Outcome of percutaneous transluminal coronary angioplasty in subsets of unstable angina pectoris. A report of the 1985-1986 National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry.

OBJECTIVES: The purpose of this study was to characterize the outcome of coronary angioplasty according to the various presentations of unstable angina pectoris. BACKGROUND: Although unstable angina is a mosaic of clinical manifestations, a comprehensive analysis of short- and long-term outcome of coronary angioplasty in subsets of unstable angina is not available. METHODS: Data from 15 clinical centers for the 857 patients with unstable angina in the 1985-1986 National Heart, Lung, and Blood Institute percutaneous transluminal coronary angioplasty registry were analyzed. Five-year follow-up was available in > 96.5%. Patients were first classified as those with (679 [79%]) or without (178 [21%]) rest angina. Patients were also allocated to five mutually exclusive categories of decreasing unstable angina severity: postinfarction angina, acute coronary insufficiency, plain rest angina, accelerating angina and new onset angina. RESULTS: The group with rest angina had more older patients (p < 0.01) and women (p < 0.001), and a greater proportion had a previous myocardial infarction (p < 0.001) and a left ventricular ejection fraction < or = 50% (p < 0.01) than did the group without rest angina. Angiographic characteristics were nearly the same, whereas procedural characteristics and outcome were the same for both categories. At 5-year follow-up, there was a higher crude mortality rate in patients with than without rest angina (p < 0.05). Resolution into five subsets yielded additional information. Women were more represented only in the acute coronary insufficiency and plain rest angina subsets (p < 0.001). Patients with angina after myocardial infarction had the second shortest history of angina (p < 0.001), the highest percent of smokers (p < 0.01) and, with those with acute coronary insufficiency, the highest incidence of congestive heart failure (p < 0.05) and an ejection fraction < or = 50% (p < 0.001). They had the highest percent of totally occluded arteries, coronary thrombus and collateral blood flow received but also the lowest rate of severe stenoses (p < 0.001 for all). Patients with new onset angina had the highest prevalence of single-vessel disease (p < 0.05), critical and complex stenoses (p < 0.001) and no coronary angioplasty-related deaths. The crude 5-year mortality rate was higher for both postinfarction and acute insufficiency groups (p < 0.05) than for the other subsets. After adjustments for risk factors, no significant differences in adverse event rates remained among the different unstable angina subgroups. CONCLUSIONS: Analysis of the diverse clinical presentations of unstable angina supports underlying pathogenetic differences. Coronary angioplasty is safe and effective in all subsets of unstable angina. Long-term survival is good in general but is related to the baseline status of left ventricular function.

Short and long term outcome of percutaneous transluminal coronary angioplasty in unstable versus stable angina pectoris: a report of the 1985-1986 NHLBI PTCA Registry.

In a cohort of 1,720 consecutive patients from the National Heart, Lung, and Blood Institute, Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry (August 1985-May 1986), we compared 768 patients (45%) with stable angina and 952 patients (55%) with unstable angina pectoris. Unstable angina patients exhibited at least one of the following characteristics: new onset angina, rapidly progressing angina, angina at rest, angina refractory to medication, variant angina, acute coronary insufficiency, or angina recurring shortly after an acute myocardial infarct. The distribution of single- and multi-vessel disease was similar among stable and unstable angina patients; multi-vessel disease predominated. Average severity of stenosis and incidence of tubular and diffuse stenosis morphology were higher among patients with unstable angina (both p less than 0.001). Patient success rates were similar in stable and unstable patients. However, on a per lesion basis, overall angiographic success rate and average reduction of severity of stenosis in successfully dilated lesions were significantly higher among patients with unstable angina (both p less than 0.001). Incidence of major patient complications (p less than 0.01) and of emergency coronary bypass surgery (p less than 0.05) were also higher in patients with unstable angina but consistent with their more precarious clinical condition and stenosis morphology. During a two year follow-up, the cumulative distributions of death, myocardial infarct, repeat PTCA, and coronary bypass surgery were not significantly different in patients with stable angina compared to patients with unstable angina. Comparison of the current PTCA Registry cohort with the cases reported in the 1979-1982 Registry revealed a 19% higher success rate for both stable and unstable angina patients. Major complication rates decreased between time periods for stable but not for unstable angina patients. Incidence of emergency bypass surgery decreased more for stable than for unstable angina patients. Coronary angioplasty is indicated in properly selected patients with unstable angina and both single- and multi-vessel coronary disease.

Incidence and consequences of periprocedural occlusion. The 1985-1986 National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry.

Of 1,801 patients in the 1985-1986 Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry, 122 (6.8%) had periprocedural occlusion (4.9% in the catheterization laboratory, 1.9% outside the laboratory). Baseline patient factors independently associated with increased occlusion rates included triple-vessel disease, high risk status for surgery, and acute coronary insufficiency. Lesion characteristics showing significant positive association included severe stenosis before PTCA, diffuse or multiple discrete morphology, thrombus, and collateral flow from the lesion. Intimal tear and dissection were also very strongly associated with occlusion. Sixty patients (49%) had a transient occlusion that was reopened with PTCA, 43 (35%) were not redilated and managed with bypass surgery, and 19 (16%) were not redilated and managed medically. In-hospital mortality was 5% in each of these treatment groups, compared with 1% in occlusion-free patients. In-hospital infarction rates ranged from 27% in patients with transient occlusion to 56% in the patients managed with surgery, compared with 2% in patients without occlusion. During 2 years of follow-up, somewhat increased mortality continued in patients with occlusion, whereas follow-up infarction rates were comparable for all patients regardless of occlusion. Patients with an occlusion that was reopened or managed medically had increased rates of surgery during follow-up. Rates of repeat PTCA were comparable (about 23% by 2 years) in patients with transient occlusion and those without occlusion. Occlusion remains a serious complication of angioplasty and is associated most strongly with major events and surgical procedures that occur during the in-hospital period.

Immediate and long-term results of percutaneous transluminal coronary angioplasty. Comparison of the National Heart, Lung and Blood Institute Registry experience with current experience.

The immediate and long-term results of percutaneous transluminal coronary angioplasty (PTCA) in 1939 patients with single-vessel coronary disease (SVD) from the National Heart, Lung and Blood Institute Registry on PTCA (early experience) have been compared to recent results in 1551 patients, also with SVD, pooled from three centers in the USA (current experience). The circumflex artery, rarely subjected to PTCA in the past, now constitutes 16% of the total. The success rate has increased from 65 to 92% and, contrary to previous results, all three coronary arteries share at present a similar rate of success. The complications rate has been halved from 8.4 to 4.2%. These differences stem from the present level of operator expertise and the improved instrumentation. On the other hand, the severity of coronary stenosis and its reduction in successfully treated patients, as well as the rate of recurrence after successful PTCA in the current experience, show no difference from the past. The possible reasons for these similarities are only speculative at this time.

Death from coronary air embolism during percutaneous transluminal coronary angioplasty.

A patient undergoing percutaneous transluminal angioplasty of a critical proximal stenosis of his anterior descending coronary artery died as a result of coronary air embolism from a defective dilatation catheter. The probable mechanism responsible for this lethal complication is discussed. Simple precautions are described that will prevent its future occurrence.

Long-term efficacy of percutaneous transluminal coronary angioplasty (PTCA): report from the National Heart, Lung, and Blood Institute PTCA Registry.

The NHLBI PTCA Registry has collected data from 3,079 patients who underwent PTCA at 105 centers from September 1977 through September 1981 that document the initial risks and benefits of PTCA. A subgroup of 2,272 patients at 65 centers was chosen to examine the long-term effects of PTCA (97% follow-up). All patients were followed for 1 year, 191 for 3 years and 57 for 4 years. Initial success occurred in 1,397 (61%), and 72% remained improved at 1 year with no further procedures; during the first year of follow-up, 14% had repeat PTCA, 12% had CABG, 3% had MI and 1.6% died. After 1 year, 67% were asymptomatic; of these, 52% had no other procedure, 7% had a second PTCA and 8% had CABG. Follow-up at 2 to 4 years was similar except that there were few repeat PTCA or CABG procedures after 1 year. The annual mortality rate after PTCA in patients with 1-vessel diseases was less than 1% per year and with multivessel CAD, 3% per year. Thus, successful PTCA alone results in sustained improvement in 84% of patients; 59% were asymptomatic (12% had repeat PTCA). PTCA offers extended effective therapy in selected patients with CAD.

Percutaneous transluminal coronary angioplasty (PTCA) in patients with relative contraindications: results of the National Heart, Lung, and Blood Institute PTCA Registry.

The effects of relative contraindications on the immediate results of PTCA were investigated in 1,939 patients, and on long-term results in 998 patients with isolated stenosis of 1 coronary artery. Immediate results subjected to analysis were: success rate, major complications (coronary occlusion, MI and death) and emergency CABG. The analysis of long-term results included: status of angina pectoris, occurrence of MI, restenosis, repeat PTCA, CABG and death. Unstable angina and previous MI had no negative effects on immediate results, whereas a significantly lower success rate was noted in patients with angina for more than 1 year compared to patients with angina of shorter duration (p less than 0.05) and patients older than 60 years compared with younger patients (p less than 0.01). During follow-up, patients with unstable angina had higher CABG rate (p less than 0.01); the other relative clinical contraindications to PTCA did not exert adverse effects. Angiographically, there was a lower immediate success rate in patients with nonproximal stenosis (p less than 0.001) and in patients with calcium in the affected artery (p less than 0.01) and at the site of stenosis (p less than 0.001). Patients with tubular or diffuse stenoses had similar success rates but higher rates of complications, excluding death, than those with discrete stenoses (p less than 0.01). Patients with eccentric stenoses had a lower success rate and a higher rate of complications and emergency CABG than patients with concentric stenoses (p less than 0.001 for all 3 variables).(ABSTRACT TRUNCATED AT 250 WORDS)

Intracoronary thrombus in nontransmural myocardial infarction and in unstable angina pectoris.

Although intracoronary thrombus formation plays a major role in acute transmural myocardial infarction (MI), its occurrence in unstable angina (UA) and nontransmural MI has not clearly been established. To determine whether intracoronary thrombus does occur in these syndromes, coronary arteriography was performed before, during, and after intracoronary nitroglycerin and streptokinase infusion in 17 patients. None of the 8 patients with nontransmural MI and 1 of the 9 patients with UA responded to intracoronary nitroglycerin. Seven of 8 patients with nontransmural MI and 4 of 9 patients with UA responded to streptokinase infusion with opening of an occluded vessel, an increase in stenotic diameter, dissolution of an intracoronary filling defect, or a combination of these. Serial opening and closing of ischemia-related vessels occurred spontaneously and in response to streptokinase in some patients in whom thrombolysis was demonstrated. Evidence of thrombolysis was not seen in any patient studied longer than 1 week from the onset of the rest pain syndrome. The finding of thrombolysis in several patients with nontransmural MI and UA suggests that intracoronary thrombus formation plays a pathogenetic role in some patients with these ischemic syndromes.

Percutaneous transluminal coronary angioplasty: report of complications from the National Heart, Lung, and Blood Institute PTCA Registry.

The complications reported in the first 1500 patients enrolled in the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry are analyzed. Data were contributed from 73 centers between September 1977 and April 1981. PTCA was successful in 63% of attempts. Five hundred forty-three in-hospital complications occurred in 314 patients (21%). The most frequent complications were prolonged angina in 121, myocardial infarction (MI) in 72, and coronary occlusion in 70. One hundred thirty-eight patients (9.2%) had major complications (MI, emergency surgery or in-hospital death). One hundred two patients (6.8%) required emergency surgery, usually for coronary dissection or coronary occlusion. Sixteen patients (1.1%) died in-hospital; the mortality rate was 0.85% in patients with one-vessel disease and 1.9% in those with multivessel disease. The mortality rate was significantly higher in patients who had had bypass surgery (p less than 0.001). Nonfatal complications were significantly influenced by the presence of unstable angina (p less than 0.001) and initial lesion severity greater than 90% diameter stenosis (p less than 0.001). This report delineates and assesses the complications encountered with PTCA during its initial 3 1/2-year clinical experience. These results support the relative safety of PTCA as a method of nonsurgical myocardial revascularization in carefully selected patients.

Percutaneous transluminal coronary angioplasty: report from the Registry of the National Heart, Lung, and Blood Institute.

Data have been collected from 34 centers in the United States and Europe performing percutaneous transluminal coronary angioplasty since September 1977. The procedure was carried out in 631 patients, with an average age of 51 years (range 23 to 76), of whom 80 percent had single vessel coronary disease, 17 percent had double or triple vessel disease and 3 percent had stenosis of the left main coronary artery. Coronary angioplasty was successful (greater than 20 percent decrease of coronary stenosis) in 59 percent of the stenosed arteries. The mean degree of stenosis was reduced from 83 to 31 percent. Emergency coronary bypass operation was required in 40 patients (6 percent). Myocardial infarction occurred in 29 patients (4 percent). In-hospital death occurred in six patients (1 percent), three with single vessel and three with multivessel disease. Ninety-one patients have been followed up for at least 1 year after coronary angioplasty. Of the 65 patients with an initially successful angioplasty, 83 percent were in improved condition compared with their status before angioplasty. Thus, the initial satisfactory results obtained in a few centers have now been confirmed in many centers using transluminal coronary angioplasty.

Relief by intracoronary glyceryl trinitrate of coronary artery spasm resistant to sublingual route of administration.

Inappropriate percutaneous transluminal coronary angioplasty of the anterior descending artery was avoided in a 52-year-old woman when the intracoronary administration of glyceryl trinitrate immediately before the angioplasty disclosed the organic component of the supposedly fixed, critical (80%) stenosis to be less than 50% of the lumen diameter. The spastic component of the stenosis had not been unmasked by the sublingual administration of two 0.4 mg tablets of glyceryl trinitrate during diagnostic angiography two weeks earlier. Intracoronary glyceryl trinitrate is indicated when suspected coronary spasm persists after the sublingual administration of this drug in potential candidates for percutaneous transluminal coronary angioplasty or coronary bypass surgery.

Patency of saphenous vein grafts five or more years after coronary bypass surgery.

The state of preservation of 48 coronary saphenous vein grafts was investigated by angiography in 27 patients from 60 to 79 months, average 64.6 months, after their insertion. Thirty-nine of the grafts (81.2 per cent) were patent; of these, 24 (50 per cent) were in excellent, six (12.5 per cent) in good, six (12.5 per cent) in fair and three (6.2 per cent) in poor condition. Nine grafts (18.8 per cent) were occluded. The rate of graft patency in this series compares favorably with that in shorter follow-ups and presages their further prolonged viability. Atherosclerotic obstructive graft disease may emerge as an important cause of late graft deterioration in an occasional patient.

Left ventricular end-diastolic pressure response to atrial pacing in idiopathic mitral valve prolapse.

The response of several parameters of left ventricular function to right atrial pacing was compared in 21 patients with idiopathic mitral valve prolapse and 10 normal patients. An inability to appropriately lower left ventricular end-diastolic pressure with increasing rates was demonstrated in the mitral valve prolapse group. This abnormality was not related to mitral regurgitation or factors other than ventricular performance per se.

Evaluation of single plane angiography for left ventricular volume in the intact dog.

Technique and errors of quantitative single plane ventriculography (SPV), and the methods of Dodge and Sandler (Dodge et al, 1962; Sandler and Dodge, 1968) and Greene et al (1967) for determining left ventricular (LV) volume by SPV were evaluated in the intact dog. Stroke volume (SV) and cardiac output (Q) by ventriculography were compared with those obtained by the Fick and dye dilution methods, and their combination. The end-diastolic (EDV) and end-systolic volume (ESV) corrected by appropriate regression equations, the SV (SV=EDV - ESV), and the ejection fraction (EF) were: Dodge and Sandler, 2.26 1.35, 0.91 ml/kg, and 0.42; Greene et al, 2.41, 1.50, 0.91 ml/kg, and 0.39. Using adequate methods, accurate correction for x-ray image magnification, and the appropriate regression equations the standard error of LV volume calculation by single plane radiography, due to unavoidable technical inaccuracies, should not exceed 10% for a single measurement and 5% for the average of two or more successive cardiac cycles. The systematic overestimation of LV volume inherent in ventriculography, and caused by the addition of contrast medium, should not exceed 5% of the true value.