Multivessel Coronary Artery Disease Patients Research Articles

Long-term outcome of angioplasty for multivessel coronary disease: importance and price of complete revascularization

Background: Complete revascularization of multivessel coronary artery disease (MVD) by coronary artery bypass surgery has been shown to improve outcome, but there is a lack of similar data for patients treated by angioplasty. Methods: Therefore, a consecutive series of 250 patients with MVD was separated into two groups, those with complete revascularization ( n=101) and those with incomplete revascularization ( n=149). Six-month ‘clinical restenosis’ rate assessed by stress myocardial perfusion scintigraphy or symptom-driven angiography and long-term 32 months outcome were compared with an equally sized group of single vessel disease (SVD) patients. Results: MVD patients with complete revascularization had a higher ‘clinical restenosis’ rate than patients with SVD (35 vs. 22%, P<0.02), although restenosis rate per treated vessel was similar (23%, 18%, P NS). If this higher early restenosis rate were accepted as ‘price’ for complete MVD angioplasty, long-term event-free survival was no longer different from that of SVD patients (86 vs. 93%, P NS). In contrast, patients with incomplete multivessel angioplasty had a significantly worse long-term outcome (22% events), especially if initially untreated, non-occluded vessels remained untreated (25% events). Conclusion: MVD angioplasty with complete revascularization has a long-term event-free survival similar to that of SVD angioplasty but at the price of a higher rate of 6-month restenosis and repeat interventions.

Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: A report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators

Background Studies of survival of patients with multivessel coronary artery disease (MVD) in the prestent era suggested that outcomes after coronary artery bypass surgery (CABG) are similar to those after percutaneous coronary intervention (PCI) in subsets of coronary severity. The purpose of this study of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) was to examine the association between treatment and survival up to 5 years in patients with MVD enrolled from 1995 through 1998. Methods and Results Data on patient characteristics were obtained at the time of the initial coronary angiography. Survival was determined through data linkage to the provincial Bureau of Vital Statistics. Risk-adjusted hazard ratios were calculated to compare different treatments. In the 11,661 patients with MVD, CABG was the initial therapy in 3782, PCI in 3540, and medical therapy in 4339. Cumulative 5-year survival was 91.4% with CABG, 91.9% with PCI, and 82.9% with medical therapy (P <.001). Hazard ratios were CABG: medical 0.53 (95% confidence interval [CI] 0.46-0.71), PCI: medical 0.65 (95% CI 0.56-0.74), and CABG: PCI 0.81 (95% CI 0.68-0.96). Analysis across coronary severity groups revealed a benefit of CABG compared with PCI only in the group with severe left main CAD: 0.30 (95% CI 0.17-0.54). Conclusions In a multicenter clinical setting, MVD patients treated with revascularization have significantly higher 5-year survival rate than do those treated medically. Risk-adjusted comparison reveals PCI treatment to be associated with long-term survival similar to treatment with CABG in all coronary severity subgroups except the group with severe left main coronary artery disease. Patient selection factors are likely to be contributing to these findings. (Am Heart J 2001;142:119-26.)

On-line quantitative assessment of left ventricular filling during dobutamine stress echocardiography: a useful addition to conventional wall motion scoring

In order to determine whether the diastolic rate of ventricular volume change obtained on-line with an automatic border detection (ABD) system during dobutamine stress echocardiography (DSE) would provide an interpretation of the diastolic ventricular response to the drug in quantitative terms in the assessment of coronary artery disease, we studied, with ABD and DSE, 59 patients who underwent coronary arteriography within 2 months of the stress test. Eleven patients had normal coronary findings or non-significant coronary lesions. Significant (≥70% diameter stenosis) coronary artery disease (CAD) was present in 48 patients (81%). Dobutamine stress echocardiography (DSE) to a maximal dose of 50 μg/kg per min was performed in all patients. ABD images were acquired at rest and at the peak of infusion along with conventional two-dimensional images. The following measurements were evaluated: left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular ejection fraction (LVEF), slope of rapid filling segment (RFS), peak filling rate (PFR), rapid filling phase fractional change (RFFC). Patients with non-significant coronary artery lesions exhibited a hyperdynamic response with an LVEF increment of at least 20% from baseline to peak drug infusion. In these patients the effect of dobutamine produced an increase of RFS from 35.5±5.6 to 86.5±10.5 ml/s, an increase of PFR from 4.4±0.6 to 6.8±0.6 EDV/s, and an increase of RFFC from 74±8 to 92±5% ( P<0.001). Of the 48 patients with coronary artery disease, 27 had <20% LVEF increase at peak dobutamine infusion. Four of 22 patients with single vessel disease and 23 of 26 patients with multivessel disease had an abnormal systolic response. After dobutamine infusion single vessel CAD patients showed a decrease of RFS from 33.4±5.3 to 26.7±5.9 ml/s, a decrease of PFR from 3.8±0.7 to 3.0±0.7 EDV/s, and a decrease of RFFC from 73±6 to 59±4% ( P<0.001). Multivessel CAD patients showed a decrease of RFS from 32.0±5.9 to 23.1±4.1 ml/s, a decrease of PFR form 3.8±0.6 to 2.8±0.6 EDV/s, and a decrease of RFFC from 71±5 to 54±8% ( P<0.001). The overall sensitivity of detecting CAD was 85% for conventional DSE and 90% for ABD-DSE ( P=NS). The sensitivities of detecting patients with single vessel and multivessel CAD with conventional DSE were 68 and 92%, respectively, and with ABD-DSE were 91% ( P<0.01) and 96% ( P=NS), respectively. Our results show that an abnormal diastolic as well as systolic response during on-line quantitative assessment of dobutamine stress echocardiography is a sensitive marker of coronary artery disease and is predictive for the detection of extensive lesions. The described measurements can be utilized to improve the DSE sensitivity in identifying coronary artery disease. On-line quantitation of diastolic indexes with ABD can represent another step toward obtaining uniform results after stress echocardiography.

Usefulness of Exercise Echocardiography in Early Detection of Multivessel Coronary Artery Disease after Uncomplicated Myocardial Infarction

To evaluate the exercise echocardiography (EE) accuracy in identifying the presence of multivessel coronary artery disease (MVD) early after myocardial infarction (MI), 76 consecutive patients underwent coronary angiography and EE 10-15 days after uncomplicated MI. Left-ventricular wall motion abnormalities localised to more than one vascular territory were considered as the échocardiographie marker of MVD. To quantify ventricular dysfunction, a wall motion score index was calculated and the difference between baseline and exercise values (ΔWMSI) was recorded. EE correctly identified 26/33 MYD patients (sensitivity 79%), and 36/43 single-vessel disease (SVD) patients (specificity 84%). The MVD patients were more likely to have exercise- induced wall motion abnormalities (69 vs. 35% in the SVD group), which more frequently involved vascular regions with normal resting function (36% of MVD vs. 5% of SVD patients). After exercise, MVD patients showed a variable degree of ventricular dysfunction but a trend to a greater impairment of regional function was identified: ΔWMSI 0.261 ± 0.21 in MVD vs. 0.162 ± 0.09 in SVD patients (p = 0.06). In conclusion, in asymptomatic patients, after uncomplicated MI, EE allows the presence and the functional significance of MVD to be assessed nonin vasively with good accuracy.