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 coronary excimer laser angioplasty in patients with stable and unstable angina pectoris. Acute results and incidence of restenosis during 6-month follow-up

A clinical study was conducted to evaluate the efficacy and safety of percutaneous coronary excimer laser angioplasty in 60 patients with coronary artery disease. Forty-nine patients had stable exertional angina, and 11 patients had unstable angina despite medical therapy. A novel 1.4-mm diameter catheter with 20 quartz fibers of 100-microns diameter each arranged concentrically around a central lumen suitable for a 0.014-in. flexible guide wire was coupled to an excimer laser. A commercial excimer laser emitting energy at a wavelength of 308 nm with a pulse duration of 60 nsec was used. The laser was operated at 20 Hz. Mean energy transmission was 30 +/- 5 mJ/mm2. In five of the 60 patients, laser angioplasty was not attempted. In 23 patients with laser ablation alone, percent stenosis decreased from 76 +/- 14% before to 27 +/- 17% after ablation and was 34 +/- 15% at the early follow-up angiogram. In 32 patients, additional balloon angioplasty was performed because of vessel closure after laser ablation in 11 and an insufficient qualitative result in 21 patients. Of the 11 patients with unstable angina, one patient died due to vessel closure 3 hours after intervention, and two patients developed a myocardial infarction. In 22 of 47 patients with late follow-up angiography, restenosis within the 6-month follow-up period occurred. Rate of restenosis was higher in patients treated with laser ablation and balloon angioplasty (16 of 28) than in patients treated with laser ablation alone (six of 19). These results suggest that coronary excimer laser angioplasty for ablation of obstructive lesions is feasible and safe in patients with stable angina. However, development of new catheter systems is necessary for an improved success rate.     

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.     

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.     

Aggressive clinical pattern of angina at restenosis following coronary angioplasty in unstable angina.

The frequency, clinical pattern, and timing of recurrent angina following successful single-lesion percutaneous transluminal coronary angioplasty (PTCA) was assessed in a consecutive group of 104 patients with stable angina and in 85 with unstable angina. In addition, the relationship between lesion morphology and angiographic features and the pattern of recurrent angina was determined. Restenosis, defined as recurrence of symptoms with > 50% stenosis at the site of PTCA, occurred in 25 (24%) of the stable group and in 23 (27%) of the unstable group (p = NS). The pattern of angina at repeat presentation was aggressive in nature in 8% of the stable group and in 48% of the unstable group (p = 0.002). The time interval between the recurrence of symptoms and repeat coronary angiogram or PTCA was longer in the nonaggressive group than in the aggressive group, 16 +/- 12.1 and 5 +/- 6.8 weeks, respectively (p < 0.003). The key factors predicting the recurrent angina pattern identified by multiple logistic regression analysis were the angina status pre-PTCA (p = 0.001) and the presence of double-vessel disease (p = 0.01). An aggressive pattern of angina at the time of restenosis is frequent in patients with unstable angina at the time of PTCA, and close post-PTCA surveillance is necessary in these patients.     

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.     

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.     

Inflammatory cytokine release in patients with unstable angina after coronary angioplasty

The aim of the present study was to investigate inflammatory cytokine release and the interaction with platelets in patients with unstable angina (UA) after coronary angioplasty. In 50 patients with stable angina (SA) and 58 patients with UA, serial venous blood samples were obtained immediately before, and 30 minutes, 4, 12, 24, 48 and 72 hours, and 7 days after coronary angioplasty. Plasma concentrations of IL-8 and vWF were determined by immunoassay, while the expression of CD11 b/CD18 on monocytes and the expression of CD41 on platelets were assessed by flow cytometry. Differences in the baseline plasma concentrations of IL-8, vWF and CD11b/CD18, CD41 were found in the UA and SA groups before angioplasty (101.1 +/- 31.28 pg/mL to 55.8 +/- 17.24 pg/mL, 137.67 +/- 38.14% to 107.40 +/- 28.67% and 318.67 +/- 36.85 MFI to 240.72 +/- 28.43 MFI, 147.5 +/- 23.18 MFI to 104.43 +/- 26.68 MFI all p < 0.05). The peak plasma levels of IL-8 (172.24 +/- 37.82 pg/mL at 12 hours) and vWF (256 +/- 42.32% at 4 hours) significantly increased after coronary angioplasty (both p < 0.01), and were associated with significant time course increases in surface expression of CD11b/CD18 (p < 0.01) and CD41 (p < 0.01). The levels of plasma IL-8 and vWF were significantly higher pre- and post-procedure in UA patients with lesion type C compared to types A or B (p < 0.05), but there were no differences for pre-procedure in the SA group patients with different lesion types (p > 0.05). There were significant correlations between plasma IL-8 and monocyte CD11b/CD18, vWF and CD41 in the UA group (r = 0.5248, r = 0.6240 both p < 0.01, respectively). The findings demonstrate increases in plasma IL-8 and CD11b/CD18 as inflammatory mediators, vWF and CD41 as the abnormal coagulation activity may therefore yield a rationale for pharmacological anticytokines in patients with UA after coronary angioplasty.     

Identifying patients at high risk for restenosis after percutaneous transluminal coronary angioplasty for unstable angina pectoris

To study the determinants of late restenosis after percutaneous transluminal coronary angioplasty (PTCA) performed in patients with unstable angina pectoris, a prospective study was undertaken in 90 patients. Primary PTCA success was achieved in 84 (93%) patients, dilating 116 of 118 coronary narrowings (1.4/patient), while major complications during PTCA occurred in only 1 patient (1 death). Eighty-two patients (114 dilated arteries) were followed for 25 +/- 11 months: 68 (83%) were in New York Heart Association functional class I or II, 11 (13%) in class III, and there were 3 deaths. Late restenosis was found in 16 (25%) of 65 lesions (29% of 49 patients) studied by angiography 9 +/- 7 months after PTCA. Restenosis was more frequent in left anterior descending coronary artery lesions (p = 0.07) and in those which at the time of PTCA had multiple irregularities (67 vs 14%, odds ratio 12.5, p = 0.002), decreased coronary perfusion (Thrombolysis in Myocardial Infarction grade less than 3) (50 vs 15%, odds ratio 5.7, p = 0.02) or intraluminal thrombus (67 vs 19%, odds ratio 8.7, difference not significant). Multiple irregularities (p = 0.003) and decreased flow (p = 0.02) remained independent predictors of restenosis (goodness of fit 0.88) after adjustment for 12 pre- and peri-PTCA clinical and angiographic variables by logistic regression analysis. These data underline the feasibility of early revascularization by PTCA in patients with unstable angina pectoris. Careful follow-up should be instituted in patients with multiple irregular lesions, decreased coronary perfusion or intraluminal thrombus at the time of PTCA. In such patients, late restenosis may be the rule rather than the exception.     

Pulsatility of ascending aorta and restenosis after coronary angioplasty in patients >60 years of age with stable angina pectoris.

A recent study has demonstrated that the pulsatility of the ascending aorta is a strong predictive factor for restenosis after coronary angioplasty. However, whether the pulsatility of the ascending aorta is still a significant predictor for restenosis in elderly patients with a stiffer aorta is unknown. We investigated the relation between arterial pulsatility in the ascending aorta and restenosis after coronary angioplasty in patients aged > 60 years. Eighty-seven consecutive patients (80 men, aged 72.5 +/- 5.1 years) with stable angina were included. Before angioplasty, the arterial systolic, diastolic, and mean pressure waveforms of the ascending aorta were measured. We used fractional pulse pressure (PPf, the ratio of pulse pressure to mean pressure) and pulsatility index (PI, the ratio of pulse pressure to diastolic pressure) to estimate the pulsatility of the ascending aorta. Angiographic restenosis occurred in 39 patients. Pulse pressure, PPf, and PI were significantly higher in patients with restenosis after coronary angioplasty (restenosis vs without restenosis: pulse pressure, 77.6 +/- 12.2 vs 66.1 +/- 15.4 mm Hg [p < 0.001]; PPf, 0.80 +/- 0.09 vs 0.69 +/- 0.11 [p < 0.001]; PI, 1.19 +/- 0.20 vs 0.98 +/- 0.21 [p < 0.001]). After multivariate stepwise adjustment of risk factors of restenosis and using receiver-operating characteristic analysis, the odds ratio (OR) of restenosis was: pulse pressure > 66 mm Hg, OR 5.88 (95% confidence interval [CI] 2.17 to 15.93); PPf > 0.72, OR 13.71 (95% CI 4.81 to 39.05); PI > 1.06, OR 13.56 (95% CI 4.67 to 39.38). Moreover, among patients aged > 70 years (n = 60), the predictive values of PPf and PI were even higher than those in patients aged < or = 70 years (n = 27). Thus, in elderly patients with stable angina, the pulsatility of the ascending aorta is a powerful predictor of restenosis after coronary angioplasty.     

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.     

Effects of ketanserin on epicardial coronary arteries after coronary angioplasty in patients with stable angina

Previous studies have demonstrated the development of vasoconstrictionimmediately after percutanous coronary angioplasty (PTCA), distalto the dilated stenosis, presumably resulting from endothelialinjury. We have investigated the role of 5-HT₂ receptors inmediating vasomotor changes in proximal and distal coronarysegments and coronary stenoses, immediately after successfulPTCA in patients with chronic stable angina. We compared theeffects of the intracoronary infusion of 1 mg ketanserin (5-HT₂receptor antagonist) on proximal and distal coronary arterialsegments immediately after PTCA in both vessels subjected toPTCA and control vessels. Coronary diameters, before and afterangioplasty and after ketanserin administration, of proximaland distal segments and coronary stenoses were measured by computerizedquantitative coronary angiography (CAAS system) in 12 patients(10 male, two female; mean age 54 ±6 years) with stableangina subjected to PTCA. After coronary angioplasty, vasoconstrictionwas observed in the segment distal to the dilated stenosis butnot in the distal segments of control vessels ( – 0.12± 0.04 and – 0.02 ± 0.02 mm respectively,P<0.05). After ketanserin infusion significant dilatationwas found in the distal segments of both PTCA vessels and controlvessels, but the dilatation was greater in the PTCA vessels(P<0.05). No significant changes were found in the proximalsegments of either PTCA or control vessels, or at the PTCA site.In conclusion, the vasoconstriction distal to the site of PTCAis mediated, at least in part, via 5-HT₂ receptors.     

Repeat percutaneous coronary angioplasty; clinical and angiographic follow-up in patients with stable or unstable angina pectoris

This study analyses the immediate outcome and the risk of recurrentrestenosis in patients who, at the time of repeat coronary angioplastyfor a first restenosis, had unstable (n = 50), 19%) or stable(n = 218, 81%) angina. Successful angioplasty was accomplishedin 250 (93%) patients, 222 (89%) of whom hadfollow-up angiography.Mean time from initial to repeat angioplasty was shorter (P= 0.0002) and angiographic evidence of thrombus was commoner(P = 0.0001) in the unstable group. Major complications (coronaryartery bypass grafting or myocardial infarction) were morefrequent(P <0.01) in the unstable group (6% vs 0.5%); no procedure-relateddeaths occurred. The angiographic rate of restenosis was significantlyhigher in the unstable group (61% vs 43%, P <0.05). Despitethis high rate of recurrent restenosis, most of the patientsin both groups were either asymptomatic or had atypical chestpain at follow-up. Repeat coronary angioplasty, in patients with unstable angina,has a high primary success rate but a higher risk of acute complicationsthan in patients with stable angina. The angiographic rate ofrestenosis was significantly higher in unstable than in stablepatients, however, the clinical status of most patients wasimproved at follow-up.     

不稳定性心绞痛患者经皮冠状动脉介入治疗后支架内再狭窄影响因素分析

目的探讨不稳定性心绞痛(UAP)患者PCI术后支架内再狭窄的术前影响因素。方法选择成功置入雷帕霉素药物涂层支架的UAP患者157例,根据冠状动脉造影结果分为再狭窄组16例和无狭窄组141例,回顾性分析2组性别、年龄、术前收缩压、糖尿病、TC、吸烟、体重指数、体力活动、高敏C反应蛋白(hs-CRP)水平和汉密尔顿抑郁量表(HAMD)评分,COX回归模型对有差异的因素进行分析。结果与无狭窄组比较,再狭窄组患者hs-CRP和HAMD评分明显升高(P0.01);伴有抑郁症状患者hs CRP明显高于无抑郁症患者(P=0.002)。校正UAP患者术前收缩压、吸烟、糖尿病、体重指数影响后,术前hs-CRP(OR=9.205,95% CI:2.986～28.378)、TC(OR=3.762,95% CI:1.348～10.497)、HAMD评分(OR=1.376,95% CI:1.098～1.724)与术后支架内再狭窄相关。结论 PCI术前hs-CRP、TC水平和抑郁症状是UAP患者术后支架内再狭窄的独立危险因素。     

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.     

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.     

Results of using percutaneous transluminal coronary angioplasty in patients with stable and unstable angina pectoris and acute myocardial infarct

Transcutaneous transluminal coronary angioplastics (TTCA) was performed in 28 coronary heart disease patients (8 patients had stable and 5 others labile angina, 15 presented acute myocardial infarction, AMI). The patients with AMI received intracoronary thrombolytic treatment prior to TTCA. Successful dilatation was performed in one patient with narrowing of the main trunk of the left coronary artery, in 14 of 21 patients with the stenosis of the anterior interventricular branch and in 5 of 6 patients with the narrowing of the right coronary artery. In three cases TTCA was carried out in the presence of the occluded coronary artery, with two patients benefiting from the operation. In 5 patients with AMI in whom an attempt to dilate the lumen of the coronary artery was unsuccessful, emergency surgery for aorto-coronary shunting was conducted. This operation was also performed in the planned order in 2 angina patients. In 7 patients the failure of TTCA was explained by the impossibility to pass the dilatary sound through the stenosis of the coronary artery and in 1 case by the failure to enter the ostium of the left coronary artery with the guiding catheter.