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

Abstract

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, 1 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 1-vessel disease, 14 (25%) had 2-vessel disease and 25 (45%) had 3-vessel disease; 14 (25%) had ≥1 prior bypass surgery, 35 (62.5%) were within 30 days of an acute infarction, 12 (21%) had left ventricular ejection fraction <0.50 and 7 (12.5%) were >70 years of age. PTCA was successful in 61 (84%) vessels and 47 (84%) patients (≥1 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 (1.8%), 1 late death (1.8%), 2 repeat PTCAs (3.6%), 6 crossovers to bypass (10.7%) and 38 patients (68%) 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.