Improved coronary artery flow after coronary angioplasty in patients with unstable angina

Background : Coronary artery flow is impaired after myocardial infarction but there is limited information regarding coronary flow in unstable angina.
Aim : To assess baseline coronary artery flow and the effects of coronary angioplasty on coronary flow in patients with unstable angina.
Methods : Twenty-one patients with unstable angina with a culprit lesion suitable for coronary angioplasty were enrolled in the study. Coronary flow was assessed with the Thrombolysis In Myocardial Infarction (TIMI) grade and the Corrected TIMI Frame Count (CTFC) pre and post angioplasty.
Results : Baseline flow was impaired in the culprit artery compared to the non culprit artery (42.0±28.1 vs 25.3±7.0 frames, p <0.02). Pre angioplasty coronary flow was TIMI grade 2 in 52% and TIMI grade 3 in 48% of patients. Post angioplasty flow improved with TIMI grade 2 flow in 5% and TIMI grade 3 in 95%. After angioplasty coronary flow improved from 42.0±28.1 frames to 21.6±16.3 ( p =0.0001). The culprit coronary stenosis decreased from 74±9% pre angioplasty to 28±12% after intervention ( p =0.0001).
Conclusions : Angioplasty and stenting of the culprit vessel restores normal coronary flow in most patients with unstable angina. This suggests that impaired flow in unstable angina is predominantly related to the culprit lesion residual stenosis.     

Inflammatory cytokine imbalance after coronary angioplasty: links with coronary atherosclerosis

AIM: To investigate release of some inflammatory cytokines (Cys) after coronary angioplasty and its links with coronary atherosclerosis. METHODS: Twenty-seven consecutive subjects with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI) were enrolled in the study: serial blood samples were taken in order to evaluate plasma concentrations of Interleukin (IL)-2, IL-10, IL-18, TNFalpha, and IFNgamma just before PCI at 12 and 24 hours. Patients were then divided, considering balance between each inflammatory Cy and IL-10, an antiinflammatory Cy, into four groups, ranging from a prevalent antiinflammatory response (stable inflammatory Cy-increasing IL-10 values) to a marked inflammatory imbalance (increasing inflammatory Cy-stable IL-10 values). RESULTS: All Cys showed significant increases in plasma concentrations if compared with baseline values. Release curves were not significantly different when comparing subjects with ST-elevation myocardial infarction (STEMI) versus unstable angina-non-STEMI (UA-NSTEMI), diabetics versus controls. Subjects with marked inflammatory response showed a higher incidence of stenosis on left anterior descending (LAD) coronary artery (IL-2 chi(2) and IFNgamma P < 0.05); Cy release was higher in patients with multivessel coronary disease (IL-2 and IFNgamma, ANOVA P < 0.01). Correlations were also referable between Cys and myocardial enzyme release. Subjects treated with sirolimus-eluting stents (SES) showed significantly lower Cy periprocedure ratio if compared with those treated with bare metal stents. CONCLUSIONS :A significant Cy release is detectable after PCI: inflammatory response seems to correlate with both PCI due to plaque instabilization and coronary atherosclerosis. A blunted inflammatory response is detectable in subjects treated with SES.     

Higher recurrence rate after coronary angioplasty in unstable angina pectoris

PURPOSE: Recurrent stenosis after percutaneous transluminal coronary angioplasty (PTCA) is a significant problem, requiring repeat dilation in about one-third of all treated patients. Various clinical and procedure-related predictors have been proposed. Between 1983 and 1987, 257 patients underwent 322 procedures, where 380 stenoses were attempted. Indications were: stable angina pectoris 73%, unstable angina pectoris 22%, other indication 5%. The primary success rate was defined as a less than 50% remaining postprocedure stenosis. FINDINGS: Repeat angiograms were done for 88% of the initially successful cases, either six months after PTCA or if there was a clinical recurrence. Restenosis was defined as a recurrence of a more than 50% diameter stenosis. The restenosis rate was 33% and was significantly higher (p less than 0.05) for unstable (46%) than for stable angina pectoris (29%). There was a nonsignificant tendency to a higher restenosis rate in the left anterior descending artery than in the other coronary vessels. IMPLICATIONS: The increased restenosis rate seen after PTCA for unstable angina pectoris could be caused by a higher activity in systems affecting the proliferative processes in the smooth muscle cells of the arterial wall, which is thought to form the pathophysiologic basis for restenosis after PTCA.     

Percutaneous transluminal coronary angioplasty for patients with unstable angina pectoris.

Percutaneous transluminal coronary angioplasty (PTCA) was successful in 91% of 76 patients with unstable angina pectoris refractory to pharmacological treatment. However, the rate of acute occlusion and reocclusion was rather high (95). Restenosis developed in 56.5% of successful cases after initial PTCA, and 29 patients underwent 2nd, and nine 3rd PTCA. Most refractory unstable angina can be controlled by PTCA, which may require repeating in some patients.     

Transluminal angioplasty of the coronary vessels in patients with pluritruncular unstable angina

Between October, 1979 and August, 1987, 489 patients with multivessel coronary disease and unstable angina underwent transluminal angioplasty of coronary arteries with the following results: primary success in 90 p. 100 of the patients, emergency bypass surgery of occlusive dissection in 1.8 p. 100, myocardial infarction in 2.9 p. 100, death in 1.4 p. 100. These results were similar to those obtained in 369 patients with stable angina whose coronary vessels were dilated by the same group during the same period. The death rate was significantly higher in elderly people and in women. 398/489 patients were followed up for 2 to 45 months: 1.8 p. 100 died, 2 p. 100 developed myocardial infarction and 2.3 p. 100 underwent coronary bypass. 46 patients had repeat angioplasty for restenosis. After single or repeat angioplasty, 68 p. 100 of the primary success patients followed up were asymptomatic, and 73 p. 100 had lasting clinical improvement. Among 221 patients studied with different numbers of vessels treated, the degree of revascularization did not make any significant difference in the percentage of symptom-free patients. Data from the literature concerning the medical treatment of unstable angina indicate a high incidence of complications and a mediocre long-term functional benefit, while data concerning surgical treatment show a better long-term functional result. Compared with these two types of treatment, transluminal coronary angioplasty appears as a satisfactory method to treat unstable angina in patients with multivessel coronary disease.     

Decreased plasma soluble P-selectin level in coronary sinus after successful coronary angioplasty in patients with unstable angina]

P-selectin, an adhesion molecule, is involved in the alpha-granules of platelets with several factors such as platelet factor 4 (PF-4) and in Weibel-Parade bodies of endothelial cells with von Willebrand factor. The levels of the soluble form of P-selectin increase after angina episodes in patients with unstable angina, indicating that soluble P-selectin is associated with platelet activation and thrombogenesis in the coronary circulation. To evaluate the effect of successful coronary angioplasty on platelet activation or thrombogenesis in the coronary circulation, plasma soluble P-selectin, PF-4 and von Willebrand factor antigen levels were measured in blood obtained from the coronary sinus before and after successful coronary angioplasty in 15 patients with unstable angina. Fifteen patients with normal coronary angiograms served as controls. Plasma P-selectin, PF-4 and von Willebrand factor antigen levels were determined by sandwich enzyme-linked immunosorbent assays. Increased plasma soluble P-selectin (159.7 +/- 74.5 vs 78.7 +/- 26.4 ng/ml, p < 0.01) and PF-4 (456.5 +/- 87.0 vs 118.7 +/- 62.3 IU/ml, p < 0.01) levels were found in patients with unstable angina compared with those in controls, and were significantly decreased after angioplasty (147.8 +/- 69.6 ng/ml, p < 0.05; 401.6 +/- 108.5 IU/ml, p < 0.05), whereas von Willebrand factor antigen was unchanged. The ratio of plasma soluble P-selectin levels after and before angioplasty correlated with the corresponding ratio of plasma PF-4 levels (r = 0.53, p < 0.05), but not with the ratio of plasma von Willebrand factor antigen levels. The plasma levels of soluble P-selectin, which increase in the coronary circulation in patients with unstable angina, decrease after successful coronary angioplasty. Such data indicate that soluble P-selectin is associated with platelet activation and the therapeutical procedure improves the thrombogenic state in the coronary circulation.     

Long-term outcome in patients with unstable angina treated by coronary balloon angioplasty

Comparison of balloon angioplasty results in 472 patients with stable angina (SA) and 158 patients with unstable angina (UA) in 5-year follow-up is reported. Clinical success rate did not differ significantly, while periprocedural complications rate was higher in UA group (22.3 vs. 11.1%, P<0.001). During follow-up UA patients demonstrated higher: restenosis rate (48.5 vs. 30.4%, P<0.001), incidence of myocardial infarction (8.8 vs. 3.0%, P=0.004), although cardiac mortality did not differ significantly (2.2 vs. 1.6%). Reintervention rate in patients with unstable angina resultant from restenosis or significant artherosclerosis progression in coronary vessels, or originating from both of them, was also higher (53.7 vs. 34.1%, P<0.001). Event-free survival was significantly lower in UA patients (43.4 vs. 61.3%, P=0.02). The uni- and multivariate analysis proved that unstable angina was an independent risk factor in restenosis, re-intervention and cardiac events rate, despite perceptible differences in the baseline characteristics. Sub-group analysis of UA patients according to Braunwald classification revealed lower success rate and higher incidence of myocardial infarction during follow-up in post-infarction angina (class C), whereas new onset, no-rest angina (class I) had higher event-free survival in comparison with rest angina (classes II and III). CONCLUSIONS: UA patients treated by balloon angioplasty had higher periprocedural complications rate, as well as restenosis and re-intervention rate. Despite higher cardiovascular events rate during 5-year follow-up in UA group, survival rate in both groups was high and cardiac mortality did not differ significantly. Unstable angina constitutes a strong independent risk factor in adverse long-term outcome.     

Percutaneous transluminal coronary angioplasty in unstable angina: comparison with stable angina

Percutaneous transluminal coronary angioplasty was performed in 25 patients with unstable angina and in a similar group of 25 patients with stable angina. The frequency of single, double, and triple vessel disease was identical in each group. Technical success was achieved in 22 (81%) out of 27 attempts in those with unstable angina and in 14 (52%) out of 27 attempts in those with stable angina. Vessel occlusion occurred in nine patients, necessitating emergency bypass surgery in four. There was evidence of myocardial infarction in three patients in each group and one patient in the unstable group subsequently died. Twenty eight of 32 successfully treated patients were followed up by means of repeat coronary arteriography, exercise electrocardiography, and clinical assessment after a mean (SD) interval of 14 (7) months. There was angiographic evidence of restenosis in 32% (seven of 22) of lesions in the unstable group and 44% (four of nine) of lesions in the stable group. There were no late infarctions or deaths during the follow up period. These results support the growing evidence that angioplasty can be carried out safely and effectively in patients with unstable angina.     

Th2-dependent cytokine release in patients treated with coronary angioplasty

AIM: The aim of this study is to investigate the T helper (Th)2-dependent release of interleukin(IL)-4 and IL-13 in patients with unstable angina treated with coronary angioplasty (PCI). METHODS: This study involved 48 consecutive patients with unstable angina who underwent PCI. Blood samples were taken before and 48 h after PCI to evaluate serum IL-4 and IL-13 levels. Coronary atherosclerosis was assessed in terms of the severity of the treated lesions and the presence of multivessel disease, and compared with IL release. RESULTS: Before and after PCI, serum IL-4 levels were, respectively, 53.1+/-110.7 and 35.1+/-16.9 pg/ml (P not significant), and serum IL-13 levels 6.7+/-3.7 and 6.0+/-2.9 pg/ml (P<0.05). A correlation was present between the severity of the treated coronary lesions and serum IL-13 levels (r 0.36; P<0.05). The patients with multivessel coronary artery disease had a higher periprocedure ratio of IL-4 than those with single-vessel coronary artery disease (1.46+/-0.76 vs. 0.89+/-0.34, P<0.001). CONCLUSION: A significant decrease was observed in Th2-dependent IL concentrations after PCI; increased Th2-dependent IL levels before PCI seem to correlate with the severity of coronary atherosclerosis.     

Percutaneous transluminal coronary angioplasty for unstable angina

Coronary angioplasty is an effective treatment for patients with angina at rest, either refractory or initially stabilized but returning despite pharmacologic treatment, and with early postinfarction angina. The procedure has a high initial success rate, but there is an increased risk of major complications resulting from a higher incidence of acute closure, which may be related to preexisting thrombus. Resolution of this problem may be achieved by the use of more potent antiplatelet treatment, pretreatment with thrombolytic agents, or treatment that can be applied locally (e.g., laser energy, atherectomy) at the site of the unstable plaque. Results in this study have been obtained from selected groups of patients: those with predominantly single-vessel disease and well-preserved left ventricular function. It remains to be determined whether the same benefits can be achieved in patients with multivessel disease or in those who have severely reduced left ventricular function.     

Rapid progression of coronary stenosis in patients with unstable angina pectoris selected for coronary angioplasty

We studied the course of coronary stenosis in the first 62 patients (45 men and 17 women) referred for coronary angioplasty in the interval between the diagnostic arteriogram and the preangioplasty coronary arteriogram. In 42 patients, the stenosis was in the left anterior descending artery, in 17 patients in the right coronary artery, in one patient in the left circumflex, and in two patients in the vein graft. Twenty-six patients had stable angina pectoris, 34 patients had unstable angina, and two patients had no angina. The coronary stenosis did not change significantly in any patient with stable angina. Conversely, the stenosis progressed in nine of the 34 patients with unstable angina (26.5%). In five of the nine patients with progression, total occlusion ensued. In four of the five patients total occlusion occurred within the 45-day interval between the diagnostic and the preangioplasty coronary arteriogram. New or increased preexisting collaterals to the occluded vessel developed in all five patients with total occlusion. None of these patients had clinical or electrocardiographic evidence of myocardial infarction or significant changes in ventricular function. Angiographic evidence of thrombi was seen in ten of 34 patients with unstable angina (29%). We concluded that coronary artery stenosis in patients with unstable angina pectoris is progressive in a significant number after a short time. The cause of progression of coronary stenosis in patients with unstable angina is unknown. Since in a significant number of patients with unstable angina coronary thrombus was suggested by angiography, coronary thrombosis superimposed on coronary atherosclerosis may play a significant role in this syndrome. Further prospective studies are needed, including repeat coronary arteriograms to evaluate the cause of unstable angina, define the role of coronary thrombosis, and evaluate the cause of unstable angina, define the role of coronary thrombosis, and evaluate the efficacy of more aggressive treatment adding the use of prolong heparin and antiplatelet agents prior to coronary angioplasty.     

Percutaneous coronary angioplasty in stable and unstable angina

This article reviews the status of angioplasty in stable and unstable angina. It also addresses some of the major limitations of angioplasty, with comments and future directions.     

不稳定型与稳定型心绞痛冠状动脉成形术的比较

目的　比较不稳定型心绞痛 (UA)与稳定型心绞痛 (SA)患者接受冠状动脉成形术 (PTCA)的疗效。方法　行PTCA的心绞痛患者 2 0 4例 ,分组比较UA与SA患者冠状动脉造影结果及PTCA术的近期和中期疗效。结果　①分组 :2 0 4例病人中 ,UA组 112例 (5 5 % ) ,SA组 92例 (45 % )。其中UA组心绞痛分级高于SA组 (P <0 0 5 )。②UA组复杂病变血管支数为 74(3 3 % ) ,SA组复杂病变血管 43支(2 0 % ) ,两组比较差异显著 (P <0 0 1) ;而SA组多支血管病变的发生较UA组为多 (P <0 0 5 )。③支架植入情况 :UA组有 114支血管共植入支架 143枚 ,占病变血管数的 5 1% ;SA组 5 4支血管共 67枚 ,占 2 5 % ,两组比较差异显著 (P <0 0 1) ,共 15 6例病人接受支架术。④术后 3 0d内无重大并发症发生 ,UA组复发胸痛较SA组高 (9%vs 3 % ,P <0 0 5 )。⑤随访 3～ 9个月 ,发生心肌梗死 3例 ,其中UA患者2例。复发胸痛两组分别为 12例和 16例 ,占 13 %和 14% ;临床再狭窄发生率分别为 2 0 %和 2 2 % ,均无显著差别。结论　PTCA/支架术对不稳定型与稳定型心绞痛患者的疗效相似 ,即刻成功率高 ,中期疗效满意     

Percutaneous transluminal coronary angioplasty in unstable angina: comparison with stable angina.

Percutaneous transluminal coronary angioplasty was performed in 25 patients with unstable angina and in a similar group of 25 patients with stable angina. The frequency of single, double, and triple vessel disease was identical in each group. Technical success was achieved in 22 (81%) out of 27 attempts in those with unstable angina and in 14 (52%) out of 27 attempts in those with stable angina. Vessel occlusion occurred in nine patients, necessitating emergency bypass surgery in four. There was evidence of myocardial infarction in three patients in each group and one patient in the unstable group subsequently died. Twenty eight of 32 successfully treated patients were followed up by means of repeat coronary arteriography, exercise electrocardiography, and clinical assessment after a mean (SD) interval of 14 (7) months. There was angiographic evidence of restenosis in 32% (seven of 22) of lesions in the unstable group and 44% (four of nine) of lesions in the stable group. There were no late infarctions or deaths during the follow up period. These results support the growing evidence that angioplasty can be carried out safely and effectively in patients with unstable angina.     

Clinical success after percutaneous transluminal coronary angioplasty failure for unstable angina

We report a patient who had an asymptomatic total occlusion of a left anterior descending coronary artery after PTCA for unstable angina. A clinical success with a negative maximal exercise test and absence of symptoms after PTCA can not be presumed to correlate with coronary patency.     

Coronary angioplasty for medically refractory unstable angina in patients with prior coronary bypass surgery

Percutaneous transluminal coronary angioplasty (PTCA) has been applied with good results to selected patients with unstable angina and to selected patients who have had prior bypass surgery. The population with prior bypass and unstable angina has not been specifically evaluated. This report reviews the results of angioplasty of 45 vessels in 34 patients with medically refractory unstable angina and at least one prior bypass heart surgery. Of these 34 patients, 32 had rest angina; 14 had resting electrocardiographic changes, all 34 were on aspirin 325 mg QD, 31 were on a calcium blocker, 22 were on a beta blocker, 9 were on intravenous nitroglycerin, and 5 required intraaortic balloon counterpulsation for temporary stabilization. Angioplasty of a vein graft was attempted in 17 patients; the left internal mammary was attempted in 4 patients; 24 native coronary arteries in 15 patients were attempted; 3 of the native arteries were protected left main arteries. Of the LIMA angioplasties, 3 were successful; in the 1 unsuccessful case, the occluded anterior descending artery was opened. Of the 17 vein grafts, 16 were successful: 1 had an acute occlusive syndrome and went to surgery with a balloon pump and bail out catheter; his recovery was uneventful. Of the 24 native artery angioplasties, 22 were successful: one patient was technically unsuccessful in the only vessel attempted; he went to semiemergent surgery and recovered uneventfully. In the other, a right coronary lesion was successfully dilated, but an occluded anterior descending artery was not opened. There were no deaths or in-hospital myocardial infarctions.(ABSTRACT TRUNCATED AT 250 WORDS)     

不稳定型心绞痛患者冠状动脉局部炎性细胞因子的变化及临床意义

目的　研究不稳定型心绞痛 (USA)时炎性细胞因子在冠状动脉局部的变化及其临床意义。方法　测定 USA、稳定性心绞痛 (SA)及正常对照组患者右心房、外周静脉中的血浆血小板 α-颗粒膜蛋白 14 0 (GMP-14 0 )含量及中性粒细胞 (PMN)活性。结果　 U SA组冠状动脉局部表现为血小板高度活化、PMN活性明显增强 ,与外周血相比 ,GMP- 14 0含量、PMN活性均存在显著差异 (P <0 .0 5 ,P <0 .0 1) ;与 SA组及正常对照组比较 ,U SA组冠状动脉局部及外周血炎性细胞因子活性均明显增强。结论　 USA患者的冠状动脉局部存在急性炎症过程 ,炎症反应激活可诱导血管收缩、血栓形成 ,加重心肌损害     

Chronology and incidence of restenosis after coronary angioplasty. Comparison of patients with stable and unstable angina

The aim of this prospective study was to compare the incidence of restenosis after percutaneous transluminal coronary angioplasty (PTCA) in patients with stable and unstable angina before the procedure. Between January 1984 and February 1986, 344 patients with stable angina and 228 patients with unstable angina underwent PTCA. The primary success rate was 86.3 per cent in patients with stable angina (297 patients) and 87.7 per cent in patients with unstable angina (200 patients). The patients were recalled for systematic control coronary arteriography at 30, 60, 90, 120 or 150 days, and was obtained in 83.8 per cent of patients with stable angina and in 86 per cent of patients with unstable angina. The degree of stenosis before and the angiographic changes after PTCA and at control coronary arteriography were evaluated by a computer-assisted automatic contour detection system. The three criteria of restenosis were: 1) over 50 per cent loss of the benefit of PTCA, 2) residual post-PTCA stenosis increasing from less than 50 per cent to more than 50 per cent at control arteriography, 3) a decrease in the minimum intraluminal diameter of at least 0.72 mm with respect to the immediate post-PTCA result. A comparison between the two groups of patients showed that the average age was slightly greater in patients with unstable angina (56 +/- 9 years vs 58 +/- 9 years, p = 0.047). Apart from this difference, the two groups were comparable with regards to the average number of lesions dilated per patient, the date of control arteriography, the severity of the coronary artery disease and previous bypass surgery, angioplasty and infarction.(ABSTRACT TRUNCATED AT 250 WORDS)