Outcome of patients with significant coronary stenosis but without ischemic evidence on exercise myocardial perfusion scintigraphy

OBJECTIVES: The rates of cardiac events and coronary revascularization were evaluated in patients with significant coronary stenosis of more than 75% by the American Heart Association (AHA) classification but no ischemic evidence by exercise myocardial perfusion scintigraphy. METHODS: Subjects were 171 patients (113 males, 58 females, mean age 66 +/- 9 years) undergoing coronary angiography and without scintigraphic evidence of myocardial ischemia. They were divided into two groups according to the severity of coronary artery stenosis based on AHA classification. Group A was composed of 139 patients with more than 75% stenosis (101 patients with 75% stenosis and 38 patients with more than 90% stenosis), and Group B was composed of 32 patients with 50% stenosis. Cardiac events including angina pectoris (n = 63), myocardial infarction (n = 1), heart failure (n = 2) and cardiac death (n = 0), coronary revascularization and predictive factors were evaluated during follow-up of 34 +/- 21 months. Furthermore, the interval between coronary revascularization and exercise myocardial perfusion scintigraphy was estimated. RESULTS: The rates of cardiac events (45%) and coronary revascularization (29%) in Group A were significantly higher than the rate of cardiac events (9%, p < 0.05) and coronary revascularization (6%, p < 0.05) in Group B. Only percentage stenosis and the number of diseased vessels affected the rates of cardiac event and coronary revascularization. CONCLUSIONS: Patients with significant coronary stenosis, but without ischemic evidence by exercise myocardial perfusion scintigraphy, have a relatively high rate of cardiac event and coronary revascularization, especially in patients with severe stenosis or multivessel disease. However, coronary revascularization should not be performed in all patients with significant coronary stenosis.     

Clinical characteristics associated with myocardial infarction, arrhythmias, and sudden death in patients with vasospastic angina

A total of 349 patients with vasospastic angina were followed in eight centers in Japan for a period of 3.4 +/- 0.1 years (mean +/- SE). Ninety-eight percent of patients were treated with calcium blockers. Twenty-one episodes of myocardial infarction occurred in 18 patients (5%), including two fatal myocardial infarctions. The rate of myocardial infarction was higher (p less than .01) in patients with a fixed stenosis of 90% or greater than in patients with a fixed stenosis of less than 90% or normal coronary arteries. Myocardial infarctions occurred predominantly during hospital stays or at a time when the frequency of vasospastic angina increased. There were five sudden deaths (2%). Only one patient suffering sudden death had a fixed stenosis of 75% or greater. Serious arrhythmias were noted in 49 patients (14%). The risk of arrhythmias did not depend on the presence of a fixed stenosis of 75% or greater. These results suggest that cardiac events are rather infrequent in Japanese patients with vasospastic angina who are receiving treatment with calcium blockers and that the presence of a severe fixed stenosis markedly increases the risk of myocardial infarction but not the risk of arrhythmias.     

Results and indications of coronarography in mitral valvulopathies

Selective coronary angiography was carried out in 110 patients (68 women, 42 men; average age 57 +/- 8 years) with significant, isolated, non-ischaemic mitral valve disease. The indication for coronary angiography was angina or myocardial infarction in 42 cases and the investigation was carried out routinely in the other 68 cases. Coronary stenosis greater than 50 p. 100 was demonstrated in 25 cases (22.7 p. 100), 18 single vessel, 5 double or triple vessel disease and 2 cases of stenosis of the left main stem. The incidence of coronary artery disease was higher in patients with cardiovascular risk factors (0 factors: 13 p. 100; 1 factor: 22 p. 100, 2 or 3 factors: 45 p. 100; p less than 0.01). The coronary patients had higher mean pulmonary artery pressures (33 +/- 16 mmHg vs 25 +/- 8 mmHg, p 0.001), higher left ventricular end diastolic pressures (12.5 +/- 7 mmHg vs 9 +/- 5 mmHg, p less than 0.01) and greater left ventricular end diastolic volumes (83 + 40 ml/m2 vd 59 +/- 29 ml/m2, p less than 0.01). There was no difference in segmental wall motion between coronary and non coronary patients. 89 patients were referred for surgery, 17 of whom had coronary artery disease. 5 patients underwent coronary bypass surgery. The incidence of peroperative cardiac complications (low output, ventricular arrhythmias, myocardial infarction) was higher in the coronary patients (53 p. 100 vs 18 p. 100, p less than 0.01). The 6 year survival rate was 75 +/- 8 p. 100.(ABSTRACT TRUNCATED AT 250 WORDS)     

Isolated stenosis of the anterior interventricular artery. Comparison of the effects of medical and surgical treatment (in a randomised series)

Forty-five patients presenting with unstable angina having 70 p. 100 stenosis of the left anterior descending artery judged acceptable for coronary bypass surgery were randomly allocated, using a table of random numbers, for medical (21 patients) or surgical treatment (24 patients). There were no significant differences between the two groups with regards to age (53 +/- 10 years for the medical group; 55 +/- 9 years for the surgical group), the length of follow-up (55 +/- 26 vs 61 +/- 28 months), left ventricular end diastolic volumes (87 +/- 27 vs 84 +/- 18 ml/m2) or ejection fraction (62 +/- 8 vs 59 +/- 11 p. 100). There were no deaths in the medical group; two patients developed uncomplicated myocardial infarction 19 days and 7 months after coronary angiography, respectively. 5 patients had recurrent angina and were referred for surgery. This operation of second intention did not pose any special problems. 6 of the 14 patients with stenosis of the LAD before the origin of the first septal artery had complications (infarction in 1 case, recurrent angina in 5 cases). In the surgical group, 1 patient died in the immediate postoperative period, of resistant cardiac arrhythmia; 2 patients developed uncomplicated peroperative myocardial infarction; 21 patients had no complications at all. The surgical patients were heparinised in the immediate postoperative period and anticoagulant therapy was continued with oral vitamin K antagonists for 6 months to 1 year, followed in some cases, by platelet antiaggregant therapy. 20 patients in this group underwent maximal exercise stress testing which was negative in 19 cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical management of patients with coronary syndromes and negative fractional flow reserve findings

AIMS: New interventional techniques to diagnose coronary artery stenosis, such as calculation of myocardial fractional flow reserve (FFR) with a guidewire and pressure transducer, provide a functional assessment of coronary lesions. The present study was designed to investigate the occurrence of cardiac events in patients with coronary syndromes and negative FFR findings in moderately severe coronary stenosis in order to determine the usefulness of this technique in predicting coronary events during follow-up for problems commonly encountered in clinical practice. A further objective was to evaluate the safety of deferring angioplasty in patients with a negative FFR result. METHODS: We studied 43 patients with 44 moderately severe coronary artery stenoses on angiography and FFR > or = 0.75. Mean age of the patients was 58 +/- 11.4 years. The indications for coronary angiography included recent unstable angina in 24 (55.8%) patients, recent acute myocardial infarction in 10 (23.2%) patients, 5 (11.6%) patients with a coronary stent who had symptoms of uncertain cause, and stable angina in 4 (9.3%) patients. RESULTS: During a mean follow-up period of 10.7 +/- 5.9 months, clinical events (unstable angina) occurred in five patients. In three patients, the initially investigated artery was involved, and in the two patients who required coronary revascularization, unstable angina was related with an artery different from the one studied initially. CONCLUSIONS: Patients with recent coronary syndromes and negative FFR findings in moderately severe coronary stenosis were unlikely to have cardiac events during a 10-month follow-up period. Our findings suggest that FFR is a potentially useful indicator of the likelihood of cardiac events and thus represents a useful aid in clinical decision-making in the hemodynamics laboratory. This diagnostic technique also is potentially useful in identifying patients for whom angioplasty can be safely deferred.     

Prognostic value of changes in R-wave amplitude during exercise testing after a first acute myocardial infarction.

To investigate the prognostic value of exercise-induced changes in R-wave amplitude and their relation to other exercise and angiographic variables, 303 consecutive patients who underwent maximal exercise testing and coronary angiography within 2 months of a first acute myocardial infarction were studied. R-wave amplitude at peak exercise increased or was unchanged in 159 patients (57.4%) and decreased in 118 (42.6%). Increased R-wave amplitude was significantly related to underlying 3-vessel disease (p = 0.0001), the extent of ST-segment depression on exercise (p = 0.0001), and the time to 1 mm ST depression (p less than 0.05). Follow-up information was available in 285 patients (86.4%) at a mean of 4 +/- 1.8 years. Death from cardiac causes occurred in 25 patients (9%); 18 (6.5%) developed recurrent myocardial infarction, and 32 (11.6%) developed angina. Variables with a predictive value for cardiac death were maximal exercise heart rate (p = 0.0005), occurrence of exercise-related supraventricular arrythmia (p = 0.02), and number of diseased vessels (p = 0.02). R-wave changes had no predictive value. No variable had a predictive value for recurrent infarction. Maximal exercise heart rate (p = 0.02) and increased R-wave amplitude (p = 0.0001) were significantly related to the occurrence of angina at follow up. Exercise-related R-wave increases were associated with the presence of angina at follow-up, but had no predictive value for cardiac death or recurrent infarction; their association with subsequent angina appears to reflect an association with more severe underlying coronary disease.     

Long-term follow-up results after plain balloon coronary angioplasty.

Between September 1987 and June 1992, 571 patients of coronary artery disease underwent percutaneous transluminal coronary angioplasty in our institute. Their ages ranged from 31-82 years (mean 51 +/- 9) and majority (88.3%) were males. At baseline, 318 (55.7%) patients had chronic stable angina, 184 (32.2%) unstable angina, and 57 (10%) underwent PTCA for recurrence of angina in the post-infarction period. Single vessel angioplasty was performed in 406 (71.1%), two-vessel angioplasty in 121 (21.2%) and three or more vessels were dilated in 44 (7.7%). The procedure was successful in 524 (91.8%) patients. Follow-up was available in 438 (83.6%) patients, and ranged from 78 to 135 months (mean 89 +/- 29) with all the patients completing at least 60 months of follow-up. Using Kaplan-Meier statistical analysis, event-free survival (freedom from repeat percutaneous transluminal coronary angioplasty, myocardial infarction, coronary artery bypass surgery, or death) was 72.5 percent at three, 68.0 percent at five, 61.8 percent at seven and 55.6 percent at 10 years of follow-up. Freedom from major adverse cardiac events (myocardial infarction, coronary artery bypass surgery or death) was 88.3, 85.8, 82.0 and 75.4 percent at 3, 5, 7 and 10 years, respectively. Overall survival was 97.4 and 95.2 percent, respectively at 5 and 10 years. Subgroup analysis for all major events was done between males and females, diabetics and non-diabetics, previous history or absence of myocardial infarction, stable versus unstable angina and single versus multivessel disease. Event-free survival rates were compared between the groups using log rank test. On follow-up, the need for surgical revascularisation was more in males compared to females although statistically insignificant, and in patients with unstable angina compared to stable angina (p < 0.02). Similarly, freedom from major adverse cardiac events was significantly better in females compared to males (p < 0.05) and in stable versus unstable angina (p < 0.01). Event-free survival (repeat percutaneous transluminal coronary angioplasty, myocardial infarction, coronary artery bypass surgery, death) was also significantly better in patients with stable angina (p < 0.02). The other outcomes were comparable in all the subgroups. In conclusion, plain balloon angioplasty provides excellent long-term results in patients with coronary artery disease in terms of reduction in major adverse cardiovascular events and need for subsequent revascularisation.     

Results of coronary surgery in patients over 70 years of age

Among the 628 consecutive patients who underwent coronary bypasses performed by the same surgical group between January 1, 1982 and December 31, 1987, 71 (11 p. 100) were aged 70 years or more (mean: 72.5 years; range: 70-83 years). 99 p. 100 of the patients had a history of severe, disabling exertional angina (46 p. 100) or unstable angina (52 p. 100) of 55 months' duration on average; 35 patients (49 p. 100) had already experienced myocardial infarction. Coronary angiography showed a one-vessel disease in 1 case, a two-vessel disease in 1 case, a two-vessel disease in 31 cases and a three-vessel disease in 39 cases; 11 patients (15 p. 100) had stenosis of the left main coronary artery. The ventricular function was considered unaltered in 59 cases (83 p. 100). Altogether, 155 bypasses, including 25 internal mammary grafts, were performed, i.e. an average of 2.2 bypasses per patient. There was only one early (21st day) post-operative death. The post-operative period was uneventful in 57 patients (60 p. 100); 9 developed peri-operative necrosis. Seventy patients have been followed up for a mean period of 24 months: there were 3 late deaths of non-cardiac origin; 60 patients (84.5 p. 100) are now asymptomatic and 3 (4.5 p. 100) are suffering from residual angina. Early mortality excluded, the cumulative probability of survival at 5 years is 94 p. 100.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of the readaptation of patients with triple coronary vessel disease unfit for by-pass surgery

The objective of this study is to evaluate the effects of rehabilitation in 46 consecutive patients with triple vessel coronary disease, and unfit for by-pass surgery: there were 45 men and 1 woman (mean age = 58 years), admitted during the 3rd week of a myocardial infarction (N = 31) or following unstable angina (N = 15). The stroke volume (SV) is normal in 50 p. cent of the patients, but 15 p. cent presented as SV less than 0.30. 3 patients were unable to start their rehabilitation because of unstable angina (N = 2), or severe pulmonary edema (N = 1). Following 4 weeks of rehabilitation, comparison of the stress tests pre- and post-rehabilitation, reveals improved functional capacities (maximum level reached 103.6 +/- 27 vs 126.4 +/- 31; p less than 0.001, and an improvement of the ischemic threshold (82 +/- 32 vs 92 +/- 31; p less than 0.05). During the long-term follow-up (32.5 months), 4 patients died from cardiac complications (8.7%) and one from extra-cardiac reasons. Among the 41 alive patients, 58.6 p. cent were asymptomatic, 39 p. cent presented cardiac complications, one had a GI malignancy. The rate of return to work among the active population is 68.5 p. cent within a mean time of 1.7 months after rehabilitation. Overall, this study demonstrates the possibility of cardiac rehabilitation under medical supervision in patients with severe triple vessel coronary disease. The improvement of the functional abilities under stress conditions is obvious, enabling the patient to regain confidence in him/herself and improve his/her comfort.     

Long-term outcome of conservatively treated patients with borderline coronary lesions--role of the fractional flow reserve measurement

BACKGROUND: Coronary fractional flow reserve (FFR) has been recommended as one of the functional methods which can be used to establish indications for revascularisation in patients with borderline coronary lesions. AIM: To assess long-term outcome of patients with borderline coronary lesions in whom the decision to implement conservative treatment was based on the results of FFR. METHODS: The study group consisted of 41 patients (13 females, mean age 61+/-9 years) who had CCS class II angina, an isolated borderline (40-70%) coronary lesion and FFR >0.75. All patients received 40 mg of simvastatin, angiotensin converting enzyme inhibitor and aspirin. The follow-up duration ranged from 7 to 32 months (mean 15.2+/-7.1, median 14.5 months). The analysed end-points included cardiac death, myocardial infarction (MI) (with or without ST segment elevation) and revascularisation of the target coronary artery. RESULTS: The mean FFR value in the whole study group was 0.91+/-0.05. Three (7%) patients had complications during follow-up: one patient developed MI, and two had coronary artery stenosis progression, requiring angioplasty. These patients had similar clinical and angiographic characteristics as well as FFR values as patients without complications. Among patients with uneventful outcome, in 33 (87%) anginal symptoms improved whereas in the remaining 5 (13%) patients CCS class did not change. Patients with angina alleviation were older and had higher FFR values than patients without improvement (63+/-8 vs 48+/-6 years, p=0.0005; and 0.92+/-0.05 vs 0.86+/-0.08, p=0.04, respectively). CONCLUSIONS: In patients with borderline coronary lesions and stable angina, angioplasty can be delayed on the basis of the FFR results. This approach is safe and is associated with an asymptomatic long-term follow-up in more than 90% of patients.     

Tolerance and prognostic value of Thallium 201 myocardial tomoscintigraphy with dipyridamole in the aged subject

The authors present a retrospective study of 46 consecutive patients aged from 70 to 79 years (mean 73.3 +/- 2.5 years) with suspected coronary artery disease who, being unfit for exercise tests, were explored by myocardial scintigraphy with thallium 201 after coronary dilatation with intravenous dipyridamole. The examination was well tolerated by 30 patients. Such classical side-effects as chest pain, malaise, dizziness, headache, flushing, vomiting and transient arrhythmia or repolarization disorders were recorded, but they were not more frequent than in younger subjects. However, the occurrence of severe hypotensive malaise relieved by theophylline in two cases and of angina in about one third of patients with myocardial ischaemia means that the procedure must be performed under close supervision. A fall in blood pressure (-11 mmHg on average) and a rise in heart rate (+8 beats/min on average) were usual. Post-scintigraphy follow-up of patients over a mean period of 11.1 +/- 6.2 months showed that a reversible defect of thallium 201 uptake, due to redistribution, is a highly selective indicator of patients who are particularly exposed to a cardiac accident in the short--or mid-term. Only one out of 26 patients without reversible ischaemia (4 p. 100) subsequently presented with a major coronary event (unstable angina). In contrast, in the group of 20 patients with reversible ischaemia three required early myocardial revascularization; furthermore, five serious accidents (29 p. 100) occurred among the 17 patients who were left under medical treatment, including two sudden deaths, two cases of unstable angina and one case of myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of asymptomatic ischemia on long-term prognosis in chronic stable coronary disease

BACKGROUND. Ischemia on ambulatory electrocardiographic monitoring has been shown to adversely affect short-term prognoses in patients with unstable angina, after myocardial infarction, and with chronic stable angina. METHODS AND RESULTS. In this long-term study, we followed 138 patients (mean age, 59 +/- 9 years) with chronic stable angina and positive exercise tests for cardiac events (e.g. death, myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery). In 105 patients, ambulatory electrocardiographic monitoring was performed after all antianginal medication was withheld for 48 hours. In 26 patients, the diagnostic tests were repeated while on their usual medication. In addition to the 105 patients, 33 patients had their monitoring performed only while on their usual medication. During 37 +/- 17 months of follow-up, there were nine deaths, nine myocardial infarctions, and 35 revascularization procedures. In patients monitored off medication, Cox survival analysis showed that the occurrence of ischemia on electrocardiographic monitoring was the most significant predictor of death and myocardial infarction in the subsequent 2 years (p = 0.02) and all adverse events for 5 years (p = 0.009). Patients who were monitored on medication and did not have ischemia (n = 18) appeared to have more adverse events than patients who had no ischemia while being monitored off medication (n = 43). CONCLUSIONS. Asymptomatic ischemia on ambulatory electrocardiographic monitoring in patients with stable angina predicts death and myocardial infarction for 2 years and all adverse events for 5 years. Monitoring performed while on medication may show no ischemia; however, this may not indicate low risk of future coronary events.     

Prognosis of silent myocardial ischemia: follow-up of 100 patients with positive treadmill test and exertion myocardial scintigraphy

Prognosis of asymptomatic myocardial ischemia is largely unknown and the opportunity is still controversial of seeking for patients with silent ischemia. Aim of the present study is to evaluate the prognosis of painless myocardial ischemia documented by exercise test and myocardial scintigraphy. From June 1981 through November 1986, 206 patients without angina, history or ECG signs of old myocardial infarction, presenting a positive (decreases ST greater than or equal to 1.5 mm) exercise treadmill test, underwent exercise Thallium 201 myocardial imaging. Myocardial scintigraphy showed a normal scan in 85 cases and a reversible or fixed perfusion defect in 121. Patients with abnormal scan presenting ischemia at a low to moderate ergometric work-load were treated with betablockers or calcium-antagonist drugs. Out of patients with positive myocardial scintigraphy a sample of the first 100 consecutive subjects was considered. They were 87 men and 13 women aged 28-72 years (mean 54.8) observed during a mean follow up period of 33.1 +/- 1.6 months. Seven patients underwent coronary angiography which showed 3-vessel critical stenosis in 3 cases, 3-vessel lesions plus critical stenosis of the left main coronary-artery in 1 and 2-vessel lesions in 3. Two patients underwent coronary artery bypass surgery. A non fatal myocardial infarction occurred in 1 and 1 became symptomatic for angina, 11 and 20 months respectively after the diagnosis of ischemia. Three patients with ischemia at a low work-load and extensive scintigraphic perfusion defects died of sudden death and one of cancer.(ABSTRACT TRUNCATED AT 250 WORDS)     

Initial and late results of coronary angioplasty for early postinfarction unstable angina

Unstable angina that occurs in the early postinfarction period is associated with an increased incidence of unfavorable cardiac events despite aggressive medical therapy. We examined the results of coronary angioplasty in 47 consecutive patients with postinfarction unstable angina who were referred for the procedure 12.9 +/- 7 days following myocardial infarction, 14 of which were Q wave and 33 of which were non-Q-wave. Coronary angioplasty was performed on a total of 55 arteries with a mean predilatation stenosis of 95 +/- 8%. These included 46 infarct-related arteries and nine noninfarct arteries. Double-vessel angioplasty was performed in eight patients. Successful coronary angioplasty (greater than 30% reduction of predilatation stenosis) was achieved in 43 patients (91%), with a mean residual stenosis of 33 +/- 28%. There was one in-hospital death, one patient required emergency bypass surgery, and two patients had early reocclusion resulting in myocardial infarctions. The 39 patients who had successful angioplasty procedures and who were discharged from the hospital without an unfavorable outcome were followed for 16.3 +/- 7 months, and repeat coronary angioplasty was required in five patients from 45 to 105 days after the initial procedure. Two patients had subsequent elective bypass surgery, one had a recurrent myocardial infarction, and one patient had a noncardiac death. For selected patients with suitable coronary anatomy, coronary angioplasty appears to offer an efficacious therapeutic option for early postinfarction unstable angina.     

Amounts of coronary arterial narrowing by atherosclerotic plaque at necropsy in patients with lower extremity amputation.

In 26 patients (mean age at death 68 +/- 9 years) who had undergone amputation (at mean age 63 +/- 12 years) of 1 or both lower extremities due to severe peripheral arterial atherosclerosis, the amounts of narrowing at necropsy in the 4 major (left main, left anterior descending, left circumflex, and right) epicardial coronary arteries were determined. During life, 15 of the 26 patients (58%) had symptoms of myocardial ischemia: angina pectoris alone in 1, acute myocardial infarction alone in 5, and angina and/or infarction plus congestive heart failure or sudden coronary death in 9. Twelve of the 26 patients (42%) died from consequences of myocardial ischemia: acute myocardial infarction in 5, sudden coronary death in 3, chronic congestive heart failure in 3, and shortly after coronary bypass surgery in 1. Grossly visible left ventricular necrosis or fibrosis, or both, was present in 21 patients (81%). Of the 26 patients, 24 (92%) had narrowing 76 to 100% in cross-sectional area of 1 or more major coronary arteries by atherosclerotic plaque. The mean number of coronary arteries per patient severely (> 75%) narrowed was 2.3 +/- 1.0/4.0. Of the 104 major coronary arteries in the 26 patients, 60 (58%) were narrowed > 75% in cross-sectional area by plaque. The 4 major coronary arteries in the 26 patients were divided into 5-mm segments and a histologic section, stained by the Movat method, was prepared from each segment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Usefulness of percutaneous transluminal coronary angioplasty for unstable angina pectoris after non-Q-wave acute myocardial infarction

Without revascularization, patients with non-Q-wave acute myocardial infarction (AMI) are predisposed to angina, recurrent AMI and cardiac death. Percutaneous transluminal coronary angioplasty (PTCA) was performed in 68 patients with angina an average of 2.3 months after non-Q-wave AMI (41 anterior, 27 inferior). Mean diameter stenosis was 95%, with collateralized total occlusion of the infarct-related artery in 23 patients. PTCA was successful in 87% (59 of 68), with a mean residual stenosis of 30%. One patient had emergency bypass surgery. Long-term follow-up (average 17 +/- 10 months) was available for 58 of the 59 patients in whom PTCA was successful. Recurrent angina developed in 41% (24 of 58), but was relieved by repeat PTCA in 14, by late coronary artery bypass surgery in 4 and by medical therapy in 6. There was 1 nonfatal AMI, due to progressive disease in a nondilated vessel, and 1 noncardiac death At last follow-up, 46 of 58 patients (79%) were asymptomatic and fully active or employed. Thus, patients undergoing PTCA for angina after non-Q-wave AMI appear to have a relatively high clinical restenosis rate, but with repeat PTCA have a low incidence of subsequent angina, AMI and cardiac death.     

Coronary angioplasty in cardiac transplant patients. Results of a multicenter study.

BACKGROUND. Accelerated allograft atherosclerosis is the main cause of death of cardiac transplant recipients after the first year after transplantation. Because no medical therapy is known to prevent or retard graft atherosclerosis and transplantation is associated with a shortened allograft survival, alternative, palliative therapy with percutaneous transluminal coronary angioplasty (PTCA) has been attempted. Because no single medical center has performed angioplasty in a large number of cardiac transplant recipients, representatives of 11 medical centers retrospectively analyzed their complete experience of coronary angioplasty in cardiac transplant patients to determine the safety, efficacy, limitations, and long-term outcome of angioplasty in allograft coronary vascular disease. METHODS AND RESULTS. Thirty-five patients underwent 51 angioplasty procedures for 95 lesions 46 +/- 5 months (mean +/- SEM) after transplantation. The primary indications for angioplasty included angiographic coronary disease in 22 cases (43%) and noninvasive evidence of ischemia in 18 procedures (35%). Angiographic success, defined as less than or equal to 50% post-PTCA stenosis, occurred in 88 of 95 lesions (93%). Mean pre-PTCA stenosis was 83 +/- 1.1%; mean post-PTCA stenosis was 29 +/- 2.1% (p less than 0.0001). Periprocedural complications included myocardial infarction and late in-hospital death in one patient and three groin hematomas. Twenty-three of the 35 patients (66%) had no major adverse outcome such as death, retransplantation, or myocardial infarction at 13 +/- 3 months after angioplasty. Four patients died less than 6 months after angioplasty, and four died more than 6 months after angioplasty (range, 6-23 months). Two patients had retransplantation 2 months after PTCA, and one patients had retransplantation 18 months after angioplasty. CONCLUSIONS. Coronary angioplasty may be applied in selected cardiac transplant recipients with comparable success and complication rates to routine angioplasty. Whether angioplasty prolongs allografts survival remains to be determined by a prospective, controlled trial.     

Repeat myocardial revascularization]

Eighty-two consecutive patients undergoing reoperation for coronary revascularization from January 1980 to November 1990 were reviewed to determine early and late results and predictors of survival. Seventy patients were male and 12 female; age ranged from 36 to 75 years (mean 56.4 +/- 8.1). All were symptomatic for angina. The mean interval between first and second operation was 62.8 +/- 47.8 months (range 1 to 220 months). Angiographic indications for reoperation were: graft failure (34.1%), progression of atherosclerosis in the native coronary circulation (6.1%) and combination of the two (59.8%). Mean ejection fraction was 45.9 +/- 10.2 (range 11 to 67). Surgical indication was elective in 79.3%, urgent in 14.6% and emergent in 6.1%; 199 grafts were performed (2.4 +/- 1 grafts/patient). Hospital mortality was 6.1% (5 cases). Late mortality was 5.2% (4 cases). Actuarial survival rate (including hospital mortality) was 87.9% at 3, 5 and 10 years. Multivariate analysis identified left main stenosis (p = 0.00001), family history of coronary disease (p = 0.003), urgent/emergency operation (p = 0.015) as predictors of increased in-hospital mortality; postoperative myocardial infarction (p = 0.002) and preoperative heart failure (p = 0.01) as predictors of increased late mortality. Follow-up of in-hospital survivors (mean interval 42.7 +/- 25.8 months, range 3 to 120 months) documented 27 cardiac major events (other than death) in 24 patients (32.9%). Actuarial rates of freedom from major cardiac events were 70%, 52.9% and 48.1% at 3, 5 and 10 years respectively. Multivariate analysis identified preoperative ejection fraction (p = 0.01) as predictor of recurrence of angina and preoperative heart failure (p = 0.02) as predictor of occurrence of cardiac major events.     

Unstable angina: individualized stratification and prognosis.

OBJECTIVE: To analyse the methodology of risk stratification and the prognosis of patients admitted with unstable angina. POPULATION AND METHODS: This retrospective study involved a population of 68 patients (43 males and 25 females with a mean age of 65.8 +/- 9.8 years) consecutively admitted for suspected unstable angina during the year of 1996. Thirty six patients (52.9%) had angina at rest, 13 patients (19.1%) had both exertional and rest angina, 9 patients (13.2%) crescendo angina, 6 patients (8.8%) new onset exertional angina (less than 1 month), and 4 patients (5.8%) post-infarction angina (less than 2 weeks). The risk stratification was individualized. The coronary angiography (35 patients) was only performed when the medical therapy failed in patients with recurrent angina, or with proved ischemia after an exercise test and/or thallium 201 stress scintigraphy. Thirteen patients (19.1%) did not undergo these tests (advanced age and or bad general condition, or refusal). The follow-up of patients with and without ST-T changes was compared, as well as those revascularized versus non-revascularized. It was possible to achieve a mean follow-up of 13.7 +/- 6.2 months (3 to 25 months). RESULTS: The exercise test and/or thallium-201 stress scintigraphy were positive for myocardial ischemia in 28 pts (41.1%) and negative in 7 patients (10.2%). The coronary angiography revealed three-vessel coronary artery disease in 18 patients (26.4%), one vessel disease in 11 patients (16.1%) and two-vessel disease in 5 patients (7.3%). One patient had normal coronary arteries. Medical therapy was the initial approach. Coronary surgery was urgently performed in 3 patients and coronary angioplasty in 5 patients for refractory unstable angina. In the whole group coronary artery surgery was undertaken in 14 patients (20.5%) and coronary angioplasty in 12 patients (17.6%). A mean follow-up of 13.7 +/- 6.2 months was obtained in the 68 patients. During this period 6 patients (8.8%) died due to cardiac causes and 16 patients (23.5%) were readmitted: 8 patients (11.7%) for unstable angina, 5 patients (7.3%) for congestive heart failure and 3 patients (4.4%) for myocardial infarction. Fifty two patients (76.4%) remained free of cardiac events. The patients with transitory ST-T changes had more cardiac events (unstable angina, myocardial infarction, mortality) than the patients without ECG changes (13/30 vs 2/30, p = 0.003). When the revascularized patients were compared to the non revascularized no significant differences were observed regarding myocardial infarction and mortality, however revascularized pts had a less significant incidence of rehospitalization for unstable angina (0/26 vs 8/42 p = 0.02). CONCLUSIONS: An individualized strategy can be effective in pts with unstable angina. In this study 76.4% of patients remained free of cardiac events during the follow-up, 23.6% had severe cardiac events and the cardiac mortality was 8.8%. The patients with transitory ST-T changes had more cardiac events and worse prognosis. No patients significant difference was observed in the revascularized versus non revascularized patients for myocardial infarction and mortality; however, the revascularized patients had less significant incidence of rehospitalization for unstable angina.     

Clinical outcomes, risk stratification and practice patterns of unstable angina and myocardial infarction without ST elevation: Prospective Registry of Acute Ischaemic Syndromes in the UK (PRAIS-UK)

AIMS: To determine characteristics, outcomes, prognostic indicators and management of patients with acute coronary syndromes without ST elevation. METHODS AND RESULTS: A prospective registry was carried out with follow-up for 6 months after index hospital admission. A history of acute cardiac chest pain was required plus ECG changes consistent with myocardial ischaemia and/or prior evidence of coronary heart disease. Patients with ST elevation or those receiving thrombolytic therapy were excluded. A total of 1046 patients were enrolled from 56 U.K. hospitals. The mean age was 66+/-12 years and 39% were female. The rate of death or non-fatal myocardial infarction at 6 months was 12.2% and of death, new myocardial infarction, refractory angina or re-admission for unstable angina at 6 months was 30%. In a multivariate analysis, patients >70 years had a threefold risk of death or new myocardial infarction compared with those <60 years (P<0.01) and those with ST depression or bundle branch block on the ECG had a five-fold greater risk than those with normal ECG (P<0.001). Aspirin was given to 87% and heparin to 72% of patients in hospital. At 6 months 56% received no lipid-lowering therapy at all. The 6-month rate of coronary angiography was 27% and any revascularization 15%. CONCLUSIONS: In this cohort there was a one in eight chance of death or myocardial infarction, and a one in three chance of death, new myocardial infarction, refractory angina or re-admission for unstable angina, over 6 months. Age and baseline ECG were useful markers of risk. Aspirin, heparin and statins were not given to about one-sixth, one-third and one-half respectively. Rates of angiography and revascularization appear low. A review of treatment strategies of unstable angina and myocardial infarction without ST elevation is warranted in the U.K. to ensure that patients are receiving optimum treatments to reduce mortality and morbidity.