Quality of life after coronary angioplasty or continued medical treatment for angina: three-year follow-up in the RITA-2 trial. Randomized Intervention Treatment of Angina

Comparison of interventional versus conservative treatment of isolated ostial lesions of coronary diagonal branch arteries

This study compares percutaneous coronary intervention of isolated ostial stenosis of diagonal branches with a luminal diameter >/=2.0 mm with medical treatment with regard to cardiac events during hospitalization and follow-up. Medical treatment is an alternative to percutaneous intervention without a greater incidence of death or myocardial infarction at 12-month follow-up. Interestingly, patients with isolated ostial stenosis of diagonal branches who were treated interventionally showed a significantly greater probability of rehospitalization for severe angina, recatheterization, and reintervention compared with medically treated patients.

Evaluation of routine functional testing after percutaneous coronary intervention

Following percutaneous coronary intervention, 348 patients were randomized to either routine or selective functional testing strategies. For the primary end point of maximal exercise endurance on a treadmill at 9 months, achievement was similar in the routine and selective groups. For the secondary end points measuring functional status and quality of life, scores were also similar. There was little difference in the rates of invasive cardiac procedures for the 2 groups at 9 months.

Gender differences in quality of life among cardiac patients

OBJECTIVE

Prior studies of quality of life among cardiac patients have examined mostly men. This study evaluated gender differences in quality of life and examined the degree to which social support was associated with quality of life.

METHODS

A sample of 536 patients (35% women) was recruited during a 14-month period from the inpatient cardiology service of a University-based hospital. Participants completed assessments at baseline and at 3-month intervals over the subsequent 12 months, for a total of 5 assessments. Measures at each assessment included quality of life [Mental Component Score (MCS) and Physical Component Score (PCS) from the Medical Outcomes Study--Short Form 36] and social support [Interpersonal Support Evaluation List--Short Form].

RESULTS

A total of 410 patients completed the baseline assessment and at least one follow-up, and were included in the data analyses. Linear mixed effects modeling of the MCS score revealed a significant effect of gender (p =.028) and time (p <.001), as well as a significant interaction of gender by social support (p =.009). Modeling of the PCS revealed a significant effect of gender (p =.010) and time (p <.001).

CONCLUSIONS

Women with cardiac disease indicated significantly lower quality of life than men with cardiac disease over the course of a 12-month longitudinal follow-up. Social support, especially a sense of belonging or companionship, was significantly associated with emotional quality of life (MCS) among women. Strategies to increase social support may be important for health and well-being of women with cardiac disease.

Improvement and factors associated with improvement in quality of life during 10 years after coronary artery bypass grafting

AIM

To describe (1) the improvement in various aspects of quality of life (QoL) and (2) predictors of improvement, during 10 years after coronary artery bypass grafting (CABG).

PATIENTS AND METHODS

All patients who underwent CABG in western Sweden between June 1988 and June 1991 without simultaneous valve surgery and with no previous CABG were approached with an inquiry prior to and 5 and 10 years after the operation. QoL was measured with three different instruments: (1) Nottingham health profile (NHP), (2) psychological general well-being index (PGWBI) and (3) physical activity score (PAS).

RESULTS

There was a significant improvement in QoL with all three instruments from before to 10 years after the operation. The mean improvements +/-SD were for NHP, - 4.2+/-17.0 (P<0.0001), for PGWBI, +9.7+/-17.6 (P<0.0001) and for PAS, -0.96+/-1.23 (P<0.0001). However, there was also a deterioration with all three instruments between 5 and 10 years after surgery. The mean deteriorations +/-SD were for NHP, +4.4+/-12.8 (P<0.0001), for PGWBI, -4.6+/-14.8 (P<0.0001) and for PAS, +0.44+/-0.94 (P<0.0001). Independent predictors for an improvement in QoL with at least one of the instruments were low preoperative QoL, a younger age, being a man, high functional class (New York Heart Association), no hypertension, proximal left anterior descending coronary artery stenosis, short extracorporeal circulation time, use of internal mammary artery and a short postoperative time in the intensive care unit.

CONCLUSION

There is a higher estimated QoL 10 years after CABG than before, despite the fact that the patients are 10 years older. However, there is also a deterioration in QoL between 5 and 10 years after surgery. Predictors of improvement during the 10 years included age, sex, previous history, localization of stenosis, type of graft and preoperative and postoperative factors.

Prognosis of angina with and without a diagnosis: 11 year follow up in the Whitehall II prospective cohort study

OBJECTIVE

To investigate the prognosis of angina among people with and without diagnosis by a doctor and an abnormal cardiovascular test result.

DESIGN

Prospective cohort study with a median follow up of 11 years.

SETTING

20 civil service departments originally located in London.

PARTICIPANTS

10 308 civil servants aged 35-55 years at baseline.

MAIN OUTCOME MEASURES

Recurrent reports of angina; quality of life (SF-36 physical functioning); non-fatal myocardial infarction; death from any cause (n = 344).

RESULTS

1158 (11.4%) participants developed angina, and 813 (70%) had no evidence of diagnosis by a doctor at the time of the initial report. Participants without a diagnosis had an increased risk of impaired physical functioning (age and sex adjusted odds ratio of 2.36 (95% confidence interval 1.91 to 2.90)) compared with those who had neither angina nor myocardial infarction throughout follow up. Among reported cases of angina without a diagnosis, the 15.5% with an abnormality on a study electrocardiogram had an increased risk of death (hazard ratio 2.37 (1.16 to 4.87)). These effects were similar in magnitude to those in participants with a diagnosis of angina.

CONCLUSION

Undiagnosed angina was common and had an adverse impact on prognosis comparable to that of diagnosed angina, particularly among people with electrocardiographic abnormalities. Efforts to improve prognosis among people with angina should take account of this submerged clinical iceberg.

Seven-year outcome in the RITA-2 trial: coronary angioplasty versus medical therapy

OBJECTIVES

This study was designed to compare the long-term consequences of percutaneous transluminal coronary angioplasty (PTCA) and continued medical treatment.

BACKGROUND

The long-term effects of percutaneous coronary intervention need evaluating, especially in comparison with an alternative policy of continued medical treatment.

METHODS

The Second Randomized Intervention Treatment of Angina (RITA-2) is a randomized trial of PTCA versus conservative (medical) care in 1,018 patients considered suitable for either treatment option. Information on clinical events, interventions, and symptoms is available for a median seven years follow-up.

RESULTS

Death or myocardial infarction (MI) occurred in 73 (14.5%) PTCA patients and 63 (12.3%) medical patients (difference +2.2%, 95% confidence interval -2.0% to +6.4%, p = 0.21). There were 43 deaths in both groups, of which 41% were cardiac-related. Among patients assigned PTCA 12.7% subsequently had coronary artery bypass grafts, and 14.5% required additional non-randomized PTCA. Most of these re-interventions occurred within a year of randomization, and after two years the re-intervention rate was 2.3% per annum. In the medical group, 35.4% required myocardial revascularization: 15.0% in the first year and an annual rate of 3.6% after two years. An initial policy of PTCA was associated with improved anginal symptoms and exercise times. These treatment differences narrowed over time, mainly because of coronary interventions in medical patients with severe symptoms.

CONCLUSIONS

In RITA-2 an initial strategy of PTCA did not influence the risk of death or MI, but it improved angina and exercise tolerance. Patients considered suitable for PTCA or medical therapy can be safely managed with continued medical therapy, but percutaneous intervention is appropriate if symptoms are not controlled.

Modeling predictors of quality of life after coronary angioplasty

Psychological predictors of quality of life in patients undergoing coronary angioplasty were investigated using a prospective model based on self-regulation and stress-coping theories. Predictors (chest pain, disturbance of personal goals, stress perception, approach coping, avoidant coping, and optimism) and three quality of life indicators (disease-specific quality of life, positive affect, and negative affect) were measured with questionnaires in 158 patients both when they were admitted on the waiting list for angioplasty and 3 months after angioplasty. The results were congruent with expectations based on the theories and indicated that the models predicting disease-specific quality of life and negative affect fit the data well. Avoidant Coping and Stress Perception predicted all quality of life indicators. Goal Disturbance predicted only negative quality of life variables, and Approach Coping predicted only positive quality of life variables. Chest Pain predicted Disease-Specific Quality of Life and Positive Affect. Optimism served as a coping resource. Individualized behavior modification interventions were recommended, but the data suggest that patients may not be easily persuaded to engage in health behavior.

Health-related quality of life after percutaneous coronary intervention versus coronary bypass surgery in high-risk patients with medically refractory ischemia

OBJECTIVES

We compared six-month health-related quality of life (HRQL) for high-risk patients with medically refractory ischemia randomized to percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery.

BACKGROUND

Mortality rates after PCI and CABG surgery are similar. Therefore, differences in HRQL outcomes may help in the selection of a revascularization procedure.

METHODS

Patients were enrolled in a Veterans Affairs multicenter randomized trial comparing PCI versus CABG for patients with medically refractory ischemia and one or more risk factors for adverse outcome; 389 of 423 patients (92%) alive six months after randomization completed an Short Form-36 (SF-36) health status survey. Primary outcomes were the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36. Multivariable analyses were used to evaluate whether PCI or CABG surgery was associated with better PCS or MCS scores after adjusting for over 20 baseline variables.

RESULTS

There were no significant differences in either PCS scores (38.7 vs. 37.3 for PCI and CABG, respectively; p = 0.23) or MCS scores (45.5 vs. 46.1, p = 0.58) between the treatment arms. In multivariable models, there remained no difference in HRQL for post-PCI versus post-CABG patients (for PCS, absolute difference = 0.56 +/- standard error of 1.14, p = 0.63; for MCS, absolute difference = -1.23 +/- 1.12, p = 0.27). We had 97% power to detect a four-point difference in scores, where four to seven points is a clinically important difference.

CONCLUSIONS

High-risk patients with medically refractory ischemia randomized to PCI versus CABG surgery have equivalent six-month HRQL. Therefore, HRQL concerns should not drive decision-making regarding selection of a revascularization procedure for these patients.

Clinical outcome of coronary angioplasty in patients with ischaemic cardiomyopathy

OBJECTIVE

To assess the clinical outcome of successful percutaneous transluminal coronary angioplasty (PTCA) in patients with poor ventricular function.

METHODS

Analysis of angiographic, echocardiographic and clinical records of patients with severe LV dysfunction who underwent PTCA from January 1, 1995 to December 31, 1997 was undertaken. Forty-one patients aged 63+/-10 years, 36 men, all with significant coronary artery disease and impaired LV function (fractional shortening, FS<or=20%) were identified. Patients' data before and after angioplasty were analyzed.

RESULTS

Post PTCA: angiographic success was 95.2%. Major complications occurred in 19.5% and hospital mortality was 2.7%. At 6 months after PTCA:LV fractional shortening (FS) increased from 15.9+/-3.4% to 19.6+/-6.6%, P=0.02 and consequently cardiac output from 4.28+/-0.98 to 5.34+/-1.77 l/min, P<0.01. Change in at least one class of angina and cardiac functional status was observed in 46% of patients, P<0.001, and this was maintained to the end of the year. After 12 months follow-up: restenosis occurred in 10.8%; mortality was 5.4%; event-free and actuarial survivals were 62.3% and 91.9%, respectively.

CONCLUSIONS

In patients with severe LV dysfunction, continued symptomatic improvement can be achieved with successful coronary angioplasty. This is associated with significant recovery of LV systolic function and cardiac output. In order to minimize procedure-related complications, careful patient selection should be considered.

Outcome of elderly patients with chronic symptomatic coronary artery disease with an invasive vs optimized medical treatment strategy: one-year results of the randomized TIME trial

CONTEXT

The risk-benefit ratio of invasive vs medical management of elderly patients with symptomatic chronic coronary artery disease (CAD) is unclear. The Trial of Invasive versus Medical therapy in Elderly patients (TIME) recently showed early benefits in quality of life from invasive therapy in patients aged 75 years or older, although with a certain excess in mortality.

OBJECTIVE

To assess the long-term value of invasive vs medical management of chronic CAD in elderly adults in terms of quality of life and prevention of major adverse cardiac events.

DESIGN

One-year follow-up analysis of TIME, a prospective randomized trial with enrollment between February 1996 and November 2000.

SETTING AND PARTICIPANTS

A total of 282 patients with Canadian Cardiac Society class 2 or higher angina despite treatment with 2 or more anti-anginal drugs who survived for the first 6 months after enrollment in TIME (mean age, 80 years [range, 75-91 years]; 42% women), enrolled at 14 centers in Switzerland.

INTERVENTIONS

Participants were randomly assigned to undergo coronary angiography followed by revascularization (if feasible) (n = 140 surviving 6 months) or to receive optimized medical therapy (n = 142 surviving 6 months).

MAIN OUTCOME MEASURES

Quality of life, assessed by standardized questionnaire; major adverse cardiac events (death, nonfatal myocardial infarction, or hospitalization for acute coronary syndrome) after 1 year.

RESULTS

After 1 year, improvements in angina and quality of life persisted for both therapies compared with baseline, but the early difference favoring invasive therapy disappeared. Among invasive therapy patients, later hospitalization with revascularization was much less likely (10% vs 46%; hazard ratio [HR], 0.19; 95% confidence interval [CI], 0.11-0.32; P<.001). However, 1-year mortality (11.1% for invasive; 8.1% for medical; HR, 1.51; 95% CI, 0.72-3.16; P =.28) and death or nonfatal myocardial infarction rates (17.0% for invasive; 19.6% for medical; HR, 0.90; 95% CI, 0.53-1.53; P =.71) were not significantly different. Overall major adverse cardiac event rates were higher for medical patients after 6 months (49.3% vs 19.0% for invasive; P<.001), a difference which increased to 64.2% vs 25.5% after 12 months (P<.001).

CONCLUSIONS

In contrast with differences in early results, 1-year outcomes in elderly patients with chronic angina are similar with regard to symptoms, quality of life, and death or nonfatal infarction with invasive vs optimized medical strategies based on this intention-to-treat analysis. The invasive approach carries an early intervention risk, while medical management poses an almost 50% chance of later hospitalization and revascularization.

Health-related quality of life in patients with coronary artery disease treated for angina: validity and reliability of German translations of two specific questionnaires

The German versions of two patient-perceived heart disease specific health-related quality of life (HRQL) questionnaires, the Seattle Angina Questionnaire (SAQ) and the MacNew Heart Disease questionnaire, were examined for their psychometric properties in patients with angiographically documented coronary artery disease and angina who were treated either medically or invasively and followed up for 1 year. Both HRQL questionnaires and the modified Canadian Cardiovascular Society (CCS) angina-associated disability scale were completed by 158 patients at baseline and 12 months later when they also completed a generic health status questionnaire, the SF-36. Both specific HRQL questionnaires were acceptable to patients. Three of the four MacNew scales, but none of the SAQ scales, discriminated between patients by baseline CCS disability levels I and IV. Internal consistency ranged from 0.75 to 0.94 for the SAQ and from 0.86 to 0.97 for the MacNew scales. Test-retest reliability over a 4-week period of time ranged from 0.45 to 0.81 for the SAQ scales and 0.61 to 0.68 for the MacNew scales. Over 12 months, HRQL improved (p < 0.001) on three of the five SAQ and on all four of the MacNew scales with the responsiveness statistic ranging from 0.59 to 1.55 for the SAQ and 0.86 to 1.12 for the MacNew. The 12 month scores on all SAQ and MacNew scales were significantly higher in patients who improved than those who deteriorated on the SF-36 reported health transition question. We conclude that the SAQ and the MacNew are both valid, reliable, and responsive in German, that the MacNew discriminates better between angina grades at baseline, that HRQL improves over 12 months with both measures, that the SAQ angina frequency and disease perception scales have the largest effect sizes, and that the 12-month change in HRQL with both instruments was associated with change in SF-36 reported health transition status.

Filgrastim in patients with neutropenia: potential effects on quality of life

Treatment- and disease-related neutropenia are associated with a number of negative clinical effects such as febrile neutropenia, documented infection, hospitalisation for infection-related morbidity, infection-related mortality, and decreased ability to administer the planned chemotherapy dose on schedule. Reductions or delays in dosage have the ability to jeopardise the effectiveness of treatment by lowering response rates. Not only are clinical outcomes adversely affected, but these complications can have a negative influence on patient quality of life. Filgrastim is a haematopoietic growth factor that primarily acts to stimulate the proliferation and differentiation of neutrophil progenitor cells. Filgrastim is capable of reducing the incidence and severity of neutropenia and the complications that accompany it in patients with cancer or HIV infection. Although there are few data evaluating the effect of treatment with granulocyte colony-stimulating factor on quality of life, it is assumed that the benefits would be seen through both the reduction of treatment-related complications and the enhanced potential for long-term disease control. A new, longer-acting form of filgrastim is now available that has the potential to simplify the management of neutropenia and further improve patient quality of life by decreasing the number of necessary injections. Additional prospective controlled trials that contain quality-of-life issues as endpoints are needed.

Criteria for definition of regional functional improvement on quantitative post-stress gated myocardial SPET after bypass surgery in patients with ischaemic cardiomyopathy

Myocardial viability can be defined as functional improvement of dysfunctional myocardium after revascularization. The purpose of this study was to define the optimal criteria for definition of regional functional improvement after coronary artery bypass graft (CABG) surgery on quantitative gated single-photon emission tomography (SPET). Thirty-two patients (26 men, 6 women; age 56 +/- 13 years) with coronary artery disease (three-vessel disease, 17; two-vessel disease, 15; previous history of myocardial infarction, 9) and severe left ventricular dysfunction (LVEF < or = 35%) underwent CABG. Rest thallium-201/dipyridamole stress technetium-99m methoxyisobutylisonitrile gated myocardial SPET was performed before and 3 months after CABG. Global LV functional improvement was defined as either an improvement in LVEF of 10% ( n = 15) or an improvement in LVEF of 5% combined with a decrease in end-systolic volume of 10 ml ( n = 2) after CABG on quantitative gated SPET. Postoperative regional wall thickening improvement (DeltaRWT), regional wall motion improvement (DeltaRWM) and regional resting (DeltaRP) and stress perfusion improvement (DeltaRstrP) were used to determine global functional improvement by ROC curve analysis, and the optimal criteria for definition of viable regional dysfunctional myocardium were defined on the ROC curves. Correlations were verified by determining the number of improved myocardial regions and LVEF improvement. LVEF was improved from 25% +/- 6% to 34% +/- 11% after CABG. A total of 229 segments were dysfunctional (wall motion < or = 2 mm, thickening < or = 20%) before CABG. On ROC curve analysis using global functional improvement as an indicator of viability, the areas under the ROC curves (AUCs) of DeltaRWT and DeltaRWM were 0.717 and 0.620, respectively. The AUC of DeltaRWT was significantly larger than that of DeltaRWM ( P = 0.009) and the optimal cut-off value of DeltaRWT was 15%. The AUCs of DeltaRP and DeltaRstrP were not significant. The correlation coefficients between summed DeltaRWT and DeltaRWM and LVEF improvement were 0.591 and 0.472, respectively. The number of segments with a DeltaRWT of more than 15% correlated with LVEF improvement (rho = 0.533 by Spearman rank correlation). Regional wall thickening improvement showed the best correlation with global LV functional improvement after CABG. The most reliable regional criterion of myocardial viability was improvement in regional wall thickening by > or = 15% on quantitative gated SPET.

Percutaneous coronary intervention vs. medical therapy: what are the implications for women?

There have been eight major studies assessing percutaneous coronary intervention (PCI) vs. medical therapy in the past 10 years. Women were inadequately represented in many of these studies, but because of similar long-term survival curves in women and men, most of the PCI data can be applied to women until more trials are published. According to currently available data, PCI offers greater angina relief and improvement in exercise tolerance than medicine alone, but has a greater risk of procedure-related complications in women. As a result of the rapid advancement of cardiovascular therapy, many of these studies did not incorporate optimal medical therapy or current PCI therapies. It is likely that for most patients (including women) with moderate angina, the best management may be a combination of PCI, medical therapy, and lifestyle changes.

Effects of enhanced external counterpulsation on Health-Related Quality of Life continue 12 months after treatment: a substudy of the Multicenter Study of Enhanced External Counterpulsation

BACKGROUND

The Multicenter Study of Enhanced External Counterpulsation (MUST-EECP) was the first prospective, randomized, blinded, sham-controlled study of enhanced external counterpulsation (EECP) in the treatment of chronic stable angina. We previously reported that EECP therapy lengthens the time to exercise-induced myocardial ischemia and reduces angina. We now describe the effects of EECP therapy versus a sham-treated control group in terms of patients' functioning, their senses of well-being and other Health-Related Quality Of Life (HQOL) parameters from baseline to end of treatment and from baseline to 12 months after treatment.

OBJECTIVE

To determine whether a 35-hour course of EECP affects the HQOL of patients with symptomatic coronary artery disease, 12 months following treatment.

METHODS

Seventy-one of the 139 patients enrolled in MUST-EECP provided evaluable patient-completed questionnaires at baseline, at the end of treatment, and 12 months post-treatment. The Medical Outcomes Study 36-Item Short-Form Health Survey and the Quality of Life Index-Cardiac Version III were used to assess effects on HQOL.

RESULTS

Both groups had similar HQOL scores at baseline. At end of treatment and at 12-month follow up, patients who had active-CP reported greater improvement than those who had inactive-CP in all nine quality of life scales, including ability to perform activities of daily living, ability to work, bodily pain, confidence in health, energy, ability to engage in social activities with family and friends, anxiety and depression, and quality of life issues from the effects of angina on health and functioning. Despite small sample sizes, active-CP patients demonstrated significantly greater improvement at 12 months following treatment in bodily pain, social functioning, and quality of life specific to cardiac patients compared with inactive-CP patients.

CONCLUSION

Significant health-related quality of life improvements were measurable up to 12 months after the completion of treatment with EECP. Improvements in this controlled study are consistent with HQOL changes reported in case series and patient registries. Larger studies are warranted.

Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomised trial

BACKGROUND

Since previous randomised treatment trials in coronary disease have focused on patients younger than 75 years of age, their findings might not apply to the elderly population in whom the cardiac risk profile, risk of intervention, and comorbidities are increased. We aimed to assess quality of life and outcome of elderly patients with coronary disease after medical or revascularisation therapy.

METHODS

In this randomised, prospective, multicentre trial, we enrolled patients aged 75 years or older with chronic angina of at least Canadian Cardiac Society class II despite at least two antianginal drugs. Patients were randomly assigned coronary angiography and revascularisation or optimised medical therapy. The primary endpoint was quality of life after 6 months, as assessed by questionnaire and the presence of major adverse cardiac events (death, non-fatal myocardial infarction, or hospital admission for acute coronary syndrome with or without the need for revascularisation). Analysis was by intention to treat.

FINDINGS

150 patients were assigned medical therapy and 155 invasive therapy. Two protocol violators in each group were not included in the analysis. After 6 months, angina severity decreased and measures of quality of life increased in both treatment groups; however, these improvements were significantly greater after revascularisation. Major adverse cardiac events occurred in 72 (49%) of patients in the medical group and 29 (19%) in the invasive group (p<0.0001).

INTERPRETATION

Patients aged 75 years or older with angina despite standard drug therapy benefit more from revascularisation than from optimised medical therapy in terms of symptom relief and quality of life. Therefore, these patients should be offered invasive assessment despite their high risk profile followed by revascularisation if feasible.

Revascularization interventions for ischemic heart disease

Coronary artery bypass grafting and percutaneous transluminal coronary angioplasty are now well established methods of myocardial revascularization. The choice of a method of revascularization depends on several clinical and angiographic parameters. Patients who derive the greatest benefit from coronary artery bypass grafting are those with left main coronary artery disease or those with three-vessel disease with left ventricular impairment. Patients with single-vessel disease achieve more symptomatic relief with coronary angioplasty than with medical therapy alone, but with no improvement in long-term mortality. In nondiabetic patients with multiple-vessel disease, angioplasty and bypass grafting likely yield similar results, and the choice of revascularization technique rests on weighing the more invasive nature of bypass grafting against the need for additional future revascularizations with angioplasty. Diabetic patients with multiple-vessel disease seem to achieve better outcomes with bypass grafting. Minimally invasive bypass surgery is an evolving technique. It is less invasive in nature but its applications are limited, and its advantages over traditional bypass grafting have not yet been shown. Stenting now plays a major role in percutaneous revascularization and is performed in more than two thirds of all interventional procedures. It improves both the short-term and the long-term outcomes of coronary angioplasty. Other novel percutaneous techniques such as directional or rotational atherectomy, laser angioplasty, or thrombectomy devices have not shown convincing superiority over coronary angioplasty alone. Transmyocardial laser revascularization can be performed surgically or percutaneously and may be beneficial in patients with angina refractory to traditional revascularization procedures.