Percutaneous Transluminal Coronary Angioplasty for Rest Angina Pectoris Requiring Intravenous Nitroglycerin and Intraaortic Balloon Counterpulsation Douglass A. Morrison, MD, with the technical assistance of Charles Barbierre, RN, Amy Cohan, RN, MN, Mary Ann Olsen, CMA, Ray Stovall, CNMT, and Dianne Wolff, CCRN

In selected patients with medically refractory rest angina, percutaneous transluminal coronary angioplasty (PTCA) might be a reasonable alternative to coronary artery bypass graft surgery. Between January 1987 and November 1989,l operator at a Veterans Administration center performed PTCA on 73 vessels in 56 patients with rest angina of sufficient severity to require intravenous nitroglycerin in all 56 and intraaortic balloon counterpulsation (IABP) in 18. Of the 56 patients, 17 (30%) had l-vessel disease, 14 (25%) had P-vessel disease and 25 (45%) had 3-vessel disease; 14 (25%) had ll prior bypass surgery, 35 (62.5%) were within 30 days of an acute infarction, 12 (21%) had left ventricular ejection fraction 70 years of age. PTCA was successful in 61(64%) vessels and 47 (64%) patients (21 vessel plus relief of angina). During index hospitalization, there were 2 deaths (3.6%), 4 myocardial infarctions (7.2%), 4 emergent bypass surgeries (7.2%) and 1 semiemergent bypass (1.8%) for technically unsuccessful PTCA. In follow-up from 3 to 36 months, there has been 1 additional myocardial infarction (l.S%), 1 late death (l.S%), 2 repeat PTCAs (3.6%), 6 crossovers to bypass (10.7%) and 36 patients (66%) have remained cardiac-event free. Although this angioplasty cohort is small and selected, these data raise the possibility that a prospective randomized comparison of PTCA versus bypass surgery might be feasible and appropriate in a subset of unstable angina patients who require intravenous nitroglycerin or IABP. (Am J Cardiol1990;66:166-171)

From the Denver Veterans Administration Medical Center, Denver, Colorado. This study was supported in part by the Research Service, Denver Veterans Administration Medical Center, Denver, Colorado. Manuscript received February 13, 1990; revised manuscript received and accepted March 15, 1990. Address for reprints: Douglass A. Morrison, MD, Cardiology (11 lB), Denver Veterans Administration Medical Center, 1055 Clermont Street, Denver, Colorado 80220.

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ercutaneous transluminal coronary angioplasty (PTCA) has proved to be effective in relieving symptoms in selected patients with unstable angina.1-20 Nevertheless, the question as to which patients with unstable angina might be better served with PTCA than either medical therapy or coronary artery bypass graft surgery is an area of controversy.21,22 For example, a number of observational studies have suggested higher rates of acute occlusion and/or restenosis for patients with unstable angina as compared to patients with stable angina.5~9~11~13~17~20~22 Similarly, because emergent bypass surgery for failed PTCA can be expected to carry significantly higher risks than elective or semielective bypass surgery in the same patients, many centers avoid PTCA in unstable patients deemed to have a high operative risk.23,24 We considered PTCA as an alternative to high-risk bypass surgery.25 Several subsets of unstable angina patients with a high operative risk have been identified.26 Two such subsets were the subsets of patients requiring intravenous nitroglycerin and intraaortic balloon pumping (IABP).26 This study reviews our experience with consecutive patients in these subsets. The results are presented to consider the possibility of a prospective randomized trial of PTCA versus bypass in these unstable angina subsets. METHODS Patient population:

Fifty-six patients with rest angina, which necessitated intravenous nitroglycerin and intraaortic balloon pumping (n = 18), and who underwent coronary angioplasty (PTCA) between January 1987 and November 1989, constitute the study population (Table I). All subjects, except 2, were men with ages ranging from 36 to 76 years of age. Medical therapy was as prescribed by the medicine and cardiology attending staffs; specifically, 34 of 56 patients were on aspirin 325 mg daily, 38 of 56 were on either nifedipine or diltiazem, 24 of 56 were on p blocker (propranolol, metoprolol or atenolol) and 48 of 56 patients were on continuous heparin infusion. There were 17 (30%) with l-vessel coronary artery disease, 14 (25%) with 2-vessel disease, and 25 (45%) with 3-vessel disease. Of the 56 patients, 14 (25%) had I1 prior coronary artery bypass graft operation, 35 (62.5%) were within 30 days of an acute infarction, 12 (21%) had left ventricular ejection fraction 70 years old.

TABLE

I Patient

Population

I Intravenous Nltroglycerln n = 56 (%)

CAD

17 (30)

2-vessel CAD 3-vessel CAD Prior CABG Angina (70 yrs Left ventricular ejectIon

l-vessel

14 (25) 25 (45) 14(25) 35 (62.5) 7 (12.5) 12/42

fraction

70 years old; 5 of 10 had left ventricular ejection fraction 2 orthogonal views. Cine films were reviewed by L2 angiographers,including the primary angioplasty operator and > 1 cardiothoracic surgeon.Stenosesare expressedas a percentage of the normal artery diameter with >50% being considered significant. Angioplasty: The decisionto perform coronary angioplasty in our hospital is subject to a weekly conference attended by all cardiologists and cardiothoracic surgeons.The target lesionswere all graded as >70% stenosisby consensusof the conference. Decisionsregarding emergency angioplasty are always made in consultation with the cardiac surgeon. All angioplasties were performed by 1 operator (DAM). Vesselsin which angioplasty was attempted are listed in Table II. Commercially available guiding catheters, wires and balloon catheters were used. Whenever over the wire systemswere used, the balloon catheter was flushed with saline and the mean gradient acrossthe lesion was recorded before and after angioplasty whenever possible. Procedural policies were as follows: maximal inflation pressurewas 1 atmosphereabove full inflation and/ or >_7 atmospheres2’;a maximal inflation duration of 160 secondswas strived for if the patient would tolerate this duration; all patients were given 10,000 U intravenous heparin at the start of the procedure and an additional 5,000 U intravenous heparin was given if the procedure took >2 hours; 5,000 U heparin intracoronary was given at the completion of the case; all patients were kept on heparin infusion 112 to 18 hours after the procedure; and all were given 2.5 mg oral coumadin daily after the angioplasty to discharge; all patients were kept on aspirin and a calcium blocker (diltiazem or nifedipine) indefinitely. Intraaortic balloon counterpulsation was discontinued 4 hours after the

Percutaneous

Intravenous Nltroglycerln Left anterior descending Right coronary artery or postertor descending artery Circumflex, obtuse marginal Diagonal Saphenous vein graft Left internal mammary artery IABP = Intraaortlc

balloon

Transluminal

Attempted (n = 73)

IABP (n = 22)

26 18

8 4

16 2 10 1

6 1 3 0

p”mp,ng

heparin was stopped in the 13 successfulPTCA patients who required it during angioplasty. Patients were kept at bed rest for 24 hours after the sheathswere removed. Of the 47 patients with successfulPTCA, 41 underwent symptom-limited exercise testing within 1 week of the PTCA. Of the 13 IABP patients with successful PTCA, 11 underwent symptom-limited exercise testing within 1 week of PTCA. Complications-follow-up: A single page registry data sheet is filled out by the cardiology fellow who assistson each angioplasty.‘” For long-term follow-up, the patients and/or their referring physicians were contacted by phone. RESULTS Angiography and gradient: The target lesions were all assessed to be >70% narrowed in all 56 patients before angioplasty; 7 were total occlusions. After procedure, 47 of 56 patients had 21 artery graded as 170%; all of these were improved by 230%. Five patients had acute occlusive syndromesand 1 patient had technically unsuccessfulPTCA. The technical failure was not accompanied by clinical deterioration and the patient went to surgery semielectively. Four patients went to emergent coronary artery bypass graft (3 had occlusive syndromes; 1 had a large dissection but was clinically stable). Translesional gradients were measured in 37 vesselsin 35 patients. Before PTCA, the gradient was >20 mm Hg in 34 of 37 lesions.After PTCA, the gradient was 120 mm Hg in 35 of 37 lesions. Clinical results: short-term or in-hospital: With the exception of the 1 technically failed angioplasty and the 4 emergency coronary artery bypass graft and 4 acute myocardial infarctions, the remaining 47 successfulpatient angioplasties were accompanied by relief of rest angina (Table III). All together, 41 of 47 patients underwent exercise testing and 41 were completely asymptomatic. Complication: short-term: There were 2 deaths and 4 myocardial infarctions subsequentto angioplasty during the index hospitalization. As above, 4 patients underwent emergency bypass; 1 patient died during surgery as a result of a tear of the left atrium (the 1 emergent bypass surgery patient who did not have an occlusive syndrome). The 1 semielective surgery for technically failed angioplasty was uncomplicated. There were no complications of the short-term intraaortic balTHE AMERICAN

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TABLE

III

In-Hospital

TABLE

Course Intravenous Nitroglycerin n = 56 (%)

Successful PTCA Patients Vessels Complications Death Myocardial infarction Emergent coronary artery bypass graft Elective coronary artery bypass grafting PTCA = percutaneous

transluminal

47 (84)

61GW

coronary

Event-free Death Myocardial infarction Repeat PTCA CABG

13 (72) 16 (73) l(5.5) l(5.5) 1 (5.5)

l(l.8)

l(5.5)

CABG = coronary PTCA = percutaneous

angoplasty

loon counterpulsation used in a total of 18 patients undergoing angioplasty. Clinical results: long-term: Follow-up of these patients has ranged from 3 months to 36 months (Table IV). There have been 6 late crossovers to surgery and 2 patients have required repeat angioplasty. There has been 1 late death and 1 late myocardial infarction after the index hospitalization. DISCUSSION

Percutaneous transluminal coronary angioplasty can be an effective means of improving coronary flow and relieving angina.lm20 Although patients with both multivessel anatomy and unstable physiology have been successfully treated with PTCA, the exact role of PTCA relative to either medical therapy or bypass surgery is not always clear and complication rates appear to be higher than in stable patients.21,22,28 In this retrospective study, patients with rest angina of sufficient severity to require intravenous nitroglycerin and IABP who underwent PTCA are reviewed. In our hospital, the use of intravenous nitroglycerin and IABP imply medically refractory rest angina. Similarly, undergoing PTCA implies at least one >70% epicardial coronary artery narrowing. Accordingly, these are patients with documented coronary disease (70% had multivessel disease) and rest angina that was medically refractory. The remaining treatment options were PTCA or bypass surgery. A major problem in the study of care for patients with unstable angina has been the diverse patient groups that have been lumped together under the general category of unstable angina.21,22 From a number of excellent studies, specific groups with particularly unfavorable short-term prognoses have been identified. Among these groups are the following: rest angina; medically refractory angina; and rest angina early after an acute myocardial infarction. All of the patients in this study had medically refractory rest angina and 62.5% were within 30 days of an acute myocardial infarction. Additional cardiac factors predictive of a poor outcome for these patients included (Table I) age >70 years (12.5%), left ventricular ejection fraction m patuzntu uith urxtnblc angina pcctorn 4n1 Hcarr .I lvl?l,lO2~/-v. 5. dcFc)ter PJ. Serru!, I’\+‘. van den Brand M. Balakumaran K. Mochtar B, Soward .4L. :\mold i\ER. Hugenholtr PG. Emergenq coronaq angmplaq in refractor) unstable angina .\ Enfil J Med /985;3/3;342-346. 6. deFe>ter PJ. Sur)apranata H. Scrruys PW. Beat KJ. van Domburg R. Van den Brand M. Hugcnholtr PG. Coronar) angloplasty for unstable anginaummcdiate and late results in 200 consecutive patients with identification of rirk lhctors for unfavorable early and late outcome. ./.4(-C /VX8:/2:~24-~~j. 7. Kamp 0. Beatt KJ. defeyter PJ. van den Brand M, Sur)apranata H. Lui~tan Ht:. Serruys PW. Short. medium and long term follow up after percutaneou\ transluminal coronary angiopla~t) for stable and unstable angina pectoris. Aw Hmrt J /V8V:li7 VYI-YYO. 8. Meyer J. Schmitt H. Kicsslich T . Erbel R. Krebs W. Schulz W, Bardos P. Minalc C. Brunt JM, Effert S. Percutnncouc transluminal coronary angioplaa) an patients with stable and unstable angina: ,malyv\ of earl) and late reu~lt\. .4/x llrur~ J /V8~,106.Y7j ~YXO 9. Qulgley P. Erwin J. Maurer BJ. Walsh ,MJ, Geart) GF Percutaneous transluminal angioplasty in unstable angma. comparison with atable angina. Br Henrf J /985;55:?27-230. 10. TimmiP A, Griffin B. Crick JCP. Sowton E. Early percutaneous translummal coronary angiophy in the management of urxtable angina INI J Cardml /987:14:2S-3/. 11. Sharma B, Wyeth K, Kolath GS. G~rncncz 11.1, Frnncio\a .JA. Pcrcutaneou~ tr.msluminal coronar) anglopla\t\ of one vesuzl for refrxtorq unstable angina pectoris: efficacy m smgle and multnewl disease. Hr //cur/ J /9&'59.2KU 2X6. 12. Leeman D. McCabe C. Fxwn 0. Lorell BII. Kellet MA, McKq Rti. Larricchione T . Bnim DS. Useof percutaneous transluminal coronary angioplasty and bypas? surgery despite m~provcd medical therapy for unstable angmn pcctoris. 4171 J Canlml lV88;6/ .3RG- 44G 13. Plokker II. ‘Gnat S. Bel E. van den Berg ECJM. Mast GEC. van dcr Felt/ rk Ascoap CAPL Percutaneous tr:m\lummaI coronary angloplahty m pat&t\ H ith unstable angma pectori\ refractor) to medical therxpq: long term clinical and .mgiographlc reults. C'nthrt ~hrdio~~s~~ l)iap /VKN;/4-15 IX. 14. deFeyter P. Serruys P. Soward .A, ban den Brand M, Bo, E. llugenholtr PG. Coronar! ang~oplnst> for carI> postinfarction unstable angina. Crrctrlor~o,~

/986,74.1365-1370. 15. deFcytcr P. Serruys P. Surqapranata II, Beat K. van den BraId M. Coronar> angioplast! earl) after dlagnosi, of unstable angina. An? //an J /9X7;/ 14.4X 54. 16. Gottheb S, Walfoord G, Ouyang P. Gerstenblith G. Brln KP. Mclht\ ED. Riegel MB. Brmker J.4. Initial and late results of coronarq anguplaaty for earl> patinfarction unstable angina. Cather Cnrdiornsr Drop /YX7:/3-Y3YY. 17. Safian R. Snyder L, Snyder B. McKay RG. Lorcll BH, Aroeht) JM. Pasternak RC. Bradley AB. Monrad ES. Bairn DS. UsefulnesT of percutaneous transluminai coronaq angioplast) for unstable anglnn pectoris alter non-Q-wave acute myocardial infarction. ,lnz J Cordial /YX7:>Y:263-266. 18. Steffenino G. M&r B, f-inci I.. Rutishauser M’ FoIlon-up result\ of trcatmrnt of unstable angina by coronar) angioplaaty. Br Hrarf J /987;57:4/&4/Y. 19. llolt G. Sugrue D, Bresnahan J. Vliestra Rt. Bresnahan UK. Reeder GS, Holmes DR Jr. Results of pcrcutancous translummal coronar) angloplasty for unstable nngma pectorls in patients 70 bearc of age and older. Au! J Chrdml /988:6/:994-997. 20. Pcrr) R. Seth .A. I lunt A, Shlu MF. Coronary angioplastq in unstable angina ;and stable angina: a comparison of SUCCC~S and complication? b’r Herr J lVKK,60:367-372. 21. Conti CK, Hill JA. Mayfield WK. Unstable angina pectori,: pathogenwa and management. C‘urr Proh Cardiol /989:/4:55/-623. 22. deFeyter PJ Coronaq angioplasty for unstable angina. .4nl Henrr J /YR9~118.R60 MR. 23. Norell MS, Lyon\ J, I.ayton C, Balcon R Outcome of early surger) after coronaq angioplast). Br Hurr J lYR6;55.223 226. 24. lurph) DACraverJM. Jone\EL.GruentrigAR. KmgSB 111, IlatcherCK Jr Surgical revascularization following unsuccessful percutaneous tran,lummal coronary angioplasty. J Thorac Cardiomw Surg 1YX2S4.342 348. 25. Wohlgelertncr D. Clenan M, HIghman HA, Zarct BI. Percutaneous translutminal coronaq angioplasty of the “culprit” lesion for management of unstable angina pcctori\ in pnticnts with multivcsxl coronnry artcr) dlscasc. An, J Cardiol /986.58:460 464. 26. Grover t’, Hammerm&ter Kh. Burchfvzl C and the VA Cardlothoracic Surgeons Initial report of the VA pre-operative ri$k assessment study for cardiac surgery. Ann 'Thhorac Surg IYYO, in prrss. 27. M&r B, Gruentzig AR, King SB Ill. Douglas JS. Hollman J. lschinger 1. Galan K. Highcr balloon dilatatton prcssurc in coronary angioplasty. An? Hem .I /9R4;107:6/9-622. 28. Brcdlau CE. Roubin GS. Lcimgrubcr PP. Dougla?, JS Jr. Kmg SB III, &cur&g AR. In hospital morbidit) and mortahty in patients undergolog elective cmmary angiopla\t! (‘vi ulnrron lY85;72:/044 /OS? 29. Dimaa .A, Loop 1:. WhItIon P. H&man J. Lktle B, France I. Cosgrove 0. Taylor P, Rogers A. Ilcal) B. Editorial: treatment wxtegy for coronq artcq disease: d balancing act. Clew C‘lirr J Mrd IY90.57 /Y-2/.

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Percutaneous transluminal coronary angioplasty for rest angina pectoris requiring intravenous nitroglycerin and intraaortic balloon counterpulsation.

In selected patients with medically refractory rest angina, percutaneous transluminal coronary angioplasty (PTCA) might be a reasonable alternative to...
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