Is coronary angioplasty safe in the elderly?

OBJECTIVE: To evaluate the use of percutaneous transluminal coronary angioplasty (PTCA) and the immediate procedural outcomes in the elderly at a tertiary care centre. PATIENTS AND METHODS: Between January 1992 and December 1997, a total retrospective cohort study of 2322 consecutive patients aged 60 years or older underwent PTCA. Patients were categorized into three age groups: group A (60 to 69 years of age), which included 1294 patients; group B (70 to 79 years), which included 895 patients; and group C (80 years of age or older), which included 133 patients. PTCA was performed using the newest catheter technology as it became available. RESULTS: Men comprised 63% of the patients in groups A and B combined, and 44% of group C (P<0.001). Canadian Cardiovascular Society angina class IV was present in 45% of group C compared with 30% and 35% in groups A and B, respectively (P<0.001). The proportion of patients with diabetes mellitus and hypertension was similar among the three groups. Acute myocardial infarction before PTCA was twice as common at 4.5% (95% CI 3.7% to 5.3%) in group C, compared with 2.9% (95% CI 2.7% to 3.1%) and 2.2% (95% CI 2.0% to 2.3%) in groups A and B, respectively. The procedural success rate was similar at 93%, 92.7% and 91.7% in groups A, B and C, respectively. A total of five (0.2%) deaths and eight (0.34%) myocardial infarctions occurred in groups A and B combined, while none occurred in group C (not significant). More patients in groups A and B underwent emergency coronary artery bypass graft than in group C: group A - 22, 3.4% (95% CI 3.2% to 3.6%); group B - 16, 3.4% (95% CI 3.2% to 3.6%) and group C - one, 0.75% (95% CI 0.6% to 0.9%). CONCLUSIONS: In this retrospective series of patients, it was shown that PTCA may be performed in the very elderly with high procedural success and acceptable risk. Age alone should not be the criterion to limit the use of PTCA.

Aortic valve area discrepancy by Gorlin equation and Doppler echocardiography continuity equation: relationship to flow in patients with valvular aortic stenosis.

BACKGROUND: In vitro studies have shown a discrepancy between aortic valve area (AVA) measurements derived invasively by Gorlin equation (Gorlin AVA) and noninvasively by Doppler echocardiography (Doppler-echo) continuity equation (Doppler AVA) during low flow states. OBJECTIVE: To assess whether a flow-related discrepancy between Gorlin AVA and Doppler AVA occurs in the clinical setting in patients with isolated valvular aortic stenosis. PATIENTS AND METHODS: Seventy-five consecutive patients with isolated valvular aortic stenosis, who had AVA determined both invasively by Gorlin equation and noninvasively by Doppler-echo continuity equation, were retrospectively reviewed. RESULTS: Gorlin AVA and Doppler AVA correlated (r=0.68) over the narrow AVA range (Gorlin AVA 0.30 to 1.22 cm2); however, Doppler AVA was systematically larger than Gorlin AVA (0.80+/-0.21 versus 0.70+/-0.23 cm2, AVA difference = 0.10+/-0.17 cm2, P<0.0001). The AVA difference was inversely related to invasive cardiac index (r=-0.51) and was significantly greater at low flow states (cardiac index less than 2.5 L/min/m2) than at normal flow states (cardiac index 2.5 L/min/m2 or more) (0.16+/-0.15 versus -0.03+/-0.15 cm2, P<0.0001). Independent predictors of the AVA difference were the difference between Doppler-echo and invasive cardiac output (P<0.0001); the difference between Doppler-echo and invasive mean transvalvular pressure gradient (P=0.0002); and the average cardiac output (Doppler-echo plus invasive cardiac output/2, P=0.001) at the time of the hemodynamic assessments. The AVA difference was not related to average pressure gradient, average AVA or patient characteristics. CONCLUSIONS: A flow-related discrepancy between Gorlin AVA and Doppler AVA occurs in the clinical setting of patients with isolated valvular aortic stenosis. This discrepancy should be considered when assessing aortic stenosis severity during low flow states, where Gorlin AVA may be significantly smaller than Doppler AVA.

Preliminary assessment of patients' opinions of queuing for coronary bypass graft surgery at one Canadian centre.

OBJECTIVES: To explore psychological and socioeconomic concerns of patients who queued for coronary artery bypass surgery and the effectiveness of support existing in one Canadian cardiovascular surgical center. DESIGN: Standardised questionnaire and structured interview. SETTING: Victoria General Hospital, Halifax, Nova Scotia. SUBJECTS: 100 consecutive patients awaiting non-emergency bypass surgery. RESULTS: Most patients (96%) found the explanation of findings at cardiac catheterisation and the justification given for surgery satisfactory. However, 84 patients complained that waiting for surgery was stressful and 64 registered at least moderate anxiety. Anger over delays was expressed by 16%, but only 4% thought that queuing according to medical need was unfair. Economic hardship, attributed to delayed surgery, was declared by 15 patients. This primarily affected those still working--namely, blue collar workers and younger age groups. Only 41% of patients were satisfied with existing institutional supports. Problems related mainly to poor communication. CONCLUSIONS: Considerable anxiety seems to be experienced by most patients awaiting bypass surgery. Better communication and education might alleviate some of this anxiety. Economic hardship affects certain patient subgroups more than others and may need to be weighed in the selection process. A more definitive examination of these issues is warranted.

Noninvasive testing in women presenting with chest pain: evidence for diagnostic uncertainty.

OBJECTIVE: To gain insight into the diagnostic utility of exercise stress testing in women. DESIGN: Observational prospective cohort study. SETTING: The Victoria General Hospital, Halifax, Nova Scotia. PARTICIPANTS: Consecutive women with chest pain referred by cardiologists or internists for exercise stress testing between May 30, 1992 and November 30, 1992 and followed prospectively to February 28, 1993. INTERVENTION: The proportion of patients subsequently referred for thallium scintigraphy and/or coronary angiography and their clinical profiles were determined. MAIN RESULTS: Of 183 patients studied, stress testing was positive in 48 (26.2%), negative in 48 (26.2%) and nondiagnostic in 87 (47.5%). Women with negative results were more likely to have had normal baseline electrocardiograms (ECGs) (P = 0.002) and least likely to have undergone prior angiography (P = 0.0003). Subsequent thallium scintigraphy and/or coronary angiography was undertaken in 33.3%, 18.8% and 27.6% with positive, negative and nondiagnostic index stress tests, respectively. None of chest pain, cardiac risk factors, previous cardiac investigations or baseline ECG discriminated 33 patients with negative or nondiagnostic stress results who had additional tests from 102 who did not. CONCLUSION: Exercise stress testing poorly screens women with chest pain for coronary artery disease (diagnostic in only 52.5%). Further study was undertaken in 27.6% with nondiagnostic tests and, surprisingly, in 18.8% with negative results. Why certain women with nondiagnostic, and so many with negative, stress tests were referred for further investigation was unclear. These results suggest diagnostic uncertainty when females presenting with chest pain are assessed.

Spontaneous pericardial tamponade during PTCA.

A case of acute hemorrhagic pericardial tamponade complicating a successful percutaneous transluminal coronary angioplasty (PTCA) is described, in the setting of rheumatoid arthritis (with no evidence of prior or concomitant pericarditis), large doses of intravenous heparin administration and a relatively high activated clotting time. There was no evidence of coronary artery rupture and there was no recent use of other anticoagulants or thrombolytic agents. Successful treatment comprised emergency pericardial drainage and intravenous protamine sulphate. The authors believe this to be the first reported case of acute hemorrhagic pericardial tamponade due solely to heparin administration. The possibility of acute hemorrhage of a rheumatoid nodule was considered but subsequent magnetic resonance imaging scan with contrast gadolinium was normal.

Does the speed of balloon deflation affect the complication rate of coronary angioplasty?

Two hundred consecutive coronary arteries in 157 patients undergoing angioplasty were randomized to fast or slow balloon deflation. Angioplasty was successful in 188 cases (101 with slow and 87 with fast deflation). There was no significant difference between the 2 groups with regard to the total number of dissections, although there was a greater number in the slow deflation group, and no difference in the number of minor dissections (National Heart, Lung, and Blood Institute types A and B). There was a significantly greater number of more severe dissections (types C to F) in the slow deflation group (20 vs 5; p = 0.013). It is proposed that the greater number of severe dissections is due to either increased turbulence or movement of the partially deflated balloon during slow deflation. Thus, slow balloon deflation during coronary angioplasty is associated with a higher complication rate than is conventional rapid deflation.

Comparison of fixed-wire and over-the-wire balloon dilatation systems for percutaneous transluminal coronary angioplasty.

There is controversy concerning the relative safety and efficacy of the 2 currently available percutaneous transluminal coronary angioplasty dilatation systems--fixed-wire (FW) and over-the-wire (OW). A randomized, prospective trial comparing the 2 systems was performed to examine this controversy. Of 1,513 patients undergoing percutaneous transluminal coronary angioplasty at 3 centers between June 1990 and October 1991, 602 (40%) fulfilled the eligibility criteria for the study. There were 643 lesions, of which 327 were randomized to FW and 316 to OW systems. There was no difference in the success rate between FW (92%) and OW (94%) systems. Inability to cross with a wire was infrequent with either system (FW: 1.8%; and OW: 1.6%). Inability to cross with a balloon when the wire crossed the lesion did not occur. An FW system was successful in 6 cases (1.9%) in which the OW system had been unsuccessful, whereas an OW system succeeded in 14 (4.3%) after the FW system had been unsuccessful (p = NS). Time to cross stenoses was 200 +/- 21 and 233 +/- 22 seconds, procedural time was 21 +/- 1.3 and 21 +/- 1.0 minutes, fluoroscopy time was 6.7 +/- 0.4 and 7.1 +/- 0.4 minutes, contrast used was 89.0 +/- 4.2 and 84.0 +/- 3.5 ml, and number of cine runs was 5.9 +/- 3.0 and 6.3 +/- 3.4 in the FW and OW systems, respectively. Complications were infrequent with either system (FW: 10.4%; and OW: 9.5%). Acute closure occurred in 1.8 and 2.2% of cases in the FW and OW systems, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Disease severity in the coronary care unit.

The impact of analysis of the severity of illness on the in-hospital mortality was reviewed retrospectively on a cohort of patients admitted to a coronary care unit. Three hundred and eighty-six patients were admitted during the study period, with diagnoses including myocardial infarction (49 percent), unstable angina (23 percent), arrhythmias (11 percent), congestive heart failure (5 percent), and nondiagnostic chest pain (5 percent). Total in-hospital mortality was 13 percent. Severity of illness was measured using the acute physiology and chronic health evaluation (APACHE 2) score. Mortality was found to be influenced by admitting diagnosis (p = 0.01), source of referral (p = 0.03), and APACHE 2 score (nonsurvivors, 16.5 +/- 10.1; survivors, 8.5 +/- 4.8; p less than 0.001). The receiver operating characteristic (ROC) curve for the APACHE 2 confirmed it as a predictor of mortality, with an area under the curve (+/- SE) of 0.75 +/- 0.04 (95 percent confidence limits, 0.67 to 0.83). Logistic regression analysis showed the APACHE 2 score and the diagnosis on admission to be significant multivariate predictors of mortality, and a series of diagnosis-specific coefficients are presented. We conclude that the APACHE 2 score is a useful tool for the overall assessment and management of the CCU, as it is in the multidisciplinary medical-surgical intensive care unit.

Therapeutic irradiation over a permanent cardiac pacemaker.

Therapeutic irradiation of fields containing cardiac pacemakers presents a unique problem to pacemaker physicians and radiation oncologists alike. The present case involved a proposed radiation field containing both subclavian pockets. As an alternative solution, the Cordis model 334A implantable pulse generator was irradiated using a backup temporary pacemaker that was kept outside of any significant radiation exposure. A total of 60 Gy was delivered in 30 fractions, with backup temporary pacing and continuous ECG monitoring used for the first 5 fractions. Frequent re-evaluation of pacing and sensing function revealed no changes as a result of irradiation; following radiotherapy, transtelephonic monitoring showed normal pacemaker function for a 4 month follow-up. This represents a useful alternative, particularly for nonmultiprogrammable pacemakers that are made of more radiation-resistant technology.