Repeat Percutaneous Transluminal Coronary Angioplasty Research Articles

Systematic comparison of the effectiveness of radial artery and saphenous vein or right internal thoracic artery coronary bypass grafts in non-left anterior descending coronary arteries

Coronary artery bypass grafting surgery is increasingly being carried out on patients with multi-vessel coronary artery disease, but the best grafting candidate for non-left anterior descending coronary arteries is unclear. This research sought to systematically compare the efficacies and safeties of coronary bypass with radial artery and other available grafts. A systematic literature retrieval was performed for all clinical trials comparing the outcomes of coronary artery bypass surgery with radial artery and other grafts in PubMed, EMBASE, and the Cochrane Library. Seven eligible clinical studies, comparing radial artery and great saphenous vein grafts, were found between 1966 and 2010: one prospective non-randomized and six prospective randomized trials. The pooling analysis obtained a relative risk of 0.507 (P<0.05) of graft occlusion in radial arteries compared with great saphenous veins. There was a significantly lower infection rate in arms (i.e., harvest sites for radial arteries) relative to legs (harvest sites for veins), with a pooled relative risk of 0.140 (P<0.05). From the reports on mortality after follow-up ranging from one year to six years, there was no significant difference in mortality between the two graft types (P=0.927). In addition, four cohort controlled trials for radial and right internal thoracic artery grafts were included. The radial graft was associated with less cardiac related events relative to the right internal thoracic artery graft (P=0.014), but with comparable mortality and comparable rates of repeat percutaneous transluminal coronary angioplasty. Subjects with radial arteries seemed to have a lower occlusion rate and a lower graft harvest site infection rate than those with great saphenous veins. Moreover there were fewer cardiac related events with radial arteries relative to the right internal thoracic artery grafts. More studies are needed to confirm these findings concerning the favorable outcomes of coronary artery bypass grafting with radial arteries on long-term patency and mortality.

Coronary stent disease: When will enough be enough?

CLINICAL SUMMARY A 60-year-old man was transferred to the Sir Charles Gairdner Hospital with unstable angina. His comorbidities were obesity (body mass index 33.6 kg/m), hypertension, type II diabetes mellitus requiring insulin, hypercholesterolemia, and chronic renal failure (creatinine 150 mmol/L) due to diabetic nephropathy. The patient was an ex-smoker. Left ventricular ejection fraction was 45% with hypokinesis of the inferolateral wall. He had severely diseased left anterior descending (LAD) and left circumflex (LCx) coronary arteries with multiple in-stent stenoses (Figure 1) and a small nondominant right coronary artery. The patient had been previously managed elsewhere. In March of 2002, he was admitted with unstable angina and underwent percutaneous transluminal coronary angioplasty (PTCA) of the obtuse marginal (OM) branch. During angioplasty, the OM branch was dissected. A 2.5-mm Tsunami stent (Terumo Corporation, Tokyo, Japan) and a 2.5-mm Pixel stent (Guidant, Santa Clara, Calif) were placed to overlap the area of dissection. In October of 2002, unstable angina and in-stent stenosis of the OM developed, which were managed by PTCA alone. In May of 2003, unstable angina recurred. The patient underwent repeat PTCA to the LAD and LCx arteries, during which 3 Cypher stents (Cordis Corporation, Warren, NJ) were placed in the proximal LAD occluding the second diagonal branch and 4 Zeta stents (Abbott Laboratories, Abbott Park, Ill) were placed in the LCx. In January of 2007, the patient presented with unstable angina, inferolateral myocardial infarction, and pulmonary edema. The in-stent stenosis in the distal LCx was demonstrated, and the flow was restored with 4 Cypher stents. In March of 2007, he presented again with a prolonged episode of angina and inferolateral infarction and was found to have

Analysis of nonintervention strategy for in-stent restenosis in pauci- or asymptomatic patients

Between January 1996 and May 2000, we retrospectively identified 66 patients (61 ± 11 years) with in-stent restenosis who did not undergo percutaneous coronary intervention and/or bypass surgery and were maintained on medical treatment alone. In-stent restenosis was diffuse or proliferative in 86% of these patients. At 33 ± 11 months, 2 patients died, none developed myocardial infarction, and 6 (9%) had target lesion revascularization only (repeat percutaneous transluminal coronary angioplasty). Medical treatment alone was associated with a good long-term clinical follow-up in selected patients with significant documented in-stent restenosis.

Utilization of eptifibatide for treatment of severe dissections as a bail-out procedure

Background: It has been shown in several large trials that the inhibition of glycoprotein (GP) IIb/IIIa receptors of platelets can reduce the rate of ischemic complications following percutaneous transluminal coronary angioplasty (PTCA). We sought to determine the efficacy of eptifibatide in patients with severe dissections or threatened vessel closure after PTCA in small coronary arteries (<2.5 mm). Methods: Eptifibatide was used in 51 patients after conventional balloon angioplasty complicated by severe dissections with or without threatened vessel occlusion. Eptifibatide was administered as a double-bolus of 180 μg/kg bodyweight, followed by a continuous infusion at a dosage of 2.0 μg/kg min over a time period of 20 h. In this situation, the implantation of a coronary stent was avoided if a prompt antegrade flow of contrast dye could be maintained. Results: Using the GP IIb/IIIa antagonist eptifibatide, it was possible to increase or to maintain antegrade blood flow in 28 (55%) patients. In 45% of the patient population, however, repeat PTCA was needed, and in four patients (7.8%) an intracoronary stent had to be implanted. During hospitalization three (6%) patients underwent target lesion revascularization (two Re-PTCAs, one coronary bypass graft operation). There were no myocardial infarctions and there was no intrahospital death. The cumulative event rate including acute and long term events was 25%. Conclusions: The findings of our study indicate that eptifibatide is able to prevent vessel occlusion after PTCA complicated by severe dissections with or without threatened vessel occlusion associated with a low-in-hospital complication rate.

Acute Thrombosis after Elective Direct Intracoronary Stenting in Primary Antiphospholipid Syndrome: A Case Report

Antiphospholipid syndrome (APS) is an uncommon prothrombotic disorder that has been increasingly recognized in recent years. The diagnosis of APS must be associated with venous or arterial thrombosis or both. Patients with APS usually present with recurrent deep vein thrombosis, pulmonary thromboembolism, thromboembolic stroke, or myocardial infarction. Here, we report a case of a 61-year-old female who presented with a 3-month history of increasingly frequent retrosternal chest tightness. After treadmill test and thallium-201 myocardial perfusion scan, she was admitted and underwent elective coronary angiography but developed acute thrombosis after direct intracoronary stenting. She was successfully rescued with repeat percutaneous transluminal coronary angioplasty and prolonged heparin and glycoprotein IIb/IIIa antagonist use. Laboratory data showed prolongation of partial thromboplastin time and positive anti-cardiolipin antibody. These findings satisfied the criteria for APS; the patient was diagnosed with primary APS because she had neither typical symptoms nor signs of systemic lupus erythematosus or other immunologic disorders. Thereafter, long-term oral anticoagulant appeared to be effective. To our knowledge, this is the first report of acute stent thrombosis in a patient with primary APS.

An updated meta-analysis of calcium-channel blockers in the prevention of restenosis after coronary angioplasty

Background In 1994, a meta-analysis of 5 small randomized trials reported a 30% reduction in the odds of angiographic restenosis when calcium-channel blockers (CCB) were given after percutaneous coronary intervention. Recently, the results of 2 large similar trials (Nisoldipine In Coronary Artery Disease in Leuven [NICOLE], and Coronary AngioPlasty Amlodipine in REstenosis Study [CAPARES]) were published. An extended meta-analysis including the results of the latter trials was performed. Methods A total of 2380 patients were analyzed. Statistical analysis included calculation of odds ratios for each trial, common odds ratio, and homogeneity for treatment effects across trials. Results The incidence of angiographic restenosis was 36% in the CCB-treated group and 42% in the placebo group. The odds ratio of restenosis with CCB therapy was 0.78 (95% CI 0.64-0.95) compared with control patients ( P = .01). Treatment effects were homogeneous across the trials. For the combined end point of death, coronary artery bypass grafting, repeat percutaneous transluminal coronary angioplasty, and myocardial infarction, 126 of 626 events occurred in the CCB group and 191 of 655 in the placebo group (odds ratio 0.61 [95% CI 0.47-0.80], P < .001). Conclusions This extended meta-analysis confirmed a reduction in the odds of restenosis and clinical events when CCBs were added to standard therapy after percutaneous coronary intervention. (Am Heart J 2003; 145:404-8.)

A pharmacoeconomic evaluation of results from the coronary angioplasty amlodipine restenosis study (CAPARES) in Norway and Canada

Introduction: The objective of this analysis was to evaluate the health economic benefits of using amlodipine in patients undergoing angioplasty procedures in Canada and Norway. Methods: A decision tree model was constructed to find the total expected cost per patient for a 4-month time period following an initial angioplasty. The model used clinical data from the Coronary Angioplasty Amlodipine Restenosis Study (CAPARES), a prospective, randomized, double blind, placebo-controlled trial conducted to investigate the effects of amlodipine on restenosis and clinical events in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). Outcomes of interest to this analysis included MI, repeat PTCA, CABG, and all-cause mortality. Clinical experts from Canada and Norway were enlisted and a modified Delphi study approach was used to quantify healthcare resources consumed for each clinical outcome. Results: The use of amlodipine decreased the rates of MI, PTCA, and CABG by 2.0, 4.7, and 2.7%, respectively. The total expected cost per patient using amlodipine was $6,398.30 (US$4,323) in Canada and kr 59,993.27 (US$6,846) in Norway. The total expected cost per patient not using amlodipine was $6,519.37 (US$4,405) in Canada and kr 64,292.17 (US$7,337) in Norway. The model demonstrated potential cost-savings over a 4-month follow up period resulting from the improved clinical outcomes for patients using amlodipine with PTCA—$121,071 (US$81,844) per 1000 patients in Canada and kr 4,298,899 (US$490,074) per 1000 patients in Norway. Conclusions: The adjunctive use of amlodipine is a cost-effective therapeutic strategy to achieve more favorable clinical outcomes in patients undergoing PTCAs in Canada and Norway.

Six-month outcomes of percutaneous transluminal coronary angioplasty in hypertensive patients: Results from the ROSETTA registry

Purpose Hypertension is an important risk factor for coronary artery disease. However, the impact of hypertension on the outcomes of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) is unknown. Our purpose was to evaluate the association between hypertension and adverse outcomes and repeat cardiac procedures during the 6-month period after PTCA. Methods We studied 791 patients who were enrolled in the Routine Versus Selective Exercise Treadmill Testing After Angioplasty (ROSETTA) registry. This registry is a prospective multicenter study examining the use of functional testing after a successful PTCA. Results We compared 411 hypertensive patients (mean age 60.1 ± 10 years, 31.1% female) with 380 normotensive patients (mean age 59.1 ± 12 years, 16.2% female). Patients with hypertension had a higher 6-month rate of composite clinical events (unstable angina, myocardial infarction, death) than did normotensive patients (16.5% vs 10.5%, P =.017). In addition, there was a trend for hypertensive patients to have higher rates of cardiac procedures (angiography, repeat PTCA, coronary artery bypass graft surgery) compared with normotensive patients (19.8% vs 14.9%, P =.074). However, functional testing after PTCA was lower among hypertensive subjects (44.4% vs 54.0%, P =.008). Among the 411 hypertensive patients, a regression analysis showed that several variables were independently associated with increased 6-month adverse event rates, including pre-PTCA Killip class III-IV (odds ratio [OR] 5.7, 95% CI 1.7-19.0), Canadian Cardiovascular Society angina class III-IV (OR 2.1, 95% CI 1.1-4.2), unstable angina as the reason for PTCA (OR 2.3, 95% CI 1.2-4.3), peripheral vascular disease (OR 3.2, 95% CI 1.5-6.4), PTCA of a bypass graft (OR 3.1, 95% CI 1.2-7.6), and calcium antagonist usage at admission for the index PTCA (OR 1.9, 95% CI 1.1-3.4). Conclusions During the 6-month period after a successful PTCA, patients with hypertension have significantly higher adverse event rates than do those without hypertension. Several clinical variables may help identify which hypertensive patients are at higher risk for clinical events. (Am Heart J 2002;143:124-9.)

Coronary stenting in diabetic patients: Results from the ROSETTA registry

Objective Diabetes mellitus is associated with high rates of restenosis and adverse outcomes after percutaneous transluminal coronary angioplasty (PTCA). It is unclear whether coronary stenting reduces adverse events in diabetic patients after PTCA. Our purpose was to determine whether coronary stenting improves clinical event rates in diabetic patients after PTCA. Methods The Routine Versus Selective Exercise Treadmill Testing After Angioplasty (ROSETTA) registry was a prospective multicenter observational study examining functional testing and adverse outcomes after successful PTCA. Results Among the 791 patients enrolled, 180 were diabetic. A total of 90 diabetics received stents while the remaining 90 patients did not. Baseline clinical characteristics were similar between the 2 groups of patients. However, patients with stents were more likely to have complex lesions, whereas those without stents were more likely to undergo atherectomy and have greater residual coronary stenosis. At 6-month follow-up, the composite end point defined as cardiac death, unstable angina, myocardial infarction, need for repeat PTCA, or coronary artery bypass graft surgery (CABG) occurred in 25.0% of stented and 22.2% of nonstented diabetic patients (P not significant [NS]). A multivariate logistic regression analysis showed that coronary stenting was not associated with a reduced incidence of the composite end point among diabetic patients (odds ratio 0.97, 95% CI 0.46-2.05, P NS). Conclusion Coronary stenting does not improve clinical event rates in diabetic patients after PTCA. (Am Heart J 2001; 142:960-4.)

Restenosis after Angioplasty.

Angiographic restenosis occurs in 30% to 50% of patients after percutaneous transluminal coronary angioplasty (PTCA) with 20% to 30% target vessel revascularization at one year, and is associated with increased morbidity, mortality and health care costs. Intracoronary stents are the first line of therapy against restenosis after angioplasty. Depending on lesion morphology and location, stents can reduce restenosis and target lesion revascularization (TLR) by 20% to 30%. Obstructive coronary lesions in vessels with a diameter larger than 3.0 mm should be stented. The benefit of stenting in vessels smaller than 3.0 mm is controversial, with the BESMART (Bestent in Small Arteries) and ISAR-SMART (Intracoronary Stenting or Angioplasty for Restenosis Reduction in Small Arteries) studies demonstrating conflicting results. Chronically occluded and subtotal vessels should be stented after PTCA. Obstructive lesions in saphenous vein grafts should be stented. It is preferable to stent ostial lesions after PTCA. Restenosis can occur in 15% to 25% of patients within 6 months of stent placement. Initial approach to focal in-stent restenosis is to repeat PTCA. Patients with diffuse restenosis may require debulking prior to PTCA to improve acute results. "Stenting within-stent" has not proven beneficial unless there is diffuse in-stent restenosis, neointimal prolapse or vessel dissection during PTCA. There are no pharmacologic therapies approved by the Food and Drug Administration available to treat restenosis at present. Brachytherapy, gamma or beta, is an effective adjunctive therapy that can reduce recurrent in-stent restenosis by 40% to 70%. Patients at high risk for recurrent in-stent restenosis (proliferative or total occlusion pattern) can be considered for brachytherapy to treat the first episode of in-stent restenosis. Patients with focal in-stent restenosis should be treated with brachytherapy after multiple recurrences of in-stent restenosis. Emerging therapies for treatment of restenosis include antiproliferative-coated stents and photoangioplasty.

Unprotected left main coronary artery stenting: Correlates of midterm survival and impact of patient selection

OBJECTIVESThe study served to present the in-hospital and six-month clinical outcome and also the long-term survival data of a consecutive series of patients undergoing stenting for unprotected left main coronary artery (LMCA) disease.BACKGROUNDRevascularization with coronary bypass surgery has been generally recommended for treatment of left main coronary stenosis. Improvements in angioplasty and coronary stent techniques and equipment may result in the wider applicability of a percutaneous approach.METHODSA total of 92 consecutive patients underwent unprotected LMCA stenting between March 1994 and December 1998. For the initial 39 patients (group I) angioplasty was performed only when surgical revascularization was contraindicated. The remaining 53 patients (group II) also included patients in whom surgery was feasible. Patients were followed for 7.3 ± 5.8 months (median 239 days; range 49 to 1,477 days).RESULTSCompared to group I, group II patients had higher left ventricular ejection fraction (60 ± 12% vs. 51 ± 16%, p < 0.01), less severe LMCA stenosis (68 ± 12% vs. 80 ± 10%, p < 0.001), lower surgical risk score (13 ± 7 vs. 20 ± 7, p < 0.001), and had angioplasty more often performed via the radial approach (88% vs. 23%, p < 0.001) with smaller guiding catheters (6F: 49% vs. 15%; 8F: 2% vs. 77%, p < 0.001). The procedural success rate was 100%. In-hospital mortality was 4% (4 deaths, 3 cardiac). During follow-up there were six deaths, 13 patients required repeat percutaneous transluminal coronary angioplasty (4 LMCA), and two required coronary artery bypass graft surgery. Estimated survival (±SEE) was 89 ± 6.3% at 500 days and 85 ± 12% at 1,000 days post-stenting. Overall mortality was 3.8% in group II and 20.5% in group I (p < 0.02).CONCLUSIONSCoronary stenting can be performed safely in high-risk individuals with acceptable intermediate-term outcome. It may be feasible to broaden the application of this technique in selected patients needing revascularization for left main coronary disease.

Brachytherapy: A New Weapon Against Coronary Restenosis

Since its introduction in the late 1970's, coronary angioplasty has become a common procedure for treating coronary atherosclerotic disease. It offers significant improvement in symptoms of coronary artery disease through a less invasive procedure than coronary artery bypass grafting (CABG). Each year, over 500,000 percutaneous transluminal coronary angioplasty (PTCA) procedures are performed in North America alone. In larger epicardial vessels that are 3 millimeters or greater in diameter, a metal stent can be placed during angioplasty to reduce the incidence of restenosis. In fact, stents are now deployed in approximately 80 percent of PTCA procedures. The success rate of PTCA in achieving significant dilation of stenotic lesions and relief of symptoms of angina approaches 90 percent. However, restenosis occurs in approximately 30 to 40 percent of patients within six months of PTCA alone, and in 20 to 30 percent of patients who undergo stent placement. Repeat PTCA can be performed following restenosis, but the risk of further episodes of restenosis increases as well.

Reappraising the role of immediate intervention following thrombolytic recanalization in acute myocardial infarction

Early studies indicated that after successful thrombolytic recanalization, adjunctive percutaneous transluminal coronary angioplasty (PTCA) was not appropriate, even when a significant residual stenosis was present. The aim of this study was to assess in-hospital clinical outcomes of patients with acute myocardial infarction (AMI) who underwent successful recanalization after thrombolytic therapy. The relation between repeat AMI/unstable angina and the severity of the stenosis, as well as other angiographic and clinical features was also examined. One hundred patients with AMI of <10 hours underwent coronary angiography 2 hours after receiving thrombolytic therapy. Salvage PTCA ± stenting was performed if recanalization was unsuccessful (Thrombolysis In Myocardial Infarction [TIMI] trial grade 0 to 2), and no PTCA was undertaken if there was brisk anterograde flow (TIMI 3). Angiographic analysis was performed to assess the severity of the residual lesion, as well as the presence or absence of thrombus. Forty patients had unsuccessful recanalization, and of these, 36 underwent attempted PTCA. Of the 60 patients with TIMI 3 flow, 15 required repeat angiography and PTCA after repeat AMI (n = 13) or unstable angina (n = 2) within 5 days. Receiver-operating characteristic analysis indicated an optimum percent diameter stenosis predictor of 85% for repeat AMI/unstable angina. There was no additional relation to age, gender, time to thrombolysis, the infarct-related artery, or the presence of culprit lesion thrombus. After recanalization, a high-grade stenosis >85% is common (n = 25, 42.4%). This is associated with a 54% repeat AMI/unstable angina risk—a ninefold increase in the incidence of such events than in patients with lesions <85%. Thus, patients with narrowings >85% may benefit from early intervention rather than a conservative approach. Narrowings <85% have a 94% probability of no repeat AMI/unstable angina and do not require early intervention.

Results of Stent Supported Percutaneous Transluminal Coronary Angioplasty in Octogenarians With Coronary Artery Disease.

Between January 1995 and July 1998, percutaneous transluminal coronary angioplasty was performed on 27 lesions in 24 octogenarians. Half of the patients were African American. Women comprised 67% of the study group. Patients with unstable angina and myocardial infarction constituted 54% of the cohort. Two-thirds of the patients (83%) had single vessel disease with predominant class A and B lesion complexity of the angioplasty site. Acute success rate was 92%. Stents were successfully placed in 11 subjects (46%). None had acute myocardial infarction, emergency coronary artery bypass surgery, or stroke as a complication of the procedure. One patient presenting with acute myocardial infarction complicated by cardiogenic shock, died. Significant bleeding complications requiring blood transfusions occurred in 17% of patients. Of the patients, 23 (96%) were discharged in a clinically stable condition. Follow up during a two year period was completed in 21 patients (88%). One patient died of cancer. Four subjects (19%) underwent repeat percutaneous transluminal coronary angioplasty. One other patient had recurrent chest pain requiring multiple hospitalizations. The remaining 16 patients (76%) remained free of recurrence of angina. We concluded that percutaneous transluminal coronary angioplasty with stent placement can be performed in octogenarians with a high rate of clinical and angiographic success with an acceptable range of morbidity and mortality, and favorable long term (two year) outcome. (c) 2000 by CVRR, Inc.

Outcome 14 to 18 years after percutaneous transluminal coronary angioplasty

Outcome 14 to 18 years after percutaneous transluminal coronary angioplasty

Diabetes and Multiple Stents Independently Double the Risk of Short-term Revascularization

Several studies show worse outcome for diabetic patients after percutaneous transluminal coronary angioplasty (PTCA). There are relatively few studies evaluating outcome in the modern era of coronary stenting. We compared the incidence of death, myocardial infarction (MI), and repeat target lesion revascularization (RTLR) by PTCA or coronary artery bypass grafting (CABG) over a 6-month follow-up in 110 diabetic and 400 nondiabetic patients receiving Palmaz-Schatz stents. All patients received aspirin/ticlopidine and stents were deployed using high-pressure inflations. Seventy-five (68.2%) diabetic patients and 272 (68%) nondiabetic patients had single stents, while 35 (31.8%) diabetic and 128 (32%) nondiabetic patients had multiple stents (≥ 2stents in the same vessel). The success rate and acute major complications were not significantly different between diabetic and nondiabetic patients. There was also no significant difference in death, MI, and repeat PTCA between these two groups. Diabetic patients underwent CABG more frequently than nondiabetic patients (12.7% vs 3.2%, respectively, P =0.001) and diabetic patients also had RTLR more frequently than nondiabetic patients (25.5% vs 12.8%, respectively, P = 0.002) during 6-month follow-up. Multivariate analysis showed that diabetes and multiple stents independently contributed to the 6-month RTLR rate. Coronary stenting in diabetic patients can be carried out with a high success rate and low incidence of acute major complications. The presence of diabetes mellitus and multiple stent placement significantly increase the incidence of repeat target lesion revascularization.

Restenosis and clinical outcome in patients treated with amlodipine after angioplasty: results from the coronary AngioPlasty Amlodipine REStenosis Study (CAPARES)

OBJECTIVESOur intent was to investigate the effect of the dihydropyridine calcium channel blocker amlodipine on restenosis and clinical outcome in patients undergoing percutaneous transluminal coronary angioplasty (PTCA).BACKGROUNDAmlodipine has sustained vasodilatory effects and relieves coronary spasm, which may reduce luminal loss and clinical complications after PTCA.METHODSIn a prospective, double-blind design, 635 patients were randomized to 10 mg of amlodipine or placebo. Pretreatment with the study drug started two weeks before PTCA and continued until four months after PTCA. The primary angiographic end point was loss in minimal lumen diameter (MLD) from post-PTCA to follow-up, as assessed by quantitative coronary angiography (QCA). Clinical end points were death, myocardial infarction, coronary artery bypass graft surgery and repeat PTCA (major adverse clinical events).RESULTSAngioplasty was performed in 585 patients (92.1%); 91 patients (15.6%) had coronary stents implanted. Follow-up angiography suitable for QCA analysis was done in 236 patients in the amlodipine group and 215 patients in the placebo group (per-protocol group). The mean loss in MLD was 0.30 ± 0.45 mm in the amlodipine group versus 0.29 ± 0.49 mm in the placebo group (p = 0.84). The need for repeat PTCA was significantly lower in the amlodipine versus the placebo group (10 [3.1%] vs. 23 patients [7.3%], p = 0.02, relative risk ratio [RR]: 0.45, 95% confidence interval [CI]: 0.22 to 0.91), and the composite incidence of clinical events (30 [9.4%] vs. 46 patients (14.5%), p = 0.049, RR: 0.65, CI: 0.43 to 0.99) within the four months follow-up period (intention-to-treat analysis).CONCLUSIONSAmlodipine therapy starting two weeks before PTCA did not reduce luminal loss, but the incidence of repeat PTCA and the composite major adverse clinical events were significantly reduced during the four-month follow-up period after PTCA with amlodipine as compared with placebo.

Comparison of ReoPro((R)) (abciximab) versus intracoronary thrombolysis for early coronary stent thrombosis.

AIMS: This study evaluated the treatment of early coronary stent thrombosis with intracoronary urokinase or the platelet glycoprotein IIb/IIIa receptor inhibitor ReoPro (abciximab). METHODS AND RESULTS: Seventy-four patients (126 stents) were treated immediately after identification of early (0-30 days) coronary stent thrombosis. Twenty-nine patients were treated with intracoronary urokinase (UK) (UK alone in 19; UK and additional balloon angioplasty in 10) and another 45 patients were given ReoPro((R)) (abciximab) (0.25 mg/kg as a bolus alone in 26, abciximab with additional balloon angioplasty in 19) within 30 days of stent implantation. TIMI grade 3 flow was obtained in 23 patients (79%) in the UK group and in 38 (84%) in the abciximab group (nonsignificant). Three patients (10%) in the UK group and one (2%) in the abciximab group underwent repeat percutaneous transluminal coronary angioplasty (PTCA) (nonsignificant). Five patients (17%) in the UK group and three (7%) in the abciximab group were referred for urgent coronary artery bypass graft surgery (CABG) because of residual thrombus and refractory ischemia (nonsignificant). Repeat revascularization was necessary in eight patients (28%) in the UK group versus four (9%) in the abciximab group (p < 0.05). Five patients (17%) in the UK group and eight (18%) in the abciximab group developed myocardial infarction (nonsignificant). Five patients (17%) in the UK group (cardiogenic shock (three), cerebral hemorrhage (one) and pneumonia (one)) and three (6.6%) in the abciximab group (cardiogenic shock (two), heart failure (one)) died within 30 days (nonsignificant). Overall, noncardiac complications (bleeding including surgical repair of groin) were observed in 11 patients (38%) in the UK group and three (7%) in the abciximab group (p < 0.001). CONCLUSION: Compared to urokinase, abciximab reduced the need for repeat revascularization procedures and the risk of noncardiac events, including bleeding complications in patients with early coronary stent thrombosis.

Clinical Outcome after Successful Coronary Angioplasty: Impact of Intracoronary Stent Implantation

The clinical outcome after successful conventional coronary balloon angioplasty is compared with that of stent implantation after 30 days and 12 months. The study took place at the Divisions of Cardiology and Thoracic Radiology, Norrland University Hospital, Umeå, a referral centre for northern Sweden. The first 100 consecutive patients with stable or unstable angina undergoing successful percutaneous transluminal coronary angioplasty (PTCA) in 1994 and the first 100 consecutive patients undergoing successful coronary stent implantation in 1995 were included. The cardiac endpoints studied were death, myocardial infarction, need for repeat PTCA or coronary artery bypass grafting (CABG). Significantly more adverse cardiac events were observed in the PTCA group compared with the stent group. Event-free 12 months' follow-up (no deaths, myocardial infarction or re-intervention) was 64% in the PTCA group and 86% in the stent group (p < 0.005). The main explanation for the observed difference was a reduction in the need for a repeat PTCA (7 vs 18, p < 0.05) or CABG (4 vs 12, p < 0.05) in the stent group. Patients with stable or unstable angina who can be treated with a stent have a better clinical outcome than those treated with coronary balloon angioplasty only.

Does angiography six months after coronary intervention influence management and outcome?

OBJECTIVESThis study was performed to assess whether angiography six months after coronary balloon angioplasty or stent implantation has an influence on clinical management and one-year outcome.BACKGROUNDThe Benestent II study randomized 827 patients to balloon angioplasty or stent implantation. A subrandomization was undertaken allocating patients to six-month clinical follow-up (CF) or clinical and angiographic follow-up (AF).METHODSSeven hundred and six patients (349 CF and 357 AF) had no intercurrent angiography, so that restenosis and disease progression elsewhere remained unknown until the time of six-month follow-up. These two groups, which were well matched at enrolment, were compared with respect to symptoms, medication and major cardiac events defined as death, myocardial infarction and need for revascularization at six and 12 months.RESULTSAt six-month follow-up, 53 (15%) of the CF and 76 (21%) of the AF patients had stable angina (p = 0.041), while 5 (1%) and 4 (1%) had symptoms of unstable angina. At 12-month follow-up, 44 (13%) patients in both groups had stable angina, and only 1 patient in the CF group had unstable angina. Seventy-seven patients (27 CF and 50 AF; p < 0.01) had major cardiac events between 6 and 12 months. Of the 349 patients in the CF group, 21 underwent repeat percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery between 6 and 12 months, compared with 44 of the 357 patients in the AF group (relative risk 2.05 [1.24 to 3.37], p = 0.003).CONCLUSIONSPatients who had AF six months after balloon angioplasty or stent implantation experienced more repeat revascularization procedures than those who had CF. They also had significantly more angina at six-month follow-up but this may be due to bias.