Role of percutaneous transluminal coronary angioplasty in patients with variant angina and coexistent coronary stenosis refractory to maximal medical therapy

Incidence of spontaneous and provoked coronary spasms after percutaneous transluminal coronary angioplasty

We studied the incidence of spontaneous and ergonovine-induced coronary arterial spasm during repeat coronary angiography in 96 consecutive patients with single-vessel disease who had undergone successful angioplasty. Follow-up angiography was performed after a mean of 6 months (1-8 months). Sixty patients demonstrated no restenosis and in 36 patients restenosis (greater than 50% restenosis) occurred. Spasms of the arteries at the site of dilatation were significantly (P less than 0.001) more frequent in patients with restenosis (18/36; 50%) than in patients without restenosis (4/60; 7%). Before angioplasty, no differences were found in the clinical characteristics between the two groups. Likewise, the morphologic results of angioplasty were identical. Despite long-term treatment with nifedipine (30-60 mg daily) and aspirin (0.5 g daily), 14 of 18 patients with restenosis and coronary spasm suffered from spontaneous angina, as compared to only 3 of 18 patients with restenosis without demonstrable spasm. Three of the 4 patients without restenosis but with detectable spasm were also symptomatic. Thus our findings suggest that spasm of the coronary arteries achieves some importance as a pathophysiological factor for recurrence following coronary angioplasty.

Influence of a variant angina on the results of percutaneous transluminal coronary angioplasty

Nineteen (86%) of 22 patients with variant angina and important coronary stenoses (greater than 60%) had successful percutaneous transluminal coronary angioplasty. The acute complications in two patients were not caused by coronary spasms but by dissection with disturbance of perfusion. One of these two patients required a coronary bypass graft; the other was treated conservatively. Myocardial infarction developed in both patients. Despite long term administration of nifedipine (30-80 mg daily), restenoses occurred within six months (on average after 10 weeks) in nine patients with symptoms and one without. In four patients the restenoses exceeded the degree of stenosis before angioplasty. Five patients were revascularised by surgical means. Vessels in three out of four patients were later successfully dilated. After a mean period of observation of 24 months (6-51 months) 18 of the 19 patients are symptom free and do not require medication. The results confirm that angioplasty is an effective method of treating patients with variant angina and important coronary stenoses. The problem of the high frequency of restenosis, however, remains unresolved.