BRIEF REPORTS

Percutaneous With Unstable

Transluminal Coronary Coronary Syndromes

Carlos Rizo-Patron, MD, Nidal Hamad, and Earl Beard, MD

MD, Richard

Paulus, MD, Jorge Garcia, MD,

oronary artery disease is a common and crippling C condition in the elderly population. It is estimated that limitation of activity and compromised cluality of life occurs in 85% of men and 55% of women in older age groups (>75 years) who have cardiovascular disease.’ Little information has been reported regarding the outcome of percutaneous transluminal coronary angioplasty (PTCA) in octogenarians with unstable coronary syndromes. This is because older patients are usually excluded from randomized trials for interventional treatment, and today such treatment modalities are usually avoided unless they prolong longevity. This report documents our experience with PTCA in a group of elderly patients with unstable coronary syndromes. For this study, a special computerized data base was formulated from retrospective reviews of medical records, cineangiograms and patient interviews. From July 1987 through June 1989, 53 elderly patients (mean age, 83 years; range 80 to 89) underwent PTCA for unstable coronary syndromes (Figure 1) that included angina at rest, progressive angina and early postinfarction angina. There were 31 menand 22 women in the study. Significant multivessel disease was observedin 38 patients. Thirteen patients (25%) had previously undergonecoronary artery bypass surgery (mean interval, 13 years) and 14 (26%) had experiencedprevious myocardial infarction. In the overall group, mean left ventricular ejection fraction was 45% (range 20 to 60%). The electrocardiogram was normal in only 10 patients. Ischemic ST- and T-wave changes were observed in 23 patients during pain. Before undergoing PTCA, all patients received 12 antianginal medications, including oral nitrates, P-adrenergic or calcium channel blockers; 21 patients were given nitroglycerin intravenously. Aspirin was given when not contraindicated. Informed consentwas given in all cases.All procedures wereperformed usingstandard steerable guidewires and dilation catheters. PTCA wasattempted in the most significant (culprit) lesions:1-vesselPTCA wasperformed in 39 patients, 2vesselPTCA in 12 and 3-vesselPTCA in 2. The procedure wasconsideredsuccessfulif stenosiswasreduced to 24

Repeat PTCA

MI

CABG

Death

9

1

2

3

0 0

1

2 1 1 4

2 14

Total CABG = coronary PTCA = percutaneous

1

1 4

artery bypass graft procedures; MI = myocardial transluminal coronary angioplasty.

infarction;

mean dukation of 14 months (range 6 to 34), 87% bf patients who underwent primary or repeat PTCA, or both, continued to show clinical improvement and have event-free survival in the first year. During the subsequent 2 years, 7.5% of patients had sustained improvement without a major coronary evknt.

Published reports are devoid of controlled studies comparing the effectiveness, advantages and complication rates of PTCA over medical therapy in octogenarians. The risks that preclude PTCA when medical treatment has failed should be addressed by randomized studies. Our results are consistent with those from nonrandomized studies2,3 in a cotiparable group of patients in whom procedural success rates of 67 to 80% were achieved, with a 6 to 14% incidence of emergency coronary bypass surgery and a d to 19% mortality. Our study is also consistent with other reports of elderly patients undergoing PTCA who have demonstrated lower success rates, shorter durations of sustained relief from symp-

toms, and higher morbidity and mortality rates than those reported in younger patients with similar syndromes.4j5 This is likely due to the diffuse nature of disease and lesion complexity seen in elderly patients. For our patients, successful PTCA (after failure of intensive medical treatment) resulted in medical stabilization, early hospital discharge atid improvement in activity levels. Thus, despite the significant morbidity associated with this type of interventional procedure, the limited information available on PTCA for older patients with unstable coronafy syndromes suggests that PTCA is a reasonable therapeutic option for palliation of symptoms and improvement in quality of life. Acknowledgment: We would like to express appreciation to Rebecca Teaff, who provided editorial assistance, and to Tony Jackson, PhD, who prepared the grsiphic illustrations.

1. Harris

R. Cardiovascular diseases in the elderly. Med Clin North Am 1983;67:379-394. 2. Holt GW, Sugrue DD, Bresnahan JF, Vliestra RE, Bresnahan DR, Recder GS, Holmes DR Jr. Results of percutaneous transluminal coronary angioplasty for unstable angina pectoiis in patients 70 years of age and older. Am J Cardiol 1988;61:994-947. 3. Kern MJ, Deligonul U, Galan K, Z&an R, Gabliani G, Bell ST, Bodet J, Naunheim K, Vandormae! M. Percutaneous tra&lumitial coronary angioplasty in octogenarians. Am J Cardiol 198&61:457-4X 4. deFeyter PJ, Suryapranata H, Serruys PW, Beatt K, van Domburg R, van den Brand M, Tijssen JJ, Azar AJ, Hugenholtz PG. Coronary angioplasty for unstable angina: immediate and late results in 200 consecutive patients with identification of risk factors for unfavorable early and late outcome. J Am CON Cardiol 1988:12:324-333. 5. Hamad N, Pichard AD, Lyle HR, Lindsay J. Results of percutaneous transluminal coronary angioplasty by multiple, relatively low frequency operators. Am J Cardiol 1988;61:1229~1231.

Frequency Coronary

and Causes of Failure with Angioplasty and Implications

Joel K. Kahn,

MD,

and Geoffrey 0. Hartzler,

Contempbiary Balloon for New Technologies

MD

ver the past decade of percutaneous transluminal coronary angioplasty (PTCA), greater operator ex0 perience and improvements in balloon catheters and

with non-balloon catheter technologies, we aqalyzed the frequency, cause and outcome of failed PTCA in our most recent experience.

guidewires have resulted in lesion success rates of Patients undergoing PTCA during the calendar year 190%.132 Despite the improved success of contemporary 1989 for indications other than acute myocardial infarcPTCA, numerous new technologies, including lasers, tion were selectedfor analysis. Angiographic success or stents and atherectomy devices, h&e recently been intro- failure for each lesion attempted was codedprospectiveduced and championed as potential alternatives fo the ly in a computer data base. Successful angiographic balloon catheter. The ease and success of current balloon dilatation of a lesion was defined as a reduction in diamprocedures mandate that new therapies must either in- eter stenosis after PTCA to 140% in multiple views. crease the primary success rates of interventional ap- Clinical and procedural records were reviewed in detail proaches, eliminate or help manage complications, or for all PTCAs with I1 unsuccessful dilatations. Mulreduce restenosis. To better appreciate deficiencies with tivessel PTCA was considered present when lesions in contemporary PTCA techniques that may be addressed L2 epicardial coronary arteries or their major branches Cardiovascular Consultants, Inc., Medical Plaza U-20, 4320 Wornall Road, Kansas City, Missouri 64111, and Mid America Heart Institute, St. Luke’s Hospital, Kansas City, Missouri. Manuscript received April 4, 1990; revised manuscript received May 18, 1990, and accepted May 20.

858

THE AMERICAN

JOURNAL

OF CARDIOLOGY

VOLUME

66

were dilated. A total of 1,286 PTCAs were performed for indications other than acute myocardial infarction. A total of 3,398 lesions were attempted (2.6/procedure, range 1 to 14). Angiographic success was achieved in 3,272