Role of percutaneous transluminal coronary angioplasty in multivessel disease

Early reinfarction after fibrinolysis: experience from the global utilization of streptokinase and tissue plasminogen activator (alteplase) for occluded coronary arteries (GUSTO I) and global use of strategies to open occluded coronary arteries (GUSTO III) trials

BACKGROUND

Trials report a 2% to 6% incidence of reinfarction after fibrinolysis for acute myocardial infarction (MI). We combined the Global Utilization of Streptokinase and Tissue plasminogen activator (alteplase) for Occluded coronary arteries (GUSTO I) and Global Use of Strategies To Open occluded coronary arteries (GUSTO III) populations to better define frequency, timing, and clinical predictors of in-hospital reinfarction.

METHODS AND RESULTS

In 55 911 patients with ST-segment elevation myocardial infarction (MI) who were receiving fibrinolysis, we compared baseline characteristics and mortality rate by reinfarction incidence and developed multivariable logistic regression models to predict in-hospital reinfarction and composite of death or reinfarction. Reinfarction occurred in 2258 patients (4.3%) a median of 3.8 days after fibrinolysis; rates did not differ between GUSTO I (4.0%) and GUSTO III (4.2%) or by fibrinolytic assignment (streptokinase, 4.1%; alteplase, 4.3%; reteplase, 4.5%; combined streptokinase and alteplase, 4.4%; P=0.55). Advanced age, shorter time to fibrinolysis, non-US enrollment, nonsmoking status, prior MI or angina, female sex, anterior MI, and lower systolic blood pressure were associated significantly with reinfarction. Patients with reinfarction had higher mortality at 30 days (11.3% versus 3.5% without reinfarction; odds ratio, 3.5; P<0.001) and from 30 days to 1 year (4.7% versus 3.2%; hazard ratio, 1.5; P<0.001). Significant multivariate predictors of in-hospital death or reinfarction included age, Killip class, systolic and diastolic blood pressures, heart rate, anterior MI, smoking status, prior MI, sex, and country of enrollment (all P<0.001).

CONCLUSIONS

Reinfarction occurs infrequently after fibrinolysis but confers increased risk of 30-day and 1-year mortality. Some predictors of reinfarction differ from known predictors of death after MI. Improved treatment and prevention strategies for reinfarction deserve study.

Platelet membrane activation markers are predictive for increased risk of acute ischemic events after PTCA

BACKGROUND

We wished to investigate whether platelet activation is related to the clinical outcome during the 24 hours immediately after elective percutaneous transluminal coronary angioplasty (PTCA).

METHODS AND RESULTS

In 102 patients with high-grade coronary stenosis admitted for elective PTCA, preprocedural platelet activation was characterized by flow cytometric measurement of the proteins CD62, CD63, and thrombospondin expressed on the platelet surface membrane. The prevalence of acute ischemic events during the 24 hours immediately after the procedure was then related to the pre-PTCA platelet activation status. Fifty-six patients were classified as "nonactivated," whereas 46 patients showed an increased percentage of activated platelets. Two patients developed acute occlusion (1.96%) and four patients high-grade restenosis (3.92%), as confirmed by second-look coronary angiography. All events occurred in patients classified as "activated" (six of 46, or 13%). None of these patients received beta-blocker medication, which was associated with lower expression of platelet membrane activation markers. In the nonactivated patient group, no clinical events were found (0 of 56, or 0%). This difference in prevalence is significant (p = 0.007).

CONCLUSIONS

We conclude that analysis of platelet membrane activation markers may help to predict an increased risk of acute ischemic events after angioplasty.

Angioplasty versus bypass surgery for multivessel coronary artery disease with left ventricular ejection fraction < or = 40%

Patients with multivessel coronary artery disease and left ventricular dysfunction represent a high-risk subgroup in whom coronary artery bypass grafting has been shown to improve survival compared with that of medically treated patients. The comparative benefits and risks of coronary angioplasty and bypass surgery in this subgroup of patients are unclear. This study retrospectively analyzes 100 consecutive patients treated with bypass surgery compared with a matched, concurrent cohort of 100 treated with multivessel angioplasty. Early results favored angioplasty; a hospital stay of 12.8 days was noted in the bypass group compared with 4.3 days in the angioplasty group (p < 0.001). In-hospital mortality rates were similar in the bypass (5%) and angioplasty (3%) groups (p = NS). Stroke was observed significantly more often in the bypass group (7 vs 0%). However, late follow-up favored bypass patients; repeat revascularization procedures and late myocardial infarction occurred more frequently during follow-up in the angioplasty group. During 5-year follow-up, superior relief from disabling angina (99 vs 89%; p = 0.01) and a trend toward improved survival (76 vs 67%; p = 0.09) were observed in the bypass group as compared with the angioplasty group. Multivariate correlates of late mortality included age and incomplete revascularization, but not mode of revascularization. Thus, in patients with multivessel coronary artery disease and left ventricular dysfunction, early results favor angioplasty, whereas late follow-up favors bypass surgery. However, late survival was similar in both groups of patients who were completely revascularized.

Long-term efficacy of triple-vessel angioplasty in patients with severe three-vessel coronary artery disease

Between May 1982 and December 1988, a total of 103 patients underwent angioplasty of all three major coronary arteries at a single institution. Angiographic success was achieved in 334 of 352 vessels (95%) and in 441 of 460 lesions (96%). No patients required urgent bypass surgery, and none died during the procedure; six had non-Q wave infarctions. The mean length of follow-up time was 49 +/- 15 months (range 28 to 107 months). There have been 11 deaths, and one patient has undergone cardiac transplantation. Thirty-six patients had a clinical recurrence; 30 had repeat angioplasty and five had bypass surgery. Another nine patients eventually had bypass surgery after the clinical recurrence. At 48 months actuarial event-free rates are myocardial infarction, 98%; bypass surgery, 88%; and death, 89%. Of 86 current survivors, 58 are in functional class O to I, 21 are in class II, and seven are in class III.

Comparison of percutaneous transluminal coronary angioplasty versus coronary artery bypass grafting for multivessel coronary artery disease

Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) are both widely performed in the treatment of multivessel coronary artery disease. Little data directly compare the outcomes of patients treated with these 2 techniques. We examined the characteristics and outcomes of 152 patients who underwent multivessel PTCA and 134 patients who had multivessel CABG. Patients who had prior PTCA or CABG were excluded. Baseline characteristics such as age, sex, and prior myocardial infarction were similar in the 2 groups. Ejection fraction was significantly lower in the CABG group (48 +/- 14%) versus the PTCA patients (53 +/- 15%) (p = 0.002). Narrowing distribution when analyzed by major vascular beds (left anterior descending, circumflex and right coronary arteries) as well as by individual arteries was not significantly different between the groups when left main stenosis was excluded. The surgical group received a larger number of bypasses per patient (3.9) when compared with narrowings dilated in the angioplasty group (3.7) (p less than 0.001). The left internal mammary artery was used in 75% of patients as one of the grafts. Angioplasty success was 95% by standard criteria. Over a mean follow-up of 110 weeks for PTCA patients and 134 weeks for CABG patients the occurrence of death was similar (10 and 14%, respectively) as was myocardial infarction (4 and 2%, respectively). However, all other cardiac events including subsequent cardiac catheterization (49 vs 10%), PTCA (30 vs 2%) and CABG (23 vs 2%) occurred significantly more often in the PTCA group (all p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Prognosis of culprit lesion PTCA in acute myocardial infarction for multi versus single vessel disease

We studied 417 patients undergoing single vessel culprit lesion percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction to determine the impact of disease in other vessels. Group A (189 patients, 45%) had coronary artery disease (greater than or equal to 70% stenosis) in at least 1 additional vessel while Group B (228 patients, 55%) did not. The groups were similar in sex distribution (A = 75% male, B = 76%), number of lesions in the single culprit vessel dilated (1 lesion in 83% A, 80% B), and PTCA success (A = 92%, B-94%) (all p = NS). Group A patients were older (63 +/- 10 vs. 56 +/- 11 years) and had more prior myocardial infarctions (27% vs. 7%), and more prior coronary artery bypass grafting (15% vs. 0.4%) (all p less than .01). Group A patients were more likely to have repeat catheterization (48% vs. 32%, p less than .005) although restenosis of the infarct-related vessel was similar (A = 24%, B = 16%) (p = NS). Group A was more likely to need angioplasty in a 2nd vessel (23% vs. 8%) and to need coronary artery bypass grafting (20% vs. 8%) (both p less than .001). Cumulative mortality was higher in Group A at 1 month (10% vs. 5%), 1 year (11% vs. 6%), and long-term (13% vs. 7%). This difference appeared to be due to the impact of lower mean ejection fraction in Group A.

CONCLUSION

Treatment of acute myocardial infarction by direct PTCA of the culprit lesion can be performed with a high likelihood of success in patients with or without multivessel coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous coronary angioplasty in 1,001 multivessel coronary disease patients: an analysis of different patient subsets

The prospectively collected data of 1,001 multivessel coronary disease patients who underwent percutaneous transluminal angioplasty (PTCA) was analyzed after categorization into single vessel angioplasty (SVA; group I) and multiple vessel angioplasty (MVA; group II) PTCA groups, which were each compartmentalized into "simple" (group A) and "complex" (group B) cohorts. Patients were assigned to the SVA or MVA group according to the physician's pre-PTCA assessment of how many lesions would be attempted (intention to treat) and not the number of lesions actually attempted. A "simple" patient was more likely than a "complex" patient to be clinically improved after PTCA whether or not the patient had a single dilatation (90% vs 78%; P less than 0.05) or multiple dilatations (97% vs 94%; P<0.05). Similarly, a lesion(s) was more likely to be successfully dilated in the "simple" than in the "complex" group (SVA: 90% vs 82%, P less than 0.05; MVA: 97% vs 91%, P<0.05). In addition, occluded vessels in the MVA group were more likely to be recanalized than in the SVA group (73% vs 44%, P less than 0.05). Group I-A patients had a significantly increased (10%) incidence of emergency bypass surgery. Follow-up, at 84 months, showed that "simple" cohorts had a better survival than the "complex" cohorts (MVA: 95% vs 71%, P less than 0.05; SVA: 90% vs 72%, P less than 0.05); and, nearly two thirds of all successful PTCA patients were angina free.(ABSTRACT TRUNCATED AT 250 WORDS)

Multivessel coronary angioplasty from 1980 to 1989: procedural results and long-term outcome

From June 1980 to January 1989, 3,186 patients had coronary angioplasty of two (2,399 patients) or three (787 patients) of the three major epicardial coronary systems. A mean of 3.6 lesions (range 2 to 14) were dilated per patient, with a 96% success rate. Acute complications were seen in 94 patients (2.9%) and included Q wave infarction in 47 (1.4%), urgent coronary artery bypass surgery in 33 (1%) and death in 31 (1%). Multivariate correlates of in-hospital death included impaired left ventricular function, age greater than or equal to 70 years and female gender. Complete long-term follow-up data were available for the first 700 patients and the follow-up period averaged 54 +/- 15 months in duration. Actuarial 1 and 5 year survival rates were 97% and 88%, respectively, and were not different in patients with two or three vessel disease. By Cox regression analysis, age greater than or equal to 70 years, left ventricular ejection fraction less than or equal to 40% and prior coronary artery bypass surgery were associated with an increased mortality rate during the follow-up period. Repeat revascularization procedures were required in 322 patients (46%). Restenosis resulted in either repeat angioplasty or bypass surgery in 227 patients (32%). Repeat coronary angioplasty was performed for isolated restenosis in 126 patients (18%), for restenosis and disease progression at new sites in 85 patients (12%) and for new disease progression alone in 54 patients (8%). Coronary bypass surgery was required in 110 patients (16%) during the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal angioplasty in patients with multivessel coronary disease: how important is complete revascularization for cardiac event-free survival?

The relative influences of revascularization status and baseline characteristics on long-term outcome were examined in 867 patients with multivessel coronary disease who had undergone successful coronary angioplasty. These patients represented 83% of a total of 1,039 patients in whom angioplasty had been attempted with an in-hospital mortality and infarction rate of 2.5% and 4.8%, respectively. Emergency coronary bypass surgery was needed in 4.9%. Of the 867 patients, 41% (group 1) were considered to have complete revascularization and 59% (group 2) to have incomplete revascularization. Univariate analysis revealed major differences between these two groups with patients in group 2 characterized by advanced age, more severe angina, a greater likelihood of previous coronary surgery and infarction, more extensive disease and poorer left ventricular function. Over a mean follow-up period of 26 months, the probability of event-free survival was significantly lower for group 2 only with respect to the need for coronary artery surgery (p = 0.004) and occurrence of severe angina (p = 0.04). The difference in mortality was of borderline significance (p = 0.051) and there were no significant differences between groups 1 and 2 in either the incidence of myocardial infarction or the need for repeat angioplasty. Multivariate analysis identified independent baseline predictors of late cardiac events that were then used to adjust the probabilities of event-free survival. This adjustment effectively removed any significant influence of completeness of revascularization on event-free survival for any of the above end points including the combination of death, myocardial infarction and need for coronary artery surgery. Therefore, late outcome in these patients is not significantly influenced by revascularization status but depends more on baseline patient characteristics.

Advances in interventional cardiology

The field of interventional cardiology is growing widely. This growth is the result of improvements in existing technology, development of new technology, and expansion of criteria for the selection of patients. Percutaneous transluminal coronary angioplasty (PTCA) remains the mainstay and is used to treat an increasing number of patients with coronary artery disease that manifests as stable or unstable angina or acute myocardial infarction. Atherectomy is being used to "debulk" lesions and remove atheromatous plaque as well as to remove intimal flaps after PTCA. The insertion of an intracoronary stent is a strategy designed to treat intimal dissections and acute closure as well as to attempt to decrease the incidence of restenosis. Finally, intracoronary laser therapy--independently or in combination with PTCA--is being evaluated as a treatment approach for more diffuse disease, acute occlusion, and prevention of restenosis.

Percutaneous transluminal coronary angioplasty: a review of current balloon dilatation systems

The interventional cardiologist is faced with an expanding armamentarium for performing percutaneous transluminal coronary angioplasty (PTCA). Because of rapid advances in technology, new devices are produced on a regular basis, making it difficult to maintain a working knowledge of what is available. Although several excellent textbooks about PTCA have been written, descriptions of available equipment are usually obsolete by the time publication occurs. In order to provide succinct specifications of equipment, we have documented data on balloon catheters, guiding catheters, and guidewires. This information may be useful in the selection of appropriate equipment for PTCA procedures. In addition, the publication of such data in a monthly periodical may provide a more current overview of equipment; information may be occasionally updated as new equipment is released.

A new approach for dilation of bifurcation stenoses: the dual probe technique

When coronary balloon angioplasty is performed on lesions that involve a major bifurcation in the coronary arterial tree, side-branch occlusion often results. Previously described strategies for avoiding this problem have been cumbersome and relatively impractical for routine application. In this report, we describe a simple method of dilating bifurcation lesions, made possible by recent innovations in angioplasty equipment. Two individual Probe dilation catheters are passed through a triple-armed Duostat adapter into a single guiding catheter. The bifurcation lesions are then sequentially traversed with the Probe catheters, after which the balloons can be inflated simultaneously or serially. Our early experience with this technique suggests that it is a safe, simple, and effective method to dilate bifurcation stenoses.