Canadian Cardiovascular Society Angina Class Research Articles

Functional Status in Rate- Versus Rhythm-Control Strategies for Atrial Fibrillation: Results of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Functional Status Substudy

The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) functional status substudy aimed to test the hypothesis that functional status is similar in rate-control and rhythm-control strategies. Randomized studies, including the AFFIRM study, have failed to demonstrate survival benefits between rate-control and rhythm-control strategies for atrial fibrillation (AF). However, AF may cause functional capacity or cognitive impairment that might justify maintenance of sinus rhythm. Investigators of the AFFIRM study enrolled 4,060 patients with AF who required long-term therapy and who were 65 years of age or older or who had another risk factor for stroke or death. New York Heart Association functional class (NYHA-FC) and Canadian Cardiovascular Society Angina Classification were assessed at initial and each follow-up visit. From 22 randomly chosen functional status substudy sites, 245 participants underwent 6-min walk tests and Mini-Mental State Examination (MMSE) at initial, two-month, and yearly visits. Patients were assigned randomly to rate-controlling drugs, allowing AF to persist, or rhythm-controlling antiarrhythmic drugs, to maintain sinus rhythm. The NYHA-FC worsened with time in both rate-control and rhythm-control groups, with no differences between groups. Presence of AF was associated with worse NYHA-FC (p < 0.0001). No differences were observed in Canadian Cardiovascular Society Angina Classification or MMSE scores. Six-minute walk distance improved over time in both study arms. On average, walk distance was 94 feet greater in the rhythm-control group (adjusted p = 0.049). Modest improvement in 6-min walk distance was noted in the rhythm-control arm. Presence of AF was associated with worse NYHA-FC. No difference in cognitive function was detected.

Poster 41: Functional Status is Measurably Improved in Patients With Angina Treated With Enhanced External Counterpulsation

Objective: To assess the effect enhanced external counterpulsation (EECP) has on overall functional status of individuals treated for angina. Design: Prospective cohort study with 6-month follow-up. Setting: Outpatient EECP clinic. Participants: 30 subjects (average age, 69.4y) with Canadian Cardiovascular Society (CCS) functional class III (n=21) and class IV (n=9) angina. Intervention: EECP utilizes electrocardiographic sequencing to trigger pneumatic cuffs wrapped around the lower extremities. The cuffs inflate and deflate during diastole, resulting in diastolic augmentation, increased venous return, presystolic unloading, and improved cardiac output. Main Outcome Measures: LIFEware System, a comprehensive, valid, and reliable tracking and reporting system for functional outcomes, and CCS functional angina classification. Results: 30 patients were assessed at baseline, after EECP, and at 6-month follow-up. At the conclusion of EECP patients rated their level of satisfaction with function and comfort achieved. Values ranged from 0 to 100 with the higher number referencing a better state, ie, more ability or less distress. Ratings at or above 70 were considered to define a prespecified threshold of clinical significance in functional status. Using that standard, 25 of 30 (83%) patients responded favorably to EECP. These responders reported considerable improvement in 4 variables: fatigue (mean, 41.0–59.8); satisfaction with life (mean, 45.5–68.2); social interactions (mean, 60.4–77.9); and role participation (mean, 63.2–78.8). At 6 months there was further improvement in the same four variables (mean, 76.6, 80.0, 83.2, and 86.8, respectively). CCS angina classification improved from a mean value of 3.36 to 1.24. Conclusions: EECP affords patients with angina significant improvement in quality of daily living, particularly in fatigue level, satisfaction with life, social interactions, and role participation. The overall functional status continues to improve 6 months after EECP is completed.

One-year follow-up of transcoronary sinus administration of autologous bone marrow in patients with chronic refractory angina

Based on our preclinic studies with autologous unfractionated bone marrow (AUBM) via coronary sinus with transitory occlusion, a clinic study in patients with chronic refractory angina was designed. The objectives were to evaluate tolerance of the procedure, safety, and feasibility with 1 year follow-up. Clinical study with inclusion and exclusion criteria defined by an Independent Clinical Committee was carried out. Fifteen patients underwent transcoronary sinus administration with a 15-min occlusion of freshly aspirated and filtered AUBM (60-120 ml). Feasibility was evaluated with Seattle Angina Questionnaire (SAQ), Canadian Cardiovascular Society (CCS) angina classification, perfusion dipyridamole, and coronary angiography. There were no changes in the tolerance parameters. There were no deaths or myocardial infarction during the follow-up. Three patients were readmitted into the hospital. During the follow-up, one patient was diagnosed with cancer of the lung. Improvement of 30% in the quality of life was evaluated by SAQ. The CCS angina classification showed that the mean angina class was 3.0+/-0.53 at baseline, which improved to 1.6+/-0.63 at 1 year (P<.001). Perfusion imaging (core lab) showed improvement in 12 of 15 patients, with a mean improvement of 40.9% at rest (22 vs. 13) (P<.01) and 45.3% at stress (26.5 vs. 14.5) (P<.05). Coronary angiography showed more collateral vessels in 10 of 15 patients. We can conclude that AUBM via coronary sinus is feasible in patients with chronic refractory angina after 1 year follow-up, and it appears to be safe.

Predictors of Benefit in Angina Patients One Year after Completing Enhanced External Counterpulsation: Initial Responders to Treatment versus Nonresponders

Enhanced external counterpulsation (EECP) has been shown to reduce Canadian Cardiovascular Society angina class. This study examines the factors that affect the reduction at 1 year, especially in patients who do not demonstrate an initial response. The data of 2,007 consecutive patients enrolled in the International EECP Patient Registry were analyzed. After 36.6 ± 4.9 h of EECP, angina was reduced by at least one class in 82.7%. At 1 year, 35.4% of initial nonresponders and 70.6% of responders remained improved by at least one angina class and free of major adverse cardiovascular events. Multivariate predictors of 1-year benefit are initial response to treatment (odds ratio 4.5, 95% CI 3.5–5.8), baseline angina class compared with class IV (odds ratios: class I 2.1, CI 0.93–4.81; class II 0.62, CI 0.43–0.87; class III 0.80, CI 0.62–1.01) and no history of congestive heart failure (odds ratio 1.41, CI 1.14–1.74).

Long‐Term (2‐Year) Clinical Events Following Transthoracic Intramyocardial Gene Transfer of VEGF‐2 in No‐Option Patients

The short-term clinical impact of intramyocardial gene transfer (GT) of the angiogenic protein vascular endothelial growth factor-2 (VEGF-2) has been previously reported to significantly reduce Canadian Cardiovascular Society (CCS) angina class and to prolong exercise treadmill test (ETT) time. We describe the safety and long-term events (>1 year) in consecutive, nonrandomized, patients who received intramyocardial VEGF-2. Thirty patients with intractable CCS class III or IV angina and no options for revascularization underwent direct intramyocardial GT of VEGF-2 naked DNA via limited thoracotomy at total doses of 0.2, 0.8, or 2.0 mg. Patients were followed for clinical events after 1 year by hospital records, follow-up visits or telephone contact. Due to one perioperative death, 29 patients were followed. At a mean follow-up of 751 +/- 102.5 days (range 459-959) there were four deaths (13.8%), five myocardial infarctions (MIs) (17.2%), and seven revascularization procedures (24.1%). There were 15 hospitalizations in 12 patients. At the end of the follow-up period no patient (0%) had CCS class IV angina, 3 patients (11.5%) had class III angina, and 23 (88.5%) had class I to II angina. There were two new diagnoses of cancer. Transthoracic intramyocardial injection of VEGF-2 is associated with an improvement of symptoms of angina in the majority of patients beyond the first year of treatment. Major clinical events such as death, MI, and repeat revascularization are uncommon during the first year but more frequent after 1 year at a rate consistent with the severity of underlying disease in this population with advanced atherosclerosis. The majority of events were the result of progression of disease in areas of the heart remote from the site of GT. A large randomized trial is planned to determine the efficacy of intramyocardial VEGF-2 injections in inoperable patients.

Spinal Epidural Hematoma after Spinal Anesthesia in a Patient Treated with Clopidogrel and Enoxaparin

Spinal Epidural Hematoma after Spinal Anesthesia in a Patient Treated with Clopidogrel and Enoxaparin

Comparison of abbreviated versus full course of enhanced external counterpulsation in heart failure patients with one-year follow-up

Introduction: Enhanced external counterpulsation (EECP) for 30 hrs improves myocardial perfusion, endovascular function, neurohumoral activation in angina patients (pts). However, its optimal dose and effectiveness for CHF has not been elucidated. Methods: The International EECP Registry (IEPR) prospectively tracks treatment and outcomes of sequential pts. Pts with CHF withdrawing early in EECP therapy (<10 hrs of EECP, LD group) were used as controls to evaluate 1-year outcome vs the usual course of therapy (≥ 30 hrs of EECP, FD group). Kaplan Meier survival curves were compared using log-rank test, Chi-square test for other events. Results: There were 701 CHF pts in the IEPR, 65 LD pts (5.0±2.7 hrs of EECP) and 636 FD pts (36.6±4.8 hrs). Demographics were similar in both groups except more men completed therapy (75.1% vs 60%; p<0.01). Baseline LVEF was similar in LD and FD groups (36±13.9% vs 39.6±15.1%). Both groups were high-risk CAD with refractory angina unsuitable for revascularization in >90%, and a high prevalence of DM, HBP, smoking, multivessel CAD, prior MI and revascularization. At baseline 97% of LD and 89.8% of FD pts were Canadian Cardiovascular Society Angina Class (CCS) III or IV. During EECP, there were more MACE in LD than FD groups (7.7 % versus 1.7%, p<0.05). Post therapy CCS angina class improved in 83.7% of FD vs 3.2% of LD pts (p<0.001) with significant parallel improvements in angina frequency and Ntg use. At 1 year significant CCS differences persisted comparing LD versus FD groups (CCS Class III or IV in 50% versus 25.4%), but were less marked than immediately post EECP. Kaplan Meier event rates at 15 mos post initial EECP showed significantly higher MACE in LD versus FD groups (36.9% vs 22.4%; p<0.01), rate of CABG (10.6% vs 1.5%; p<0.001). However, PCI (7.3% vs 6.7%), death (16.1% vs 10.0%), and MI (11.0% vs 7.3%) were not significantly different. Of note 24.6% of LD pts had CHF exacerbations requiring hospitalization vs 12.7% of FD pts during follow-up (p<0.01). Conclusions: Among CHF patients completing a full course, EECP is associated with significant improvement in early and 1-year CCS angina class, reduced MACE rates and fewer CHF exacerbations at one-year post-treatment, compared with patients completing an abreviated course. The randomized PEECH trial will further evaluate the benefit of EECP in treating CHF.

Usefulness and safety of percutaneous myocardial laser revascularization for refractory angina pectoris

This prospective, double-blind, randomized, sham-controlled trial was designed to control for patient and investigator bias in assessing symptomatic improvement after percutaneous myocardial laser revascularization (PMLR) therapy. Eighty-two patients with stable angina pectoris (class III or IV) not amenable to conventional revascularization and with evidence of reversible ischemia, ejection fraction ≥25%, and myocardial wall thickness ≥8 mm were randomized to either PMLR with optimal medical therapy (n = 40) or to a sham procedure with optimal medical therapy (n = 42). With the exception of 1 laser technician, all patients, investigators, and assessors were blinded to treatment through the 12-month follow-up. The primary end point was restricted to Canadian Cardiovascular Society angina class improvement to limit the number of patients exposed to a sham procedure. Secondary assessments included medication usage, quality of life, exercise testing, ejection fraction, and hospitalizations. The incidence of serious adverse events, as determined by cardiac event-free survival at 12 months, was similar between groups. At 12 months, Canadian Cardiovascular Society angina scores improved by ≥2 classes in significantly more PMLR-treated patients than sham control patients (35% vs 14%, p = 0.04). Angina-specific quality-of-life measures were significantly higher in the PMLR group at each follow-up (p <0.05). Exercise and medication usage was similar between groups at 12 months. We conclude that PMLR therapy is reasonably safe and effective as symptomatic improvement in patients refractory to medical therapy, and that the clinical benefit is not attributable to placebo effect or investigator bias.

Transcoronary sinus administration of autologous bone marrow in patients with chronic refractory stable angina: Phase 1

Purpose Based on our preclinic studies with autologous unfractionated bone marrow (AUBM) via coronary sinus with transitory occlusion, a clinic study in patients with chronic stable angina was designed. The objectives were to evaluate safety, tolerance and feasibility. Methods and materials A multicenter prospective study with inclusion and exclusion criteria defined by an Independent Clinical Committee was carried out. Fourteen patients underwent transcoronary sinus administration of freshly aspirated and filtered AUBM (60–120 ml). Safety and tolerance were evaluated. Feasibility was evaluated with Seattle Angina Questionnaire (SAQ), Canadian Cardiovascular Society (CCS) angina classification (baseline–Day 180), myocardial perfusion (baseline–Day 90) with independent core laboratory and coronary angiography (baseline and Day 30). Results There were no changes in the safety and tolerance parameters. Preliminary clinical efficacy at Day 180 disclosed a significant improvement of 38%, evaluated by the SAQ. The CCS angina classification shows that the mean angina class was 3.0±0.55 at baseline and improved to 2.0±0.00 at Day 180 ( P<.001). Semiquantitative radionuclide perfusion imaging (core lab) showed a significant improvement at Day 90 in 13/14 patients, with a mean improvement of 24% at rest ( P<.01) and 33% at stress ( P<.05). Coronary angiography showed more collateral vessels in 9/14 patients. Conclusions We can conclude that AUBM via coronary sinus with transitory occlusion is tolerable and safe. Significant improvement in the myocardial perfusion at Day 90 and in the quality of life at Day 180 was observed.

Transcoronary sinus administration of autologous bone marrow in patients with chronic refractory stable anginaPhase 1

Based on our preclinic studies with autologous unfractionated bone marrow (AUBM) via coronary sinus with transitory occlusion, a clinic study in patients with chronic stable angina was designed. The objectives were to evaluate safety, tolerance and feasibility. A multicenter prospective study with inclusion and exclusion criteria defined by an Independent Clinical Committee was carried out. Fourteen patients underwent transcoronary sinus administration of freshly aspirated and filtered AUBM (60–120 ml). Safety and tolerance were evaluated. Feasibility was evaluated with Seattle Angina Questionnaire (SAQ), Canadian Cardiovascular Society (CCS) angina classification (baseline–Day 180), myocardial perfusion (baseline–Day 90) with independent core laboratory and coronary angiography (baseline and Day 30). There were no changes in the safety and tolerance parameters. Preliminary clinical efficacy at Day 180 disclosed a significant improvement of 38%, evaluated by the SAQ. The CCS angina classification shows that the mean angina class was 3.0±0.55 at baseline and improved to 2.0±0.00 at Day 180 (P<.001). Semiquantitative radionuclide perfusion imaging (core lab) showed a significant improvement at Day 90 in 13/14 patients, with a mean improvement of 24% at rest (P<.01) and 33% at stress (P<.05). Coronary angiography showed more collateral vessels in 9/14 patients. We can conclude that AUBM via coronary sinus with transitory occlusion is tolerable and safe. Significant improvement in the myocardial perfusion at Day 90 and in the quality of life at Day 180 was observed.

Effect of enhanced external counterpulsation on dobutamine-induced left ventricular wall motion abnormalities in severe chronic angina pectoris

We studied the effect of enhanced external counterpulsation (EECP) in 23 consecutive patients with stable angina pectoris who had a positive dobutamine stress echocardiogram. After EECP, stress-induced wall motion score (WMS) improved by ≥2 grades in 43% of the patients (n = 10); the average improvement was 5.3 ± 3.8 compared with −0.6 ± 3.0 in the remaining 13 patients (p = 0.007). The diastolic/systolic augmentation ratio increased by 217% in response to the full course of EECP (p = 0.0002) among patients with improved WMS, and by 71% (p = 0.004) among the other patients; the increase was greater among patients with improved WMS than among patients with no improvement (p = 0.01). After EECP, Canadian Cardiovascular Society angina class improved from 3.1 ± 0.6 to 2.2 ± 0.7 (p <0.0001) in the entire group and exercise capacity increased by 73 seconds (p = 0.0002) in patients who were able to exercise (n = 18).

Enhanced external counterpulsation for the relief of angina in patients with diabetes: safety, efficacy and 1-year clinical outcomes

Abstract Background Patients with diabetes are at greater risk for coronary events, yet they are less likely to benefit from revascularization than those without diabetes. Enhanced external counterpulsation has recently emerged as a treatment option for select patients with chronic stable angina. Methods We examined baseline characteristics, angina response, and cardiac outcomes of patients with diabetes mellitus treated with Enhanced External Counterpulsation (EECP) for chronic stable angina. Data were collected from patients enrolled in the International EECP Patient Registry (IEPR) before and after a course of EECP, and at 1 year after completion of treatment. Results Of 1532 IEPR patients studied, 43% had diabetes mellitus at baseline. Patients with diabetes were experiencing, on average, 11 episodes of angina per week. Most had been revascularized with prior percutaneous coronary intervention or coronary artery bypass graft surgery (86%) and most were considered unsuitable for either additional procedure (87%). Treatment was completed as prescribed in 79% of patients (mean, 32 hours). Immediately after EECP, 69% of patients with diabetes demonstrated a reduction in angina of ≥1 Canadian Cardiovascular Society angina class. After 1 year, maintenance of angina reduction was reported in 72% of patients with diabetes. Quality of life was significantly improved. Despite a high-risk profile among the diabetic group in this study, 1-year mortality was similar to coronary intervention registry populations. Conclusion This study suggests that in select patients with diabetes, EECP can be a safe, effective, well-tolerated treatment option for the relief of angina.

Survival after myocardial revascularization for ischemic cardiomyopathy: A prospective ten-year follow-up study

Objective The aim was to prospectively analyze all-cause mortality, predictors of survival, and late functional results after myocardial revascularization for ischemic cardiomyopathy over a 10-year follow-up. Methods We prospectively studied 57 patients with stable coronary artery disease and poor left ventricular ejection function (<35%), enrolled between 1989 and 1994. Stress thallium was analyzed in 37 patients to identify reversible ischemia. To avoid patients with a stunned myocardium, we excluded those with unstable angina or myocardial infarction within the previous 4 weeks. Mean age of the patients was 67 ± 8 years, and 93% of patients were men. Mean left ventricular ejection fraction was 0.28 ± 0.04, 50% were in Canadian Cardiovascular Society angina class III-IV, and 65% were in New York Heart Association functional class III-IV. Results Operative mortality was 1.7% (1/57). The mean left ventricular ejection fraction (0.30) at 15 months postoperatively did not change from before operation (0.28, P = .09). There were 8 deaths at 1 year and 42 deaths over the course of the study, producing a survival of 82.5% at 1 year, 55.7% at 5 years, and 23.9% at 10 years (95% confidence interval: 14.6%-39.1%). Symptom-free survival was 77.2% at 1 year and 20.3% at 10 years. The leading cause of death was heart failure in 29% (12/42). Multivariate analysis showed that large reversible defects on stress thallium were associated with improved left ventricular ejection fraction at 1 year ( P = .01) but only male sex was associated with improved long-term survival ( P = .036). Conclusions Myocardial revascularization for ischemic cardiomyopathy is associated with good functional relief from the symptoms of angina initially and, to a lesser extent, heart failure. Revascularization may have the advantage of preserving the remaining left ventricular function. However, the long-term mortality remains high.

Poster 23: Enhanced external counterpulsation and functional improvement in octogenarians with symptomatic ischemic heart disease

Objective: To assess the functional outcomes of octogenarians with angina who receive enhanced external counterpulsation (EECP). Design: Retrospective review. Setting: Outpatient cardiac treatment facility. Participants: 24 octogenarians (avg age, 84.75y) with Canadian Cardiovascular Society (CCS) functional class III angina. Interventions: EECP is a safe, noninvasive outpatient therapy that uses computerized electrocardiographic sequencing to trigger pneumatic cuffs wrapped around the lower extremities. These cuffs sequentially inflate during diastole and rapidly deflate just prior to systole, resulting in diastolic augmentation, presystolic unloading, increased venous return, and improved cardiac output. The clinical outcomes of EECP therapy include marked symptom reduction and improved exercise tolerance in nearly 80% of patients. Main Outcome Measures: CCS angina classification and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Results: Our patients received an average of 38.75 hours of EECP therapy and reported no adverse events. 23 of the 24 patients improved their CCS angina classification by at least 1 class (8 by 2 classes) and 3 patients were entirely asymptomatic by the end of the program. All patients demonstrated improvement in exercise tolerance and functional status. The SF-36 was used to assess functional outcomes. The improvement in physical functioning ( P<.015) and emotional role ( P<.003) were statistically significant. The improvements in perception of health status was also significant ( P<.0001). Conclusions: EECP is a safe, efficacious treatment alternative for octogenarians with angina. This therapeutic physical modality leads to significant functional improvement, particularly in mobility and emotional outlook, in octogenarians with symptomatic ischemic heart disease and should be considered readily as a treatment option for this high-risk population.

Enhanced external counterpulsation for the relief of angina in patients with diabetes: safety, efficacy and 1-year clinical outcomes

Background Patients with diabetes are at greater risk for coronary events, yet they are less likely to benefit from revascularization than those without diabetes. Enhanced external counterpulsation has recently emerged as a treatment option for select patients with chronic stable angina. Methods We examined baseline characteristics, angina response, and cardiac outcomes of patients with diabetes mellitus treated with Enhanced External Counterpulsation (EECP) for chronic stable angina. Data were collected from patients enrolled in the International EECP Patient Registry (IEPR) before and after a course of EECP, and at 1 year after completion of treatment. Results Of 1532 IEPR patients studied, 43% had diabetes mellitus at baseline. Patients with diabetes were experiencing, on average, 11 episodes of angina per week. Most had been revascularized with prior percutaneous coronary intervention or coronary artery bypass graft surgery (86%) and most were considered unsuitable for either additional procedure (87%). Treatment was completed as prescribed in 79% of patients (mean, 32 hours). Immediately after EECP, 69% of patients with diabetes demonstrated a reduction in angina of ≥1 Canadian Cardiovascular Society angina class. After 1 year, maintenance of angina reduction was reported in 72% of patients with diabetes. Quality of life was significantly improved. Despite a high-risk profile among the diabetic group in this study, 1-year mortality was similar to coronary intervention registry populations. Conclusion This study suggests that in select patients with diabetes, EECP can be a safe, effective, well-tolerated treatment option for the relief of angina.

Late-Breaking Clinical Trial Abstracts

Late-Breaking Clinical Trial Abstracts

Effect of thoracic epidural analgesia on refractory angina pectoris: Long-term home self-treatment

Objectives: To evaluate the effects of long-term home self-treatment with thoracic epidural analgesia (TEA) on angina, quality of life, and safety. Design: Prospective consecutive pilot study. Setting: Department of Cardiology, Heart Center, Linköping University Hospital. Participants: Between January 1998 and January 2000, 37 consecutive patients with refractory angina began treatment with TEA, using a subcutaneously tunnelled epidural catheter. Interventions: The patients were trained to provide self-treatment at home with intermittent injections of bupivacaine. Data were collected until January 2001, and the follow-up for each patient was 1 to 3 years. Measurements and Main Results: All but 1 of the patients improved symptomatically. The improvement was maintained throughout the treatment period (4 days to 3 years). The Canadian Cardiovascular Society angina class decreased from 3.6 to 1.7, frequency of anginal attacks decreased from 46 to 7 a week, nitroglycerin intake decreased from 32 to 5 a week, and the overall self-rated quality of life assessed by visual analog scale increased from 24 to 76 (all p < 0.001). No serious catheter-related complications occurred; however, 51% of the catheters became displaced and a new one had to be inserted during the study. Conclusion: Long-term self-administered home treatment with TEA seems to be an effective and safe adjuvant treatment for patients with refractory angina. It produces symptomatic relief of angina and improves the quality of life. Copyright 2002, Elsevier Science (USA). All rights reserved.

Coronary artery bypass in patients with severe left ventricular dysfunction.

We retrospectively reviewed the case records of 82 patients with severe left ventricular dysfunction (ejection fraction < 30%) who underwent coronary artery bypass grafting between March 1993 and February 2000. They were aged 28 to 76 years (mean, 60 years), and 66 of them were male. Significant comorbid factors included hypertension (93%), diabetes mellitus (85%), and hypercholesterolemia (49%). The number of grafts used ranged from 1 to 3. The majority of the patients (91%) belonged to the Canadian Cardiovascular Society angina class III. Coronary angiography revealed single-vessel (in 16% of the patients), double-vessel (52%), and triple-vessel disease (32%), and left main stem disease (18%). Seven patients (9%) died within 48 hours after surgery. The mean duration of hospital stay was 7 +/- 2 days. The 75 patients who survived were followed up for 3 months to 7 years. At the 1-year follow-up, 61 of the 68 patients (90%) who were alive moved up from angina class III to class I. Our observations suggest that coronary bypass carries an acceptable mortality risk and may offer a better quality of life in patients with poor ventricular function.

Predictors of postoperative complications in high-risk octogenarians undergoing cardiac operations

Background. Cardiac operations in octogenarians are currently reserved for selected patients with severe symptoms and low extracardiac comorbidity; early and midterm results are satisfactory. We evaluated the outcome of high-risk octogenarians undergoing cardiac operations and investigated the predictors of postoperative complications. Methods. Between June 1998 and March 2001, 73 consecutive octogenarians (mean age = 83.1 ± 3.0 years) hospitalized and awaiting operation in our Department were analyzed for postoperative complications. We recorded the main risk factors for cardiovascular disease, symptoms of heart failure, previous myocardial infarction, reoperation, left ventricular ejection fraction, use of intraaortic balloon pump, surgical priority, and operative risk. Cerebrovascular disease, peripheral vascular disease, chronic obstructive pulmonary disease, and renal failure were the preoperative extracardiac comorbidities considered. We adopted a multidisciplinary approach to perioperative management. Results. Surgical procedures included coronary artery bypass grafting in 36 patients (49.3%), valve procedures in 20 (27.4%), and combined coronary artery bypass grafting and valve procedures in 17 patients (23.3%). In-hospital death occurred in 6 patients (8.2%). Twenty-one patients (28.8%) had major postoperative complications including renal failure (15.1%), respiratory failure (8.2%), and myocardial infarction (8.2%). The main predictors of postoperative complications were New York Heart Association functional class IV, Canadian Cardiovascular Society angina class 4, and prolonged aortic cross-clamping time. Conclusions. Cardiac operations can achieve satisfactory results even in high-risk octogenarians. Early surgical intervention before severe symptoms appear, and a multidisciplinary approach to perioperative management, may reduce postoperative complications.

Effects of enhanced external counterpulsation on stress radionuclide coronary perfusion and exercise capacity in chronic stable angina pectoris

Enhanced external counterpulsation (EECP) is an effective noninvasive treatment for patients with coronary artery disease (CAD). EECP has been demonstrated to improve anginal class and time to ST-segment depression during exercise stress testing. This study assesses the efficacy of EECP in improving stress-induced myocardial ischemia using radionuclide perfusion treadmill stress tests (RPSTs). The international study group enrolled patients from 7 centers with chronic stable angina pectoris and a baseline ischemic pre-EECP RPST. Patients’ demographic and clinical characteristics were recorded. A baseline pre-EECP maximal RPST was performed within 1 month before EECP treatment. The results were compared with a follow-up RPST performed within 6 months of completion of a 35-hour course of EECP. Four centers performed post-EECP RPST to the same level of exercise as pre-EECP, whereas 3 centers performed maximal RPST post-EECP. The study enrolled 175 patients (155 men and 20 women). Improvement in angina, defined by ≥1 Canadian Cardiovascular Society angina class change, was reported in 85% of patients. In the centers performing the same level of exercise, 81 of 97 patients (83%) had significant improvement in RPST perfusion images. Patients who underwent maximal RPST revealed improvement in exercise duration (6.61 ± 1.88 pre-EECP vs 7.41 ± 2.03 minutes post-EECP, p <0.0001); 42 of the 78 patients (54%) in this group showed significant improvement in RPST perfusion images. Thus, EECP was effective in improving stress myocardial perfusion in patients with chronic stable angina at both comparable (baseline) and at maximal exercise levels.