The effect of complete and incomplete revascularization on exercise variables in patients undergoing coronary angioplasty

Pre-discharge exercise test for evaluation of patients with complete or incomplete revascularization following primary percutaneous coronary intervention: a DANAMI-2 sub-study

OBJECTIVES

It is unclear whether the completeness of revascularization impacts on the prognostic value of an exercise test after primary percutaneous coronary intervention (PCI).

METHODS

The DANAMI-2 trial included patients with ST elevation acute myocardial infarction randomized to primary PCI or fibrinolysis. Of the 790 patients randomized to primary PCI, 572 performed an exercise test. Prospectively, 310 patients were classified as having complete and 216 as having incomplete revascularization. Primary endpoint was a composite of reinfarction and/or death.

RESULTS

Patients with incomplete revascularization had lower exercise capacity [6.5 (95% CI: 1.9-12.8) vs. 7.0 (95% CI: 2.1-14.0) METs, p = 0.004] and more frequently ST depression [43 (20%) vs. 39 (13%), p = 0.02] compared to patients with complete revascularization. ST depression was not predictive of outcome in either groups, while multivariable analyses showed that exercise capacity was predictive of reinfarction and/or death in patients with incomplete revascularization [hazard ratio = 0.71 (95% CI: 0.54-0.93), p = 0.012] or of death alone [hazard ratio = 0.56 (95% CI: 0.41-0.77), p = 0.0003], which was not found in patients with complete revascularization.

CONCLUSIONS

Exercise capacity was prognostic of reinfarction and/or death in patients with incomplete revascularization, but not in completely revascularized patients. ST segment depression alone did not predict residual coronary stenosis or dismal prognosis.

Intracoronary basic fibroblast growth factor (FGF-2) in patients with severe ischemic heart disease: results of a phase I open-label dose escalation study

OBJECTIVES

Evaluate the safety, tolerability and preliminary efficacy of intracoronary (IC) basic fibroblast growth factor (bFGF, FGF-2).

BACKGROUND

FGF-2 is a heparin-binding growth factor capable of inducing functionally significant angiogenesis in animal models of myocardial ischemia.

METHODS

Phase I, open-label dose-escalation study of FGF-2 administered as a single 20-min infusion in patients with ischemic heart disease not amenable to treatment with CABG or PTCA.

RESULTS

Fifty-two patients enrolled in this study received IC FGF-2 (0.33 to 48 microg/kg). Hypotension was dose-dependent and dose-limiting, with 36 microg/kg being the maximally tolerated dose. Four patients died and four patients had non-Q-wave myocardial infarctions. Laboratory parameters and retinal examinations showed mild and mainly transient changes during the 6-month follow-up. There was an improvement in quality of life as assessed by Seattle Angina Questionnaire and improvement in exercise tolerance as assessed by treadmill exercise testing (510+/-24 s at baseline, 561+/-26 s at day 29 [p = 0.023], 609+/-26 s at day 57 (p < 0.001), and 633+/-24 s at day 180 (p < 0.001), overall p < 0.001). Magnetic resonance (MR) imaging showed increased regional wall thickening (baseline: 34+/-1.7%, day 29: 38.7+/-1.9% [p = 0.006], day 57: 41.4+/-1.9% [p < 0.001], and day 180: 42.0+/-2.3% [p < 0.001], overall p = 0.001) and a reduction in the extent of the ischemic area at all time points compared with baseline.

CONCLUSIONS

Intracoronary administration of rFGF-2 appears safe and is well tolerated over a 100-fold dose range (0.33 to 0.36 microk/kg). Preliminary evidence of efficacy is tempered by the open-label uncontrolled design of the study.

The degree of revascularization and outcome after multivessel coronary angioplasty

Incomplete revascularization is a common occurrence following angioplasty (PTCA) in patients with multivessel disease. To determine the short-term and long-term consequences of incomplete revascularization and the influence of the functional nature of the incomplete revascularization, 139 consecutive patients with multivessel disease were analyzed: 72 were completely revascularized and 67 had incomplete revascularization. The former patients had a lower incidence of prior myocardial infarction (MI) and prior bypass surgery (CABG). All patients had at least one lesion successfully dilated. In-hospital complications were insignificantly greater in incompletely revascularized patients compared with completely vascularized patients (mortality 3% versus 1%, MI 11% versus 4%, and emergency surgery 5% versus 0%). After 1 year of follow-up, incompletely revascularized patients had similar outcomes (mortality 6% versus 3%, MI 13% versus 7%, CABG 18% versus 15%, and repeat PTCA 19% versus 31%). The degree of incomplete revascularization was categorized as functionally adequate if all stenoses in bypassable vessels supporting viable myocardium were successfully dilated. Significantly fewer adverse events (death, MI, or CABG) occurred in the functionally adequate group than in the functionally inadequate group (27% versus 6%, p less than 0.04). This study demonstrates that incompletely revascularized patients have a favorable 1-year outcome and that patients with incomplete but functionally adequate revascularization have long-term results comparable with those of patients with complete revascularization. This study emphasizes the need to assess the functional significance of a stenosis when considering incomplete revascularization in a patient with multivessel disease.