Immediate and long-term results of percutaneous coronary angioplasty in patients aged 70 years or older

Percutaneous coronary angioplasty (PTCA) nowadays appears asan attractive alternative to coronary artery by-pass graftingnot only in young adults, but also in elderly patients. Theaim of this study was to investigate the primary success, complicationsand long-term efficacy of PTCA in a consecutive series of 63patients aged 70 years or over. Results are analysed in comparisonto a younger group of423 subjects who were submitted to PTCAduring the same period of time. In the older group, PTCA wasapplied to 108 lesions. The angiographic success rate was 88%.Primary success was 87%, with a majority (91%) of complete revascularization.Failure of the procedure was recorded in eight patients (13%).Complications of PTCA were observed in three patients, (amongthese: one death). The outcome was excellent: out of 55 patientswith successful angioplasty, 52 (94.6%) were asymptomatic atthe time of hospital discharge. At follow-up (close to one year),84.6% of the patients remained asymptomatic. The comparisonwith the younger group of patients showed no difference in termsof primary success, failure rate or incidence of complications.We therefore conclude that PTCA can be performed with safetyand efficiency in patients aged 70 years or over.     

Outcome following coronary balloon angioplasty in young adults aged 35 years or less

The natural history of symptomatic young patients with coronary artery disease is often far from benign. Follow-up studies of young patients who have undergone coronary bypass graft surgery show frequent recurrence of symptoms and need for reoperation. Prompted by these considerations, we reviewed the records of 23 consecutive patients aged less than or equal to 35 years with symptomatic coronary artery disease, who underwent coronary balloon angioplasty at our center between August, 1984 and November, 1989. Mean patient age was 32 (3) (mean [SD]) years. Acute myocardial infarction was the first symptom of coronary artery disease in 7 (30%) of the 23 patients. At the time of angioplasty, 17 (74%) patients, had functional Class 3 or 4 anginal symptoms. Eight (35%) had multivessel coronary artery disease (stenoses greater than or equal to 70% in two or more major coronary arteries). Overall, a total of 36 critical coronary lesions were identified in 32 vessels of the 23 patients (mean of 1.6 lesions and 1.4 diseased vessels per patient). At angioplasty, dilatation of 31 lesions in 27 vessels was attempted. Multilesion angioplasty was attempted in 7 (30%) patients. Successful dilatation was achieved in 29 of the 31 (94%) lesions, and 25 of the 27 (93%) vessels. Primary clinical success (successful dilatation of all attempted lesions without any complications) was achieved in 21 of 23 (91%) patients. Three of the 21 patients with successful initial angioplasty had repeat angioplasty for restenosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary angioplasty in patients aged 70 and over. Immediate results and later outcome

One hundred and ninety one consecutive patients over 70 years of age (127 men and 64 women, average age 75.6 years) underwent percutaneous transluminal coronary angioplasty (PTCA) between January 1986 and February 1989. One hundred and sixty patients had severe angina (20 Class III and 140 Class IV), 72 patients had previous myocardial infarction, 36 of which were recent (less than 1 month), and 6 patients had previously undergone coronary bypass surgery. The coronary lesions affected one vessel in 67 patients and more than one vessel in 124 patients. The left ventricular ejection fraction was less than 50% in 15 patients. Angioplasty was attempted on 245 lesions (228 stenoses and 17 occlusions): 1 lesion in 141 patients, 2 lesions in 46 patients, 3 lesions in 4 patients, with a primary success rate of 81% in stenotic and 41% in occluded arteries. There were 9 deaths (4.7%) 6 of which occurred in patients with multivessel disease and unstable angina; there were 6 Q-wave infarctions (3.1%), 8 non Q-wave infarctions (4.2%) and 3 emergency coronary bypass operations (1.6%). The first 123 patients of this series were followed up for an average of 18.8 months (7 to 37 months). Follow-up of the 100 patients successfully dilated (4 lost to follow-up) showed that 55 remained improved (53 asymptomatic), 25 had recurrent angina after the initial improvement due to restenosis in 19, progression of coronary athero-sclerosis in 3, restenosis and an evolution of coronary atherosclerosis in 1 and a lesion which had been neglected in 2 cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous transluminal coronary angioplasty in patients aged 70 years and older: immediate and long-term results.

We analyzed all coronary angioplasty procedures performed in patients aged greater than 70 yr since 1987. There were a total of 92 patients with a mean age of 74 +/- 4 yr (range 70-82). The clinical diagnosis was unstable angina in 79%. Single-vessel disease was present in 41%, double-vessel in 29% and triple-vessel in 30% of patients. A left ventricular ejection fraction of less than 40% was present in 18 patients. Angioplasty was attempted on one vessel in 52 patients (56%), on two vessels in 29 patients (32%) and in three vessels in 10 patients (11%). Angiographic success was achieved in 96% of stenoses and in 53% of chronic total occlusions attempted. Complete revascularization was achieved in 56% of patients. Complications included three patients (3.2%) who underwent emergency coronary artery bypass grafting, 1 patient (1.1%) who sustained a myocardial infarction and 5 patients (5.4%) who died. During hospitalization, which averaged 3 +/- 2 days, 1 patients sustained reversible renal failure and 5 patients required blood transfusion for a large groin hematoma. Clinical success at discharge was 83%. At a mean follow-up of 13 months (range 3-45 months), symptomatic improvement was observed in 59 of the 76 patients who had achieved clinical success, with 42 of these patients (55%) being asymptomatic. The following clinical events occurred: myocardial infarction in 1 patient, new percutaneous transluminal coronary angioplasty in 9 and 3 patients died of cardiac reasons.(ABSTRACT TRUNCATED AT 250 WORDS)     

Results of coronary angioplasty in patients aged 75 years and older.

We studied a group of 47 patients greater than or equal to 75 years old. The mean age was 77 +/- 1.5 years and there were 28 (60 percent) male patients. Multivessel disease was present in 72 percent. Angioplasty was successful in 93 percent of 90 stenoses and in 30 percent of ten total occlusions. Single vessel angioplasty was done in 53 percent of patients, double vessel in 28 percent and triple vessel in 19 percent. Incomplete or absent revascularization was present in 47 percent and 9 percent, respectively. Primary clinical success was accomplished in all patients with single vessel disease; in 85 percent of patients with double vessel disease, and in only 52 percent of patients with triple vessel disease. Complications were highest in patients with triple vessel disease: 14 percent mortality and 5 percent emergency CABG. The follow-up at one year showed 91 percent survival. The PTCA is a valid alternative method of revascularization in elderly patients with single and double vessel disease. The results in triple vessel disease are less encouraging.     

Evaluation of coronary angioplasty with autoperfusion catheter in patients aged 65 years or older

In the period July 1991-December 1994, 120 consecutive patients underwent percutaneous transluminal coronary angioplasty (PTCA); 79% were males (mean age 70.0 +/- 5.4 years) and 21% females (mean age: 71.0 +/- 6.8 years). Patients have been divided into two groups: (i) Group A (67 patients), undergone PTCA with prolonged insufflations (longer than 20 minutes) with autoperfusion catheters (RX perfusion); and (ii) Group B (53 subjects) has been treated without autoperfusion catheters. The results show that maintenance of myocardial perfusion during angioplasty permits to increase the duration of inflations and to reduce the frequency and the extension of myocardial damages, both transmural and subendocardial. Therefore, the use of autoperfusion catheter can be recommended as a method of choice in selected lesions such as proximal traits of the left anterior descending coronary artery and the circumflex, ostial lesions of anterior descending artery, circumflex, of the right coronary artery or in PTCA of high risk in vessels with a diameter larger than 2.5 mm.     

Emergency coronary surgery after transluminal angioplasty. Immediate results and long-term outcome of 100 operations]

The increasing application of percutaneous transluminal coronary angioplasty (PTCA) requires evaluation of emergency coronary artery surgery for complications of this procedure. In a consecutive series of 2,576 angioplasties performed between April 1980 and January 1990, 100 patients (82 men and 18 women, average age 54 +/- 10 years, 3.9%) underwent emergency coronary artery surgery because of complications. The artery involved was the left anterior descending artery in 81% of cases. The causal lesion was a dissection and/or thrombus in 95% of cases; 85% of patients were referred for surgery with acute myocardial infarction. The average delay before surgery was 110 +/- 15 minutes (interval between coronary occlusion and starting cardiopulmonary bypass) and 155 coronary grafts were implanted (1.5 per patient). The hospital mortality was 19%; the infarction rate was 57%. The left ventricular ejection fraction decreased from 63 +/- 10% (preoperatively) to 52 +/- 9% (postoperatively), p less than 0.001. Hospital mortality was significantly related to three factors, old age, unstable angina before PTCA, and cardiogenic shock or the necessity for external cardiac massage. In the subgroup of patients developing cardiogenic shock (n = 7) or requiring external cardiac massage during transfer to the operating theatre (n = 16) the mortality was 44%. Among the 81 survivors, the global 7 year survival rate was 96% (Kaplan-Meier) with 3 cardiac deaths, 2 other patients developing myocardial infarction and 4 undergoing repeat angioplasty. After an average follow-up of 55 +/- 38 months, 80% of patients are asymptomatic, 34% have no antianginal drugs and 73% of those who were previously employed have returned to work.(ABSTRACT TRUNCATED AT 250 WORDS)     

Immediate and long-term outcome after angioplasty with stenting of the left main coronary artery

INTRODUCTION AND OBJECTIVES: Coronary artery bypass graft surgery is the treatment of choice for severe left main coronary artery stenosis. The results of a number of multicenter trials have suggested angioplasty with stenting as a possible alternative treatment. The aim of the present study was to analyze the immediate and long-term results of angioplasty with stenting of the left main coronary artery, and to identify factors predictive of death. PATIENTS AND METHOD: A total of 38 nonconsecutive patients (mean age 69 [8] years) with a severe lesion in the left main coronary artery were treated with angioplasty and stenting between November 1997 and March 2003. The procedure was elective in 27 patients and urgent in the remaining 11. In 23 patients (60.5%) the left main coronary artery was not protected by aortocoronary bypass. All patients underwent clinical follow-up examination at 25 (20) months. RESULTS: Angiographically documented success was obtained in all patients. However, one patient died from acute occlusion one hour after the operation. Four patients (10%) had a non-Q-wave myocardial infarction. In-hospital mortality was 15.8% (6/38 patients). Five of the 11 patients (45.4%) who underwent emergency angioplasty and stenting died in the hospital from acute myocardial infarction complicated by severe (Killip grade III-IV) heart failure. However, only one of 27 patients (3.7%) in the elective surgery group died (P=.007). Major clinical cardiac events during follow-up occurred in 5 patients (13%); 3 died and the other 2 had recurrent angina. All patients who died had an unprotected left main coronary artery. Cumulative survival rates for the elective group were 92 (0.5)% at 6 months, 88 (0.6)% at 1 year and 86 (0.7)% at 3 years, respectively. For the emergency surgery group cumulative survival rate was 54 (0.2)% at 6 months (P<.05). CONCLUSIONS: Elective angioplasty and stenting of the left main coronary artery in selected patients was associated with a high immediate success rate. In patients who underwent elective angioplasty and stenting, the incidence of major cardiac events during follow-up was relatively low. Emergency angioplasty and signs of left ventricular dysfunction were the main predictors of in-hospital mortality.     

Immediate and long term results of percutaneous coronary angioplasty in patients aged 70 and over.

OBJECTIVE--To study the immediate and long term clinical success of percutaneous transluminal coronary balloon angioplasty in patients over 70 years old. DESIGN--Patients undergoing percutaneous transluminal angioplasty were prospectively entered in a specially designed database. The clinical and angiographic data of all patients over 70 were reviewed. Follow up data were collected by interview, during outpatient visits, by questionnaire, or through the referring physician. SETTING--A tertiary referral cardiac centre. PATIENTS--166 patients over 70 (median 73, range 70-84) underwent coronary angioplasty because of unstable angina (81 patients), stable angina (76 patients), or acute myocardial infarction (nine patients). RESULTS--The initial clinical success rate was 86% (142 of 166 patients). A major procedural complication occurred in 10 patients (6%): four patients (2%) died, six patients (4%) underwent emergency bypass surgery, and five patients (3%) sustained an acute myocardial infarction. In 14 patients (8%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 226 lesions were attempted. The initial angiographic success rate was 192 out of 226 lesions (85%). The median follow up was 21 (range 0.5-66) months. Sixteen patients (10%) died during follow up, eight patients (5%) sustained a non-fatal myocardial infarction, 21 patients (13%) underwent a second or third balloon dilatation, and 17 patients (10%) underwent elective bypass surgery. Of the 146 survivors, 99 patients (68%) had sustained clinical improvement. The estimated survival at four years (Kaplan-Meier method) was 89 (SD 4)%. The event free survival at four years for the total study population was 61 (8)%. Multivariate logistic regression analysis showed that the extent of vessel disease was the only independent predictive factor for event free survival: the event free survival rate was 81 (10)% at four years for patients with single vessel disease, compared with 45 (12)% for patients with multivessel disease. CONCLUSIONS--Coronary angioplasty in patients over 70 was a safe and effective treatment for obstructive coronary artery disease. The extent of vessel disease, and not the completeness of revascularisation, was the only independent predictive factor for event free survival.     

Immediate and long term results of percutaneous coronary angioplasty in patients aged 70 and over.

OBJECTIVE--To study the immediate and long term clinical success of percutaneous transluminal coronary balloon angioplasty in patients over 70 years old. DESIGN--Patients undergoing percutaneous transluminal angioplasty were prospectively entered in a specially designed database. The clinical and angiographic data of all patients over 70 were reviewed. Follow up data were collected by interview, during outpatient visits, by questionnaire, or through the referring physician. SETTING--A tertiary referral cardiac centre. PATIENTS--166 patients over 70 (median 73, range 70-84) underwent coronary angioplasty because of unstable angina (81 patients), stable angina (76 patients), or acute myocardial infarction (nine patients). RESULTS--The initial clinical success rate was 86% (142 of 166 patients). A major procedural complication occurred in 10 patients (6%): four patients (2%) died, six patients (4%) underwent emergency bypass surgery, and five patients (3%) sustained an acute myocardial infarction. In 14 patients (8%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 226 lesions were attempted. The initial angiographic success rate was 192 out of 226 lesions (85%). The median follow up was 21 (range 0.5-66) months. Sixteen patients (10%) died during follow up, eight patients (5%) sustained a non-fatal myocardial infarction, 21 patients (13%) underwent a second or third balloon dilatation, and 17 patients (10%) underwent elective bypass surgery. Of the 146 survivors, 99 patients (68%) had sustained clinical improvement. The estimated survival at four years (Kaplan-Meier method) was 89 (SD 4)%. The event free survival at four years for the total study population was 61 (8)%. Multivariate logistic regression analysis showed that the extent of vessel disease was the only independent predictive factor for event free survival: the event free survival rate was 81 (10)% at four years for patients with single vessel disease, compared with 45 (12)% for patients with multivessel disease. CONCLUSIONS--Coronary angioplasty in patients over 70 was a safe and effective treatment for obstructive coronary artery disease. The extent of vessel disease, and not the completeness of revascularisation, was the only independent predictive factor for event free survival.     

Immediate and long-term outcome of percutaneous mitral valvotomy in patients 65 years and older.

BACKGROUND. We analyzed the immediate and long-term outcome of percutaneous balloon mitral valvotomy (PMV) in 99 patients who were greater than or equal to 65 years of age (81 women and 18 men; mean +/- SEM age, 72 +/- 0.5 years). METHODS AND RESULTS. There were 84 patients in New York Heart Association (NYHA) class III or IV; 26 patients had previous surgical commissurotomy; 64 had one or more comorbidities; 73 had fluoroscopically visible mitral valve (MV) calcification; and 63 had echocardiographic score greater than 8 (mean +/- SEM score, 9.2 +/- 0.2). There were three procedural deaths, all occurring in our early experience. Pericardial tamponade occurred in five patients, thromboembolism in three, and transient atrioventricular block in one. After PMV, MV area was greater than or equal to 1 cm2 in 86 patients and greater than or equal to 1.5 cm2 in 56. A successful outcome (defined as MV area greater than or equal to 1.5 cm2 without a greater than or equal to 2-grade increase in mitral regurgitation and without left-to-right shunt with a pulmonary-to-systemic flow ratio of greater than or equal to 1.5:1) was achieved in 46 patients. The best multivariate predictor of success was the combination of echocardiographic score, NYHA functional class, and inverse of MV area. Mean follow-up was 16 +/- 1 months. Actuarial survival (79 +/- 7% versus 62 +/- 10%, p = 0.04), survival without MV replacement (71 +/- 8% versus 41 +/- 8%, p = 0.002), and survival without MV replacement and NYHA class III or IV (54 +/- 12% versus 38 +/- 8%, p = 0.01) at 3 years were significantly better in the successful group of 46 patients than in the unsuccessful group of 53 patients. Low echocardiographic score was the only independent predictor of survival. Lack of MV calcification and low NYHA class, low mean left atrial pressure, and low pulmonary artery pressure were the independent predictors of event-free survival. CONCLUSIONS. PMV can be performed safely in selected patients greater than or equal to 65 years old with good immediate and long-term results. In addition to clinical examination, echocardiographic evaluation of the mitral valve and fluoroscopic screening for valvular calcification are the most important steps in patient selection for successful outcome.     

Initial and long-term outcome of 354 patients after coronary balloon angioplasty of total coronary artery occlusions.

BACKGROUND. Coronary balloon angioplasty of chronic total occlusions is associated with relatively low success rates and a high incidence of restenosis. Whether there is long-term benefit in performing angioplasty of these lesions is unknown. The purpose of the present report was to analyze the long-term outcome of a large series of patients undergoing this procedure. METHODS AND RESULTS. A computerized database analysis of 354 consecutive patients (from 1979 to 1990) who underwent coronary angioplasty of a chronic total coronary occlusion was performed (mean age, 62.3 years). Initial technical success was achieved in 69%; in 66%, success was achieved without procedural death or need for coronary artery surgery. During hospitalization, six patients suffered myocardial infarction, nine required emergency bypass surgery, and nine patients died. During a mean follow-up period of 2.7 years, no difference was found in survival or freedom from myocardial infarction among 234 successfully dilated patients compared with 120 patients with a failed attempt. However, the use of coronary artery bypass surgery was significantly less after successful dilation (p less than 0.0001 versus failed attempt). No significant difference in the cumulative incidence of severe angina was observed between these two patient populations, with the majority remaining asymptomatic. Restenosis occurred in 59% of 69 patients who returned for follow-up angiography. CONCLUSIONS. Successful recanalization is achieved in the majority of patients undergoing angioplasty of chronic total occlusions and reduces the need for coronary artery bypass surgery. However, no major impact on either survival or incidence of myocardial infarction was noted after successful recanalization when patients with surgery were included.     

Prognosis of symptomatic coronary artery disease in young adults aged 40 years or less

The clinical course and coronary angiographic features of symptomatic coronary artery disease (CAD) in patients younger than 40 years old are described with particular emphasis on the prevalence of myocardial infarction and the degree of diminished functional capacity. Eighty-five patients with CAD proven by coronary angiography were studied. There were 73 men and 12 women aged 27 to 40 years. Fifty-nine patients presented with acute myocardial infarction, most of whom denied previous chest pain, and 14% (12 patients) presented with less acute chest pain syndromes. Coronary angiography was performed in all patients, and greater than or equal to 70% luminal diameter narrowing was considered significant. Coronary angiographic findings reveal 51% with 1-vessel CAD, 31% with 2-vessel and 19% with 3-vessel. Subsequently, 23 patients had coronary artery bypass graft surgery, 7 underwent angioplasty and 55 were treated medically. Follow-up for a mean of 3 years revealed only 1 death and 4 subsequent hospital admissions for cardiac events. Fifty-three percent of the patients are entirely pain free, and only 4 (5%) have significant symptoms of angina pectoris. Although 15 (18%) are not employed regularly, the remainder work full- or part-time, or plan to work in the near future. These data suggest that the short-term prognosis and functional status of young patients with CAD is excellent.     

Prospective study of patients aged 55 years or less with acute myocardial infarction between 1981 and 1985: outcome 7 years and beyond.

OBJECTIVE--To determine the long-term prognosis of patients after a myocardial infarction (MI) at a young age. DESIGN--Prospective cohort study of patients aged 55 years or less suffering a myocardial infarction. SETTING--A single coronary care unit admitting patients from the community. PATIENTS--255 consecutive patients (210 men) aged 55 years or less admitted between 1981 and 1985 after acute MI. Twenty four patients died in hospital or within 3 months of infarction and 11 were lost to further follow up after discharge. Of the remaining patients, 150 (mean (SD) age 48 (5.7) years) able to exercise 3 weeks after infarction and who agreed to undergo coronary angiography were recruited to a study group and seen 18 months, and 3, 5, and 7 years after MI. In addition, a cross sectional analysis of survival was made to a median of 120 months. Seventy 3 month survivors (mean (SD) age 48 (5.8) years) were not recruited to the study group but were traced for late survival through their general practitioners and family health service associations to a median of 130 months. MAIN OUTCOME MEASURES--Survival in young patients after MI and the survival of 3 month survivors stratified by their ability to exercise and agreement to undergo angiography. The rate of coronary artery surgery (CAGB) and reinfarction during the first 7 years after index MI in patients recruited to the study group. RESULTS--Sixteen patients (6%) died in hospital and eight (3%) within 3 months of the index infarction. The 7 and 11 year survival rates in the whole cohort of 255 patients were 80% and 66% respectively using life table methods. Survival 7 years after MI, in patients recruited to the study group was better than in those not recruited (93% v 79%, P = 0.001), but thereafter mortality in the study group accelerated and there was no significant difference in survival 11 years after infarction (76% v 67%, P = 0.05). There was a trend towards higher mortality in patients with multivessel disease and severely impaired left ventricular function. During the first 7 years after MI, 38 of 150 patients in the study group underwent CABG and 19 suffered reinfarction, which was fatal in three. CONCLUSION--The medium-term prognosis of young survivors of MI is good, particularly in patients recruited to the study group. After 7 years there is an increase in mortality and the long-term prognosis is less favourable. This should be taken into account when planning future management and follow up of young patients after MI.     

Treatment of latent tuberculosis infection in patients aged > or =35 years.

Treating patients aged > or =35 years for tuberculosis infection has been controversial because of the hepatotoxic effects of isoniazid. A 2-year retrospective cohort study of outpatient medical records determined the completion rate in this age group and identified risk factors associated with isoniazid-associated hepatotoxicity. Isoniazid preventative therapy was well tolerated. However, toxicity occurred in women receiving concomitant medications and men who used alcohol.     

Initial management and long-term clinical outcome of restenosis after initially successful percutaneous transluminal coronary angioplasty.

Restenosis remains a critical limitation after percutaneous transluminal coronary angioplasty (PTCA). The clinical experience with restenosis was reviewed in 1,490 patients who had restenosis of at least 1 site within 1 year of their PTCA. The source of data was the clinical database at Emory University. Patients who had previous coronary bypass surgery or PTCA and patients who underwent PTCA in the setting of acute myocardial infarction were excluded. When restenosis was angiographically documented, 363 were treated medically, 1,051 with repeat PTCA, and 76 with coronary bypass surgery. In the repeat PTCA group there were 778 patients who originally had 1-vessel disease and 273 with multiple vessel disease. Re-dilatation of restenotic sites was performed in 95%. Angiographic success of all lesions dilated was achieved in 99%. Coronary bypass surgery was required in 2.5% of patients with restenosis first treated with repeat PTCA. One patient with multiple vessel disease died. Coronary bypass surgery was performed in fewer patients aged greater than or equal to 65 years, but more patients with multiple vessel disease. Two (2.6%) of the coronary bypass surgery patients had Q-wave myocardial infarction and there were no deaths. In the PTCA group, 5-year actuarial survival was 95%, and cardiac survival 96%. Freedom from cardiac events or further revascularization procedures was 51% at 5 years. Patients treated with PTCA and medically treated patients had similar cardiac survival rates. The most important correlates of cardiac survival were age and the presence of diabetes mellitus. At 5 years, cardiac survival without diabetes was 97 and 83% with diabetes (p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)