Candidates For Percutaneous Transluminal Coronary Angioplasty Research Articles

Major adverse outcomes after percutaneous transluminal coronary angioplasty: a clinical prediction rule

In this study, we developed and internally validated a clinical model for predicting major adverse outcomes in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) using a multi-institutional prospective cohort study involving all adult patients who underwent PTCA at 12 participating institutions from August 1993 to October 1995. A major adverse outcome, defined as death, renal failure, myocardial infarction, cardiac arrest, stroke, or coma, occurred in 3.3 and 3.2% of patients in the derivation and validation sets, respectively. Death occurred in 1.5% in both sets. Fourteen variables were independently correlated with major adverse outcomes. The rule, which stratifies PTCA patients into six levels of risk based on the severity score, showed excellent discrimination (receiver-operating characteristic curve area 0.82) and calibration (Hosmer-Lemeshow chi-square statistic P = .90) and performed well on internal validation. This rule allows accurate preprocedure stratification of PTCA candidates according to their risk of suffering a major adverse outcome.

Aortic pulse pressure and extent of coronary artery disease in percutaneous transluminal coronary angioplasty candidates

Background Pulse pressure and aortic stiffness are both predictors of coronary artery disease. Whether these parameters are directly related to coronary structural alterations has never been studied. Methods From September 1999 to September 2000, the following data were collected from 99 eligible patients: invasive intra-aortic systolic and diastolic blood pressures (BP), extent of coronary artery disease, cardiovascular risk factors, and the incidence of angiographically documented restenosis after coronary angioplasty. Results In the study population, independent determinants of aortic pulse pressure were age, gender, aortic mean BP, heart rate, and extent of coronary artery disease (r 2=0.57, P < .0001). In univariate analysis, invasive aortic, but not noninvasive brachial, mean pressure ( P = .017) and pulse pressure ( P = .027) were significantly associated to the extent of coronary artery disease. In a multiple regression analysis, only male gender ( P = .013) and the level of aortic pulse pressure ( P = .023) were independently associated with the extent of coronary heart disease. Restenosis was angiographically documented in 11 patients (11%). There was a borderline significant association of restenosis to aortic mean BP ( P = .05) and to a past history of multiple previous angioplasties ( P = .03). Conclusions In this study, aortic pulse pressure was a significant risk factor for the extent of coronary artery disease. There was only a borderline significant association of restenosis to the steady, but not pulsatile, component of aortic BP in the stent era.

Aortic pulse pressure and extent of coronary artery disease in percutaneous transluminal coronary angioplasty candidates

Aortic pulse pressure and extent of coronary artery disease in percutaneous transluminal coronary angioplasty candidates

Waiting for coronary revascularization: A comparison between New York State, the Netherlands and Sweden

Objective: To compare waiting times for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery in New York State, the Netherlands and Sweden and to determine whether queuing adversely affects patients' health. Methods: We reviewed the medical records of 4487 chronic stable angina patients who underwent PTCA or CABG in one of 15 New York State hospitals ( n=1021) or were referred for PTCA or CABG to one of ten hospitals in the Netherlands ( n=1980) or to one of seven hospitals in Sweden ( n=1486). We measured the median waiting time between coronary angiography and PTCA or CABG. Results: The median waiting time for PTCA in New York was 13 days compared with 35 and 42 days, respectively, in the Netherlands and Sweden ( P<0.001). For CABG, New York patients waited 17 days, while Dutch and Swedish patients waited 72 and 59 days, respectively ( P<0.001). The Swedish and Dutch waiting list mortality rate was 0.8% for CABG candidates and 0.15% for PTCA candidates. Conclusions: There were large variations in waiting time for coronary revascularization among these three sites. Patients waiting for CABG were at greatest risk of experiencing an adverse event. In both the Netherlands and Sweden, the capacity to perform coronary revascularization has been expanded since this study began. Further international cooperation may identify other areas where quality of care can be improved.

The appropriateness of intention to treat decisions for invasive therapy in coronary artery disease in The Netherlands.

OBJECTIVE: To determine the appropriateness of intention to treat decisions concerning coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for patients with coronary artery disease in The...

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.

Comparative costs of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting in multivessel coronary artery disease

The cost of percutaneous transluminal coronary angioplasty (PTCA) has been shown in a number of studies 1–3 to be significantly below that of coronary artery bypass grafting (CABG). It has been suggested that the cost of PTCA may be greater if there is a need to have a subsequent revascularization procedure for restenosis 2 or if there is a low primary success rate necessitating urgent or early elective CABG. 1,2 These earlier studies have concentrated on the traditional candidates for PTCA: patients requiring single-vessel revascularization. The relative cost of multivessel PTCA has not been examined and it is possible that the higher acute complication and restenosis rates noted in this subgroup of patients 4,5 may diminish the cost advantage of PTCA. This study examines the total 1-year revascularization costs in patients with multivessel coronary artery disease undergoing multivessel PTCA or CABG.

Assessment of residual coronary arterial stenosis after thrombolytic therapy during acute myocardial infarction

Maximal myocardial salvage appears to be related to the severity of residual coronary arterial stenosis after thrombolysis. The degree of residual infarct vessel stenosis was assessed in 119 consecutive patients with patent arteries who received streptokinase during acute myocardial infarction. After administration of streptokinase, 99 of 119 patients (83%) had a residual stenosis 70% or more in diameter. Assuming that a residual diameter stenosis of at least 70% is flow limiting, the feasibility for percutaneous transluminal coronary angioplasty (PTCA) was determined by the following criteria: length less than 10 mm, no significant distal narrowing or left main stenosis, and an adequate-sized distal artery. In 81 of 99 patients (82%), arterial anatomy was suitable for PTCA. Thus, after therapy with streptokinase for acute myocardial infarction, most patients have a significant infarct arterial residual stenosis and are candidates for PTCA.

Follow-up after successful transluminal angioplasty. Report of the initial Cleveland Clinic experience.

One hundred forty-nine patients underwent percutaneous transluminal coronary angioplasty (PTCA) over a 24-month period. PTC A was successful in 106 patients (71%) and 109 vessels (72%). Patients with primary success were followed for 9 ± 0.6 months (mean ± SEM). Follow-up, ranging from Ave to 28 months, was based primarily on the evaluation of functional status according to the New York Heart Association Classification. Forty-eight patients underwent repeat coronary angiography during the course of follow-up. Seventy-five patients (71%) experienced continued improvement in functional class at the end of the follow-up period. Sixty-nine patients (65%) were in functional class I at the conclusion of follow-up; 5 of these patients had documented angiographic recurrence, and 12 patients showed no recurrence at repeat angiography. Thirty-one patients (29%) had recurrence of anginal symptoms; 19, 5, and 7 patients were in functional class II, III, and IV, respectively. Of these 31, 14 patients were shown to have no angiographic recurrence, and 13 patients demonstrated recurrent stenosis at repeat angiography. Recurrent symptoms in patients with angiographically documented restenosis of the previously dilated site occurred on an average of 2.7 ± 2.1 months (mean ± SD) post-PTCA. The authors’ experience indicates that (a) long-term success is achievable in a substantial majority of PTCA candidates, (b) suspected recurrence must be documented angiographically, and (c) symptomatic recurrences are unusual beyond five months post-PTCA.

Natural history of patients with single-vessel disease suitable for percutaneous transluminal coronary angioplasty

To permit comparison of percutaneous transluminal coronary angioplasty (PTCA) with conventional therapy, the clinical outcome was established in patients who would have been suitable candidates for PTCA but who presented before the technique was available. Coronary angiograms were reviewed of patients who met the following criteria: single-vessel disease with proximal subtotal coronary stenosis, chest pain of at least class II, and cardiac catheterization before 1981. Angiograms were evaluated according to established criteria for PTCA by an experienced angiographer. One hundred ten patients (2.1% of the patient population) were judged suitable for PTCA. Clinical and catheterization findings closely resembled those of patients in the national PTCA registry. Five years after catheterization, 97% of PTCA candidates treated medically were alive and 85% had not had myocardial infarction. Forty-six patients had coronary artery bypass surgery within 6 months of catheterization and 10 other patients had subsequent surgery. Five years after surgery, 91% were alive and 87% had not had myocardial infarction. At 6 months of follow-up, 78% of all patients had improved at least 1 functional class, and 86% of all patients working before catheterization were still employed. Functional capacity was well maintained during long-term follow-up (median 6.5 years, range 1.4 to 12.2). These data indicate that PTCA candidates have an excellent prognosis for survival, a low risk of infarction, and well-maintained functional capacity when revascularization is reserved for those with inadequate control of symptoms by medical therapy.

Trends in the treatment of coronary disease today. Selective use of PTCA and bypass surgery.

Selection and treatment of patients with ischemic heart disease is presently undergoing an evolutionary trend. Percutaneous transluminal coronary angioplasty (PTCA) has been recommended as the initial procedure for many patients with coronary artery disease (CAD), thus possibly redefining candidates for coronary bypass surgery (CABS). Between October 1980 and June 1982, 777 patients having PTCA and 2068 patients having CABS were analyzed for differences in clinical presentation, complications, and early outcome. Patients having CABS were significantly older, had a higher incidence of hypertension (46% vs. 32%), more multivessel disease (80% vs. 12%), and poorer left ventricular function (nl. wall motion = 88% vs. 52%). The incidence of myocardial infarction in patients after PTCA was 1.0% (8/777). Emergency CAB was required in 5.3% of patients following PTCA. There were no deaths following the angioplasty procedure and 25 deaths in 2068 patients having CABS (hospital mortality rate = 1.2%). Since 1973, there has been a progressive decline in hospital mortality rate (now, less than 1%), postoperative infarction (now, 3%), requirement for inotropic drugs (now, 5%) and frequency of IABP (less than 1%). Increasing ability to achieve complete revascularization now means improved survival and freedom from angina with CAB surgery. PTCA and CAB are both procedures that may be used effectively for selected patients, depending on clinical presentation, extent of CAD, and left ventricular function (LVF). Careful patient selection affords the opportunity for use of PTCA in patients with single-vessel disease (SVD) and good LVF and CABS in patients with multivessel disease, regardless of LVF. Symptomatic patients with SVD and total vessel occlusion are not candidates for PTCA. Our data demonstrate that both PTCA and CABS may be accomplished with very low perioperative complications and hospital mortality.

Frequency and importance of unprovoked coronary spasm in patients with angina pectoris undergoing percutaneous transluminal coronary angioplasty

Coronary spasm superimposed on fixed coronary artery stenosis was discovered in 14 of 74 candidates for percutaneous transluminal coronary angioplasty (PTCA). In 3 of the 14, spasm developed during PTCA and was presumably catheter-induced. Eleven of the 14, with unprovoked spasm, are the subject of this study. Three of the 11, in whom the fixed component of the mixed stenosis was subcritical were treated medically, with good results in 2 but with persistent angina pectoris and eventual myocardial infarct in 1. Nitroglycerin administered by the intracoronary route relieved spasm resistant to sublingual nitroglycerin in 1 of the 3. In 8 of the 11 with critical fixed stenosis, spasm was discovered either before PTCA (7 patients) or on follow-up (1 patient). Six of the 8 had successful PTCA, with no or mild symptoms on follow-up. Of the 2 failures, 1, uncomplicated, was followed by successful elective coronary artery bypass surgery while the other, complicated, led to successful emergency coronary artery bypass surgery, with disappearance of symptoms in both. The rate of success was similar in patients with documented unprovoked spasm (6 of 8) and patients without (39 of 63, 62%). It is concluded that (1) coronary spasm, if properly sought for, is probably not uncommon in single-vessel candidates for PTCA; (2) patients considered candidates for PTCA should have intracoronary nitroglycerin administered before PTCA; (3) in patients with critical, fixed coronary artery disease, associated spasm does not reduce the chances of successful PTCA; (4) coronary spasm may outlast the relief by PTCA of the fixed component of the mixed stenosis and requires long-term vasodilator therapy; and (5) the lack of adverse effects when PTCA is performed in patients with spasm superimposed on critical fixed single-vessel stenosis appears to justify its use for the time being.