Coronary Angioplasty For Unstable Angina Research Articles

Effect of early statin and selective cyclooxygenase-2 inhibitor therapy on C-reactive protein level after percutaneous coronary angioplasty in unstable angina.

We evaluated the effect of cyclooxygenase-2 inhibitor rofecoxib added to atorvastatin, initiated immediately after percutaneous coronary angioplasty (PCI), on C-reactive protein (CRP) and interleukin-6 (IL-6) in patients with unstable angina (UA). Sixty patients were prospectively randomized to receive: (A) 10 mg atorvastatin or (B) 40mg atorvastatin or (C) atorvastatin 40 mg plus rofecoxib 12.5 mg. Treatment was continued for 6 months. CRP and IL-6 levels increased within 48 hours after PCI in all groups, in comparison with A and B, a more pronounced decrease in CRP (mg/l) and IL-6 (pg/ml) levels at 3- and 6-month follow-up was present in C: CRP at 6 months: 0.76 vs. 1.92 vs. 0.11, p<0.05; IL-6 at 6 months: 0.02 vs. 0.04 vs. 0.01, p<0.05. At 6-month follow-up the reduction in CRP level occurred in 70% of subjects with CRP higher than median (3.6mg/l) at baseline vs. 15% of patients with CRP lower than median (p<0.041). After PCI in UA, cyclooxygenase-2 inhibitor rofecoxib added to atorvastatin reduced CRP and IL-6 levels more profoundly than atorvastatin alone at 3- and 6-month after intervention. In the group receiving combined therapy, reduction in CRP levels was more frequently observed in patients with higher CRP at baseline.

Use of abciximab prevents microcirculatory impairment in patients treated with coronary angioplasty for unstable angina: Results of a prospective randomized study

The use of abciximab during percutaneous coronary angioplasty (PTCA) in patients with unstable angina (UA) prevents the postintervention enzyme surge and improves clinical outcomes, possibly by improving microcirculatory function. The aim of this quantitative myocardial blush grade (MBG) study was to verify whether abciximab improves postintervention microcirculation in patients with UA. This prospective randomized open-label study involved 140 UA patients scheduled to undergo PTCA of the target coronary lesion: 140 patients were randomized to receive either abciximab during PTCA (group 1, 70 patients) or conventional treatment without GP IIb/IIIa inhibitor (group 2, 70 patients). The exclusion criteria included above normal CK-MB levels. MBG was calculated by means of quantitative software that evaluates video intensity in a given region of interest: assuming that greater peak video intensity reflects a larger myocardial blood volume, a perfusion scale of 1-6 points (poor to optimal) was devised. The groups were homogeneous in terms of their demographic, procedural, and angiographic characteristics. Stents were used in 98% of the patients in both groups. The MBG score significantly increased in group 1 from 3.04 +/- 2.17 to 3.71 +/- 2.02 (P = 0.045) and slightly decreased in group 2 from 3.13 +/- 2.07 to 2.93 +/- 2.03 (P = 0.42). Consequently, group 1 showed a significantly greater postintervention MBG score (3.71 +/- 2.02 vs. 2.93 +/- 2.03; P = 0.022) and had a significantly greater MBG score change (P = 0.025). The results of this randomized study show that the administration of abciximab prevents microcirculatory impairment in patients undergoing angioplasty for acute coronary syndromes.

Bivalirudin versus heparin during coronary angioplasty for unstable or postinfarction angina: Final report reanalysis of the Bivalirudin Angioplasty Study

Background This study was a reanalysis of the Bivalirudin Angioplasty Study, which compared bivalirudin with high-dose heparin during coronary angioplasty for unstable angina. Methods Differences in rates of death, myocardial infarction, or repeat revascularization were compared at 7, 90, and 180 days after angioplasty with intention-to-treat analysis. Results The combined end point occurred in 135 of 2161 patients (6.2%) in the bivalirudin group and in 169 of 2151 patients (7.9%) in the heparin group at 7 days (P = .039). Differences persisted between the groups at 90 days (P = .012) and 180 days (P = .153). Bleeding occurred in 76 patients (3.5%) in the bivalirudin group versus 199 (9.3%) in the heparin group (P < .001). Conclusions This analysis supports the hypothesis that bivalirudin reduces ischemic complications and bleeding after angioplasty. Further trials are needed to evaluate bivalirudin versus heparin in conjunction with platelet-glycoprotein IIb/IIIa inhibitors and for coronary stenting. (Am Heart J 2001;142:952-9.)

Desirudin: a review of its use in the management of thrombotic disorders.

Desirudin, a recombinant hirudin used in the prevention and management of thromboembolic disease, is a thrombin inhibitor which binds directly and with high affinity to clot-bound and fluid phase thrombin. As a prophylaxis in patients undergoing hip replacement surgery, desirudin was significantly more effective in reducing the incidence of deep vein thrombosis (DVT) than either unfractionated or low molecular weight heparin. However, results in patients with acute coronary syndromes are less conclusive. A significant reduction with desirudin compared with heparin in the incidence of death or non-fatal (re)infarction at 24 hours in patients with acute myocardial infarction (MI) was reported in the GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) IIb trial but not in the TIMI (Thrombolysis and Thrombin Inhibition in Myocardial Infarction) 9B trial. Despite the early reduction shown in GUSTO IIb, desirudin was not associated with an improved long term clinical benefit at 30 days compared with heparin. Similar results were seen in patients with unstable angina/non-Q-wave MI enrolled in the GUSTO IIb trial. In addition, desirudin and heparin showed similar efficacy in preventing restenosis 30 weeks after coronary angioplasty for unstable angina, despite desirudin being associated with a significant reduction in the rate of cardiac events within the first 96 hours. Desirudin is as well tolerated as heparin with a similar incidence of moderate and severe bleeding, intracranial haemorrhage or stroke reported when trialled in the prevention of DVT associated with hip replacement surgery or the treatment of acute coronary syndromes. However, in the GUSTO IIb trial a significantly higher incidence of transfusions was observed in patients with unstable angina/non-Q-wave MI. Desirudin is clearly more effective than heparin in the prevention of DVT in patients undergoing elective hip replacement, although cost factors may influence its ultimate place in therapy. In the treatment of acute coronary syndromes the role of desirudin is less certain; however, it may be useful for patients in whom heparin therapy is not a viable option.

Results of percutaneous transluminal coronary angioplasty in unstable angina and non-Q-wave myocardial infarction. Observations from the TIMI IIIB Trial.

This report describes the results of percutaneous transluminal coronary angioplasty (PTCA) in the Thrombolysis in Myocardial Ischemia (TIMI) IIIB Investigation. PTCA was performed before hospital discharge in 444 of 1473 patients with either unstable angina pectoris or non-Q-wave myocardial infarction (NQWMI) enrolled in TIMI IIIB. Angiographic success was observed in 96.1% of patients. For the entire cohort, the cumulative incidences of death and infarction at 1 year were 2.0% and 8.2%, respectively. The periprocedural incidence of myocardial infarction was 2.7%; emergency coronary bypass surgery, 1.4%; and death, 0.5%. By 1 year of follow-up, 122 patients (28.0%, Kaplan-Meier) had an additional revascularization procedure, 75 (61.5%) had PTCA only, 30 (24.6%) had coronary bypass surgery only, and 17 (13.9%) had both procedures. The results of PTCA were not improved by routine pretreatment with intravenous tissue plasminogen activator (TPA). Periprocedural myocardial infarction was more common among patients receiving TPA than placebo (odds ratio [OR], 2.19; P = .03) and among those with unstable angina than those with NQWMI (OR, 15.5; P = .007). No difference in outcome was observed when patients were analyzed according to age (OR, 1.06; P = .092) or sex (OR, 1.54; P = .51). Variables predictive of poor outcome were PTCA within the first 24 hours of enrollment, PTCA site being the left anterior descending coronary artery, and unsuccessful angiography. In TIMI IIIB, PTCA was performed for patients with unstable angina and NQWMI with a very high rate of angiographic success and a low incidence of complications. By 1 year, repeat revascularization was performed in 28.0% of patients. Routine pretreatment with thrombolysis did not enhance outcome.

Percutaneous Transluminal Coronary Angioplasty for Unstable Angina: Predictors of Outcome in a Multicenter Study.

Background: Angiographic and clinical studies have demonstrated that coronary artery plaque rupture with thrombus formation, spasm, or both are frequently responsible for the syndrome of unstable angina. Percutaneous transluminal coronary angioplasty (PTCA) is commonly used in the treatment of patients with coronary artery disease and unstable angina. A number of studies have shown, however, that intracoronary thrombus increases the risk of abrupt vessel closure. The purpose of this study was to define preprocedural variables predictive of the outcome of PTCA performed on patients with unstable angina in a prospective multicenter study using a core angiographic laboratory. Methods and Results: A total of 386 patients with unstable angina underwent coronary angioplasty of 487 lesions treated with balloon PTCA at 9 medical centers. Multivessel or left main coronary artery diseasewas present in 55% and recent myocardial infarction in 22%. Clinical success was achieved in 317 of 386 patients (82.1%), as defined by <50% residual stenosis at every target lesion evaluated in the core angiographic laboratory and no major complication during hospitalization. Major complications (death, Q-wave or non-Q-wave myocardial infarction, or emergency coronary artery bypass surgery) occurred in 36 patients (9.3%), and abrupt vessel closure occurred in 50 (13.0%). Logistic regression analysis identified preprocedural variables that were predictive of outcome of angioplasty. Strong predictors of any complication (major complication or abrupt vessel closure) included age [odds ratio (OR) = 1.04; 95% confidence interval [CII 1.02. 1.071) for each additional year of age; p < 0.001), number of diseased vessels (OR = 1.58; 95% Cl = 1.16, 2.15 per additional vessel; is = 0.012), the number of le~ions treated at angioplasty (OR) = 1.04%; 95% confidence interval [CI] 1.02, 1.07]) for each additional year of age; p < 0.001), number of diseased vessels (OR = 1.58%; 95% CI = 1.16, 2.15 per additional vessel; p = 0.012), the number of lesions treated at angioplasty (OR = 1.72%; 95% CI = 1.11, 2.66;; p = 0.014), and angiographic evidence of filling defect preceding angioplasty (OR = 3.30; 95% CI = 1.11, 9.75; p < 0.001). Conclusions: The outcome of PTCA performed for unstable angina is influenced by a combination of clinical, angiographic, and procedural variables. This study suggests that PTCA performed on lesions associated with filling defects or on more than one lesion at the time of the procedure carries an increased risk of complication. The outcome of PTCA for unstable angina may be improved by identifying new strategies for the treatment of lesions associated with filling defects and by using more accurate methods to identify and treat the culprit lesion responsible for unstable angina.

Aggressive clinical pattern of angina at restenosis following coronary angioplasty in unstable angina

The frequency, clinical pattern, and timing of recurrent angina following successful single-lesion percutaneous transluminal coronary angioplasty (PTCA) was assessed in a consecutive group of 104 patients with stable angina and in 85 with unstable angina. In addition, the relationship between lesion morphology and angiographic features and the pattern of recurrent angina was determined. Restenosis, defined as recurrence of symptoms with >50% stenosis at the site of PTCA, occurred in 25 (24%) of the stable group and in 23 (27%) of the unstable group ( p = NS). The pattern of angina at repeat presentation was aggressive in nature in 8% of the stable group and in 48% of the unstable group ( p = 0.002). The time interval between the recurrence of symptoms and repeat coronary angiogram or PTCA was longer in the nonaggressive group than in the aggressive group, 16 ± 12.1 and 5 ± 6.8 weeks, respectively ( p < 0.003). The key factors predicting the recurrent angina pattern identified by multiple logistic regression analysis were the angina status pre-PTCA ( p = 0.001) and the presence of double-vessel disease ( p = 0.01). An aggressive pattern of angina at the time of restenosis is frequent in patients with unstable angina at the time of PTCA, and close post-PTCA surveillance is necessary in these patients.

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.

Coronary angioplasty in unstable angina: time for controlled clinical trials

Coronary angioplasty in unstable angina: time for controlled clinical trials

Coronary angioplasty in unstable angina and stable angina: A comparison of success and complications : Perry RA, Seth A, Hunt A, et al: Br Heart J 60:367–372, 1988

Coronary angioplasty in unstable angina and stable angina: A comparison of success and complications : Perry RA, Seth A, Hunt A, et al: Br Heart J 60:367–372, 1988

Coronary angioplasty for unstable angina: Immediate and late results in 200 consecutive patients with identification of risk factors for unfavorable early and late outcome

Two hundred patients (mean age 56 years, range 36 to 74) with unstable angina (chest pain at rest, associated with ST-T changes) underwent coronary angioplasty. In 65 patients with multivessel disease, only the “culprit” lesion was dilated. The initial success rate was 89.5% (179 of 200 patients). At least one major procedure-related complication occurred in 21 patients (10.5%): (death in 1, myocardial infarction in 16 and urgent surgery in 18).All patients were followed up for 2 years. Five patients died late; 8 had a late nonfatal myocardial infarction and 52 had recurrence of angina pectoris. The restenosis rate was 32% (51 of 158) in the patients with initial successful angioplasty who had repeat angiography. At the 2 year follow-up, after attempted coronary angioplasty in all 200 patients, the total incidence rate of death was 3% (one procedure related; five late deaths), of nonfatal myocardial infarction 12% (16 procedure related and 8 late after angioplasty), and 13% (26 patients) were still symptomatic although they had improved in functional class.Multivariate analysis showed that variables indicating an increased risk 1) for major procedure-related complications were: ST segment elevation, persistent negative T wave and stenosis ≥65% (odds ratio 3.7, 3.7 and 3.3, respectively); 2) for angiographic restenosis were: presence of collateral vessels, ST segment depression, multivessel disease, left anterior descending coronary artery stenosis and history of recent onset of symptoms (odds ratio: 2.2, 2.0, 1.9, 1.9 and 0.54, respectively); and 3) for late coronary events (recurrence of angina, late myocardial infarction or late death) were: multivessel disease, total occluded vessel and ST segment elevation (odds ratio 3.7, 2.8 and 0.44, respectively).Thus, coronary angioplasty for unstable angina can be performed with a high initial success rate, but at an increased risk of major complications. The prognosis is favorable after initial successful coronary angioplasty.

Results of percutaneous transluminal coronary angioplasty for unstable angina pectoris in patients 70 years of age and older

Between November 1980 and November 1985, 54 patients ages ≥70 years underwent percutaneous transluminal coronary angioplasty for unstable angina, defined as recent-onset (<1 month) angina, new onset of rest angina (≥2 episodes) or accelerating class III or IV angina. In these 20 men and 34 women, disease was 1-vessel in 34 (63%) and multivessel in 20 (37%). The mean (± standard deviation) ejection fraction was 0.62 ± 0.12. Angioplasty was successful in 43 patients (80%). In the 11 unsuccessful cases, emergency coronary artery bypass grafting for acute occlusion was performed in 3 and elective coronary artery bypass surgery in 8. There were no deaths. Two patients (4%) sustained Q-wave myocardial infarctions. The mean duration of follow-up for the total group was 37 months (6 to 73 months). Of the 43 patients with successful dilation, 4 died, 1 had a non-Q-wave myocardial infarction and 8 had symptomatic restenosis (4 underwent successful repeat angioplasty, 1 had repeat percutaneous transluminal coronary angioplasty and then bypass surgery, 1 had repeat bypass surgery alone and 2 had medical therapy). At last follow-up, 3 patients had stable class III or IV angina and 31 patients (72%) were angina-free.

Comparison of Complete and Incomplete Revascularization by Coronary Angioplasty for Unstable Angina

When a “culprit lesion” can be identified in a patient with unstable angina, it may be possible to achieve clinical improvement with incomplete revascularization. We analyzed actuarial survival free of an event (severe angina, myocardial infarction, coronary artery bypass graft, or death) at 6, 12, 18, and 24 months in 83 patients with multi‐vessel disease and unstable angina who had undergone successful percutaneous transluminal coronary angioplasty (PTCA); revascularization was complete in 31 patients and incomplete in 52. Event‐free survival in 85 patients with single‐vessel disease and unstable angina who had undergone successful PTCA also was analyzed. Event‐free survival at 24 months was worse in the multivessel disease patients than in the single‐vessel disease patients (62% vs 85%; P = 0.001). Multivessel disease patients with complete revascularization had the same event‐free survival as those with incomplete revascularization (63% vs 61%; P NS). Diagnostic angiograms revealed thrombus or an irregular ulcerated lesion in 42 of the multivessel disease patients. The event‐free survival of these 42 patients was not different from that of the multivessel disease patients as a whole (64% vs 60%; P NS). We conclude that in patients with multivessel disease and unstable angina the event‐free survival after PTCA is poorer than in patients with single‐vessel disease and unstable angina. In the former patients, event‐free survival does not necessarily depend on the completeness of revascularization. The outcome of patients who have intra‐coronary thrombus or an irregular ulcerated lesion resembles the outcome of patients who lack these findings. (J Interven Cardiol: 1988:1:1)

Indications for coronary angioplasty in acute myocardial ischemic syndromes.

The role of coronary angioplasty for the treatment of patients with evolving myocardial infarction, unstable angina, and early postinfarction unstable angina is discussed. It has been shown that coronary angioplasty in patients with an evolving myocardial infarction is feasible and can be performed with a high initial success rate. The most beneficial timing of dilatation is still unclear, and acute reocclusion following coronary angioplasty remains a problem. Current data suggest that the left ventricular function is greater improved and peri-infarction ischemia is less with angioplasty when compared with sole thrombolytic treatment. Coronary angioplasty for unstable angina and early post-infarction unstable angina can be performed with a high initial success rate, but at an increased risk of major complications. Thus, coronary angioplasty has nowadays obtained a definitive place in the treatment of acute myocardial ischemic syndromes. Further research is needed to improve the initial and late results of coronary angioplasty, and additional randomized clinical studies are necessary to more accurately define the indications and timing of dilatation in these acutely ill patients.

Coronary angioplasty in unstable angina and acute infarction

Coronary angioplasty in unstable angina and acute infarction