of the three major coronary arteries (left anterior descending, left circumflex, right coronary artery) was performed in 50 (11%) of 469 patients who had angioplasty of multiple vessels. There were 32 men and 18 women with a mean age of 56 years. All 50 patients had severe three vessel coronary disease and represent approximately 5% of patients with three vessel disease who had revascularization in this institution; 8 (16%) had previous coronary bypass surgery, and 23 (46%) had previous myocardial infarction. Unstable angina was present in 33 patients (66%) and 96% had Canadian Heart Association class III or IV angina; mean left ventricular ejection fraction was 57 +/- 11%. Angioplasty was performed in 176 vessels (3.5 vessels per patient, range 3 to 6) and in 250 lesions (5 lesions per patient, range 3 to 9); angiographic success was achieved in 240 lesions (96%) and 166 vessels (94%). Success in all vessels attempted was achieved in 40 (80%) of the 50 patients. Clinical success (angiographic success associated with clinical improvement) was obtained in all 50 patients in whom triple vessel angioplasty was performed; none of them required urgent bypass surgery and 5 patients (10%) had a non-Q wave myocardial infarction. In four other patients triple vessel angioplasty was planned but not performed because of failure to dilate the primary vessel; urgent bypass surgery was required in one of these, who developed a Q wave infarction. Thus, overall clinical success in 54 patients was 93%; the incidence rate of myocardial infarction was 11%, and that of urgent surgery 1.8%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Indications for coronary angioplasty in acute myocardial ischemic syndromes

Summary The role of coronary angioplasty for the treatment of patients with evolving myocardial infarction, unstable angina, and early postinfarction unstable angina is discussed.It has been shown that coronary angioplasty in patients with an evolving myocardial infarction is feasible and can be performed with a high initial success rate. The most beneficial timing of dilatation is still unclear, and acute reocclusion following coronary angioplasty remains a problem. Current data suggest that the left ventricular function is greater improved and peri-infarction ischemia is less with angioplasty when compared with sole thrombolytic treatment.Coronary angioplasty for unstable angina and early post-infarction unstable angina can be performed with a high initial success rate, but at an increased risk of major complications.Thus, coronary angioplasty has nowadays obtained a definitive place in the treatment of acute myocardial ischemic syndromes. Further research is needed to improve the initial and late results of coronary angioplasty, and additional randomized clinical studies are necessary to more accurately define the indications and timing of dilatation in these acutely ill patients.     

Short term results of percutaneous transluminal coronary angioplasty with the monorail technique: experience in the first 1000 patients.

The monorail technique allows monitoring of all steps of the coronary angioplasty procedure by high quality coronary angiography; easy, rapid, and safe recrossing and redilatation of the lesion if necessary; and stepwise dilatation of a stenosis with sequential increase of size of balloons. Transstenotic pressure differences cannot, however, be measured through the narrow shaft of the standard monorail balloon catheter. The monorail technique was used in 1014 patients (820 men, 194 women; mean age 57.8 years (range 24 to 84]. The indication for coronary angioplasty was stable angina in 52%, unstable angina in 40%, and acute myocardial infarction in 8%. Single vessel coronary angioplasty was attempted in 78%, multilesion coronary angioplasty in 11%, and multivessel coronary angioplasty in 11%. Angiographic success (reduction of stenosis to less than 50% of the luminal diameter) of all attempted lesions was achieved in 93%. The technique was clinically successful--that is, angiographic success of all attempted lesions, no occurrence of a major complication (death, myocardial infarction, acute bypass surgery), and improvement of symptoms--in 92% and partially successful in 1.3%. The clinical success rates were similar for stable angina (91%) and unstable angina (94%), but were somewhat lower for acute myocardial infarction (88%). Failure without major complication occurred in 3.4% of the patients. Failure with a major complication occurred in 3.3% (death 0.3%, myocardial infarction 2.4%, and acute bypass surgery 2.3%). The total major complication rate was higher in unstable angina (4.2%) than in stable angina (3.0%). These results indicate that the monorail technique can be applied safely and effectively for coronary angioplasty of patients with stable angina, unstable angina, and acute myocardial infarction.     

Short term results of percutaneous transluminal coronary angioplasty with the monorail technique: experience in the first 1000 patients

The monorail technique allows monitoring of all steps of the coronary angioplasty procedure by high quality coronary angiography; easy, rapid, and safe recrossing and redilatation of the lesion if necessary; and stepwise dilatation of a stenosis with sequential increase of size of balloons. Transstenotic pressure differences cannot, however, be measured through the narrow shaft of the standard monorail balloon catheter. The monorail technique was used in 1014 patients (820 men, 194 women; mean age 57.8 years (range 24 to 84]. The indication for coronary angioplasty was stable angina in 52%, unstable angina in 40%, and acute myocardial infarction in 8%. Single vessel coronary angioplasty was attempted in 78%, multilesion coronary angioplasty in 11%, and multivessel coronary angioplasty in 11%. Angiographic success (reduction of stenosis to less than 50% of the luminal diameter) of all attempted lesions was achieved in 93%. The technique was clinically successful--that is, angiographic success of all attempted lesions, no occurrence of a major complication (death, myocardial infarction, acute bypass surgery), and improvement of symptoms--in 92% and partially successful in 1.3%. The clinical success rates were similar for stable angina (91%) and unstable angina (94%), but were somewhat lower for acute myocardial infarction (88%). Failure without major complication occurred in 3.4% of the patients. Failure with a major complication occurred in 3.3% (death 0.3%, myocardial infarction 2.4%, and acute bypass surgery 2.3%). The total major complication rate was higher in unstable angina (4.2%) than in stable angina (3.0%). These results indicate that the monorail technique can be applied safely and effectively for coronary angioplasty of patients with stable angina, unstable angina, and acute myocardial infarction.     

Percutaneous transluminal coronary angioplasty in multilesion disease: complete versus incomplete revascularization

We report the results of percutaneous transluminal coronary angioplasty (PTCA) in the first 200 consecutive patients to undergo this procedure for multilesion coronary disease at Dunedin Hospital. In Group I, which consisted of 86 patients (67 men and 19 women, with a mean age of 56 years), complete revascularization of 228 lesions (2.7 lesions per patient) was undertaken. Primary success was achieved in 217 lesions (95%) in 78 patients (91%). There were five major complications, including myocardial infarction in four cases (5%) and emergency coronary artery bypass grafting (CABG) for failed PTCA in one case (1%). In Group II, which comprised 114 patients (82 men and 32 women, with a mean age of 57 years), partial revascularization of 186 lesions (1.6 lesions per patient) was attempted. Primary success was achieved in 165 lesions (89%) in 96 patients (84%). There were nine major complications, including myocardial infarction in two cases (2%), emergency CABG for failed PTCA in four cases (4%), and in-hospital death in three cases (3%). During a follow-up period ranging from 3 to 38 months (mean, 11 months), 16 (20%) of the patients in Group I and 16 (18%) of those in Group II have had recurrent angina and/or restenosis. Twenty-five of these patients have undergone repeat PTCA, with primary success in 24 cases (96%), and six have undergone elective CABG. There has been only one late death (0.6%) after successful PTCA. Complications occurred more frequently in patients with unstable angina (10.0%) and postinfarction angina (19.0%) than in those with stable angina (1.4%). However, the complication rate for multilesion PTCA has become increasingly lower until it now equals that associated with single-vessel PTCA at this institution (about 4% overall).     

In-hospital morbidity and mortality in patients undergoing elective coronary angioplasty

We prospectively recorded all in-hospital complications of the first 3500 consecutive patients to undergo elective coronary angioplasty (PTCA) at Emory University Hospitals from July 14, 1980, to August 28, 1984, by three operators. PTCA was attempted in a total of 3933 lesions, with a primary success rate of 91%. Multiple-lesion PTCA was performed in 401 patients, and PTCA of saphenous vein grafts was attempted in 172. No complications were recorded in 3116 (89%) cases, isolated minor complications occurred in 241 (6.9%), and major complications (emergency surgery, myocardial infarction, death) were observed in 145 (4.1%). Emergency coronary artery bypass graft surgery (CABG) was performed in 96 patients (2.7%), with a myocardial infarction rate of 49% (47/96), a Q wave infarction rate of 23% (22/96), and an emergency surgery mortality rate of 2% (2/96). Hospital discharge occurred within 2 weeks of attempted PTCA in 91% (87/96) of patients undergoing emergency CABG. The overall myocardial infarction rate was 2.6% (94/3500). There were two nonsurgical deaths, giving a total mortality rate of 0.1% (4/3500). Univariate and multivariate analysis of 3099 patients undergoing single-lesion PTCA identified five preprocedure predictors of a major complication: multivessel coronary disease, lesion eccentricity, presence of calcium in the lesion, female gender, and lesion length. Unstable angina, duration of angina, lesion severity, previous CABG, and vein graft dilatation were not associated with an increased incidence of major complications. The strongest predictor of a major complication was the procedural appearance of an intimal dissection. Intimal dissection was evident in 894/3099 (29%) patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-term results of thrombolytic therapy with and without percutaneous transluminal coronary angioplasty

The effects of combined intravenous and intracoronary streptokinase without (Group I, n = 103) or with (Group II, n = 103) immediate coronary angioplasty were evaluated during a long-term (3 year) follow-up of 206 patients with acute transmural myocardial infarction. There were no baseline differences between the groups with regard to gender, age, infarct location, serum creatine kinase levels, time between onset of symptoms and treatment and coronary artery patency rate. Angioplasty was performed with a success rate of 69% and a reocclusion rate of 2%. Elective angioplasty was performed in 22 (21%) of 103 patients in Group I and 9 (9%) of 103 patients in Group II, with a success rate of 86% and 100%, respectively, reflecting the higher incidence of angina pectoris and antianginal therapy in Group I. Coronary bypass surgery was performed in 21 (20%) of 103 patients in Group I and 20 (19%) of 103 patients in Group II; there was one operative death in each group. During follow-up, coronary reocclusion or reinfarction, or both, occurred in 25 (29%) of 87 patients in Group I and in 16 (18%) of 87 patients in Group II with reperfused vessels (p = NS). Heart failure occurred in 40% of the patients in both groups who had increased end-diastolic and end-systolic volumes. The survival rate after 3 years was 78% in Group I and 80% in Group II (p = NS). Thus, long-term follow-up of patients with acute transmural infarction treated with and without immediate angioplasty does not demonstrate any difference with regard to clinical outcome and mortality.     

Immediate and long-term clinical outcome of coronary angioplasty in patients aged 35 years or less.

OBJECTIVE--To study the immediate and long-term clinical success of percutaneous transluminal coronary angioplasty in patients aged 35 years or less. DESIGN--Patients undergoing percutaneous transluminal angioplasty were prospectively entered into a dedicated database. Clinical and angiographic data on all patients aged 35 years or less were reviewed. Follow up data were collected by interview during outpatient visits, by questionnaire, or from referring physicians. SETTING--A tertiary referral cardiac centre. PATIENTS--57 patients aged 35 years or less (median 33, range 22-35) underwent coronary angioplasty because of unstable angina (32 patients), stable angina (23 patients), acute myocardial infarction (1 patient), and documented ischaemia in a cardiac transplant patient. RESULTS--The primary clinical success rate (reduction in diameter stenosis to < 50% without in-hospital events) was 88%. A major procedure related complication occurred in 5 patients (9%): one patient died, two patients sustained an acute myocardial infarction, two patients underwent emergency bypass surgery, and in three patients repeat angioplasty was performed before hospital discharge. In 2 patients (4%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 60 lesions were attempted (balloon angioplasty in 57, directional atherectomy in 2). The initial angiographic success rate was 92%. The median (SD) follow up was 4.7 (3.0) years. During follow up 7 patients (12%) died, 10 sustained a myocardial infarction (18%), and 28 patients (49%) underwent repeat revascularisation (coronary artery bypass grafting in 7 (12%) and repeat angioplasty in 21 (37%)). The estimated 5 year survival and event-free survival (Kaplan-Meier method) was 87 (9)% and 50 (13)%, respectively. Multivariate logistic regression analysis showed that hypertension and the extent of vessel disease were the only independent predictive factors for event free survival. CONCLUSIONS--In young patients coronary angioplasty had a high immediate success rate but many needed repeat revascularisation procedures during the follow up period and survival was not improved. Coronary angioplasty in young patients should be regarded as a palliative procedure.     

PTCA at first sight: angioplasty based on video only

The results of 326 coronary angioplasties (PTCAs) performed during a first diagnostic angiography and based on video images only (PTCA at first sight, Group I) are compared with those of 756 PTCAs done during the same time period in patients with a previous cine-film and therefore a known or predictable coronary anatomy (Group II). Group I patients had more single vessel disease (74% versus 58%, p less than 0.001), single vessel PTCA (93% versus 84%, p<0.001), unstable angina (54% versus 28%, p less than 0.001), recent myocardial infarction (66% versus 37%, p less than 0.001), and total occlusion PTCA (29% versus 19%, p<0.01). On the other hand, they had less severe stable angina (mean New York Heart Association class 1.3+/-1.2 versus 1.8+/-1.4, p less than 0.001), less advanced disease (average of 1.3+/-0.5 versus 1.5+/-0.7 diseased vessels, p less than 0.001) and worse left ventricular ejection fraction (61+/-12% versus 63+/-12%, p less than 0.01). The angiographic and clinical success rates were 90% and 84% in Group I and 92% and 87% in Group II respectively, (p=NS). Complication rates were not statistically different between the groups (Q-wave myocardial infarction 2% versus 3%, non Q-wave myocardial infarction 4% in both groups, emergency surgery 0.3% versus 0.8% and inhospital mortality 0.9% for both groups). In selected patients, coronary angioplasty can be performed safely and effectively during a first coronary angiography based on video images exclusively.     

Influence of contrast media on thrombus formation during coronary angioplasty

The influence of contrast media on thrombus formation during percutaneous transluminal coronary angioplasty was assessed in 124 consecutive patients undergoing coronary angioplasty and receiving either ionic (n = 57) (Group I) or nonionic (n = 67) (Group II) contrast medium. The presence of thrombus was assessed by qualitative analysis of angiograms in identical pre- and postangioplasty projections by four observers who had no knowledge of other data. Quantitation of stenosis severity before and after angioplasty and qualitative analysis of lesion eccentricity and complexity and of the presence of dissection were also performed. Although the baseline clinical characteristics of the two groups (including presenting syndromes and procedural and angiographic variables) did not differ, more patients in Group II than Group I developed new thrombus during coronary angioplasty (18% vs. 4%, p less than 0.02). In particular, patients with a presenting syndrome of recent myocardial infarction or rest angina, or both, and patients with an eccentric coronary plaque were more likely to develop new thrombus if they received nonionic than if they received ionic contrast medium (p less than 0.05). Patients with new thrombus formation and patients with thrombus present both before and after angioplasty had a high incidence of acute procedural complications (36% and 23%, respectively). Patients in Groups I and II had a similar incidence of ischemic events during follow-up.     

Immediate and follow-up results of the conservative coronary angioplasty strategy for unstable angina pectoris.

To assess the results of a conservative coronary angioplasty strategy in unstable angina pectoris, the records of 1,421 consecutive patients without previous myocardial infarction undergoing a first percutaneous transluminal coronary angioplasty (PTCA) between 1986 and 1990 were reviewed. Of these patients, 631 had unstable and 790 had stable angina pectoris. Only after an intense effort to medically control symptoms, the unstable patients underwent PTCA at an average of 15.4 days (range 1 to 76) after hospital admission. Primary clinical success was achieved in 91.7% of patients with unstable and in 94.4% of those with stable angina pectoris (p = not significant). In-hospital mortality rates were 0.3 and 0.1%, respectively (p = not significant). Nonfatal in-hospital event rates for acute myocardial infarction, cerebrovascular accident and coronary bypass surgery were only slightly higher in patients with unstable angina pectoris; however, the difference from the stable group was significant when all events were combined (9 vs 5.9%; p less than 0.04). During 6-month follow-up, no significant difference in adverse events was found between the groups. The respective rates for the unstable and stable groups were 0.4 and 0.2% for death, 5.5 and 5.1% for major nonfatal events, and 17.7 and 20.1% for repeat PTCA. These results suggest that use of a conservative PTCA strategy in the treatment of patients with unstable angina pectoris results in favorable and similar immediate and 6-month outcomes compared with those in patients with stable angina pectoris.     

The comparison between self-expanding and balloon expandable stent results in left anterior descending artery

The first Wallstent results had high thrombosis and death. It was reported that the left anterior descending (LAD) artery was the vessel implicated in major complications that occurred in patients who received a Wallstent. Subsequently, Wallstent applications were refrained from with LAD lesions. However, the promising results of second-generation self-expanding Magic Wallstent implantation have been reported recently. The purpose of this study is to assess the immediate and intermediate clinical outcomes of patients undergoing self-expanding Magic Wallstent implantation at the LAD site and to compare those outcomes with those of a similar group of patients undergoing balloon expandable stenting at the same site. Between 1995 and 1999, 255 consecutive patients underwent LAD stenting at our center. The study population was divided into two groups based on the mode of delivery (self-expanding versus balloon-expandable) of stent design. Group I included 97 patients in whom self-expanding Magic Wallstents were implanted. Group II included 158 patients in whom various types of balloon-expandable stents were implanted. Procedural success was defined as successful deployment of the stent in the absence of adverse cardiac events (death, acute myocardial infarction, emergency coronary bypass surgery). Clinical success was defined as the absence of adverse cardiac events (death, acute myocardial infarction, emergency coronary bypass surgery, repeat balloon angioplasty) within the first two weeks. The mean follow-up period was 8 ± 5.3 months for Group I and 9.8 ± 7.5 months for Group II. There was no difference in baseline characteristics between the two groups. Fourteen patients in Group I and 22 patients in Group II had bailout procedures. The number of patients with reference vessel diameter less than 3 mm was 37 in Group I and 60 in Group II. The stent length was greater in Group I than in Group II (p=0.0003). In Group I, stenting improved minimal lumen diameter (MLD) from 0.65 ± 0.4 mm to 2.35 ± 0.4 and percent diameter stenosis (PDS) from 76.24 ± 17.3 to 22.78 ± 13.6. In Group II, stenting improved MLD from 0.73 ± 0.4 mm to 2.49 ± 0.5 and PDS from 76.71 ± 15.5 to 18.99 ± 9.6. Final MLD and final PDS improved more in Group II than Group I. Stent could not be delivered in three patients in Group I and nine in Group II. In Group II, six stents were dislocated from its delivery system. Procedural and clinical success and subacute stent thrombosis rates were 93.8%, 85.6%, and 7.2% in Group I, and 93%, 86.7%, and 5.1% in Group II, respectively. Within the first two weeks, death occurred in one patient in each group, acute myocardial infarction in four (Group I) and two (Group II) patients; coronary bypass surgery in three (Group I) and five (Group II) patients, and balloon angioplasty in two (Group I) and four (Group II) patients, respectively. In Group I, following the first two weeks, no patients died, two patients had nonfatal myocardial infarction, and coronary bypass surgery and target vessel repeat balloon angioplasty was required in five and ten patients, respectively. In Group II, one patient died in the follow-up period, there was no nonfatal myocardial infarction, and bypass surgery and target vessel repeat balloon angioplasties were required in three and eleven patients, respectively. None of these differences in clinical events was statically significant. We found that self-expanding Magic Wallstent implantation can be performed in LAD lesions and was associated with a rate of early clinical results and intermediate term clinical results similar to that of balloon-expandable stents in LAD arteries. In conclusion, the Magic Wallstent may confidently be used for LAD lesions.     

Efficacy of reperfusion therapy in acute myocardial infarction complicated by cardiogenic shock]

Efficacy of reperfusion therapy was studied in 40 patients with acute myocardial infarction complicated with cardiogenic shock. Among them, 27 were treated with intracoronary thrombolysis (ICT) and/or coronary angioplasty (Group I), and 13 were untreated by reperfusion therapy (Group II). In Group I, reperfusion was successful in 17 (Group Ia). It was unsuccessful in the other 10 (Group Ib). Patients' characteristics such as age, sex, infarct location, previous myocardial infarction, peak creatine kinase, and the extent of coronary artery disease were similar in Groups Ia and Ib. The in-hospital survival rate was significantly higher in Group Ia (76.5% vs 40.0%, p < 0.01). There was no significant difference in the average hospital and CCU stays, total or maximal dosage of catecholamines (dopamine and dobutamine), and duration of IABP treatment of the discharged patients between Groups Ia and Ib. Cardiac index under pressure support (IABP, catecholamines, etc) in both Groups did not differ significantly. One patient in Group Ia had re-infarction. However, no patient in either group died during a mean follow-up period of 747 days. Among the surviving patients, 3 (23%) of Group Ia and all (100%) of Group Ib suffered from congestive heart failure. These findings suggested that reperfusion therapy improves the in-hospital survival rate in patients with cardiogenic shock. Therefore, reperfusion therapy may be recommended for cardiogenic shock secondary to acute myocardial infarction.     

Clinical correlates of coronary cineangiography in young males with myocardial infarction.

Thirty-eight men who suffered acute transmural myocardial infarction before age 40, and after recovery were New York Heart Association functional Class I or II, were studied by noninvasive means and by coronary angiography in order to determine whether these nonivasive studies could predict the presence of significant coronary artery disease remote from that felt to be responsible for the previous myocardial infarction. Patients were divided into two groups on the basis of the absence (Group I) or presence (Group II) of obstructive disease in a major coronary artery supplying myocardium remote from the prior myocardial infarction. There were 21 patients in Group I and 17 patients in Group II. They did not differ with respect to age, abnormalities of lipid or glucose metabolism, family history, history of hypertension or cigarette use, presence of obesity, or infarct localization. Ten of 17 patients in Group II had angina pectoris; only 3/21 patients in Group I had angina pectoris (p less than 0.01). All 12 patients tested in Group II had a positive maximal exercise tolerance test; only 1/17 patients tested in Group I was similarly positive (p less than 0.001). The absence of angina pectoris and the presence of a negative maximal exercise tolerance test is strong evidence against the pressure of significant CAD remote from that responsible for the prior myocardial infarction.