Rapid progression of coronary stenosis in patients with unstable angina pectoris selected for coronary angioplasty

Predictors of Coronary Artery Disease Progression among High-risk Patients with Recurrent Symptoms

Background

Despite the availability of new potent medical therapies, the rate of progression of angiographic coronary artery disease (CAD) is not well described. The aim of this analysis is to describe the rate and predictors of progression of CAD among patients with recurrent symptoms.

Materials and Methods

We reviewed 259 patients (mean age 61 ± 11 years, 70% males) who underwent two coronary angiograms between 2008 and 2013. Progressive CAD was defined as obstructive CAD in a previously disease-free segment or new obstruction in a previously nonobstructive segment. Patients who had coronary artery bypass surgery between these two angiograms were excluded from the analysis. Multivariate logistic regression was used to determine the independent predictors of progression of CAD.

Results

The included cohort had a high prevalence of coronary risk factors; hypertension (71%), diabetes (69%), and dyslipidemia (75%). Despite adequate medical therapy, more than half of the patients (61%) had CAD progression. Using multivariate logistic regression, a drop in the left ventricular ejection fraction (LVEF) by more than 5% was the predictor of CAD progression (adjusted odds ratio 5.8, P = 0.042, 95% confidence interval 1.1-31.2).

Conclusion

Among high-risk patients with recurrent symptoms, the short-term rate of progression of CAD is high. A drop in LVEF >5% is a predictor of CAD progression. Further studies are needed to determine the prognostic value of CAD progression in the era of potent medical therapy.

Unstable Angina Pectoris: An Interventional Approach to Management

The therapy of unstable angina has changed consider ably in the last 15 years. An improved understanding of the pathophysiology has led to many of the changes. Thrombus, platelet activation, progression of athero sclerosis, and coronary vasospasm all appear to have a role. Initial management in unstable angina should begin with aggressive medical therapy with nitrates, calcium antagonists, beta blockers, and aspirin. In patients who are refractory to aggressive medical management, early cardiac catheterization and coronary arteriography is in dicated. The literature appears to confirm that patients with unstable angina who are stabilized with aggressive medical therapy fare as well as those treated with emer gency bypass surgery. Percutaneous transluminal coro nary angioplasty (PTCA) is the treatment of choice in medically refractory unstable angina patients with single-vessel coronary disease.

New approaches include culprit lesion angioplasty, thrombolytic therapy, coronary sinus retroperfusion, and new catheter-based revascularization methods such as intracoronary stents, laser methods and atherectomy. Culprit lesion angioplasty involves angioplasty of only the angina-producing artery in patients with multivessel coronary disease. Early data suggest that this may be an effective short-term alternative to multivessel PTCA or bypass surgery. Recent data also suggest a beneficial role for thrombolytic therapy and synchronized coronary si nus retroperfusion with arterial blood in patients with unstable angina. New catheter-based approaches are in the early stages of development, and their eventual role in the treatment of coronary artery disease and unstable angina remains to be elucidated.

Predictors of recurrent ischemic events and death in unstable coronary artery disease after treatment with combination antithrombotic therapy

BACKGROUND

Patients with non-Q-wave acute coronary syndromes (ACS) have substantial rates of recurrent ischemic events, but prognostic studies have been small or preceded the routine use of aggressive combination antithrombotic therapy. We sought to identify predictors of these events after antithrombotic treatment of non-Q-wave ACS.

METHODS

We assessed 30-day rates of a composite triple end point (death, infarction, or refractory angina) and double end point (death or infarction) among 3171 patients with non-ST-segment elevation ACS randomly assigned to enoxaparin or heparin, plus aspirin, for 2 to 8 days. We created multivariable regression models to predict these end points from baseline factors.

RESULTS

Overall, 682 patients (21%) reached the triple end point and 220 (6.8%) reached the double end point. Independent predictors of the triple end point were admission with myocardial necrosis, ST-segment depression, prior angina severity, symptom duration, and allocation to enoxaparin treatment in patients with ST-segment depression (significant interaction). Independent predictors of the double end point were admission with myocardial necrosis, ST-segment depression, enrollment region, age >75 years, prior angina severity, and rales. By deciles, the average predicted risk for the double end point ranged from 2% to 20%: a patient aged <75 years with no risk factors had a 3.5% risk, whereas a patient aged >75 years with 2 additional high-risk features (myonecrosis and ST depression) had a risk of death or reinfarction of 26%.

CONCLUSIONS

Patients with non-ST-segment elevation ACS exhibit a broad range of risk of adverse recurrent ischemic events. The predictive power of the model for the triple end point, using baseline variables, was modest. However, a subgroup at very low risk of the double end point (average 2%) can be identified with baseline variables.

Differential progression of complex culprit stenoses in patients with stable and unstable angina pectoris

OBJECTIVES

This study sought to compare the evolution of complex culprit stenoses in patients with stable and those with unstable angina pectoris.

BACKGROUND

Complex coronary stenoses are associated with adverse clinical and angiographic outcomes. However, it is not known whether the evolution of complex stenoses differs in unstable angina versus stable angina pectoris.

METHODS

We prospectively assessed stenosis progression in 95 patients with unstable angina whose angina stabilized with medical therapy (Group 1) and 200 patients presenting with stable angina (Group 2). After diagnostic angiography, all patients were placed on a waiting list for coronary angioplasty and restudied at 8 +/- 4 (mean +/- SD) months later. In each patient the presumed culprit stenosis was identified and classified as complex (irregular borders, overhanging edges or thrombus) or smooth (absence of complex features). Stenosis progression, as assessed by computerized angiography, was defined as > or = 20% diameter reduction or new total occlusion.

RESULTS

At the first angiogram, 364 stenoses > or = 50% and 383 stenoses < 50% were identified. At restudy, 36 (15%) of 236 stenoses progressed in 29 Group 1 patients and 36 (7%) of 502 stenoses in 31 Group 2 patients (p = 0.001). Forty-five (88%) of 51 stenoses > or = 50% and 6 (29%) of 21 stenoses < 50% that progressed developed to total coronary occlusion (p = 0.001). More culprit stenoses progressed in Group 1 than in Group 2 (p = 0.006), whereas progression of nonculprit stenoses was not significantly different in both groups. Culprit complex stenoses progressed more frequently in Group 1 than in Group 2 (p = 0.01). During follow-up, 3 patients died (myocardial infarction), and 51 had a nonfatal coronary event. Culprit stenoses progressed in 15 (54%) of the 28 patients with a nonfatal coronary event in Group 1 and in 9 (39%) of 23 patients in Group 2 (p = NS). Complex morphology (p < 0.001) and unstable angina at initial presentation (p < 0.01) were predictive factors for progression of culprit stenoses.

CONCLUSIONS

A larger proportion of culprit complex stenoses progress in unstable angina than stable angina, and this is frequently associated with recurrence of coronary events.

Angiographic stenosis progression and coronary events in patients with 'stabilized' unstable angina

BACKGROUND

Recent studies suggest that angiographically complex coronary stenoses are associated with an adverse short-term outcome. It is not known, however, if this applies to unstable angina patients who stabilize on medical therapy.

METHODS AND RESULTS

We prospectively studied 85 consecutive patients with unstable angina who stabilized on medical therapy but were found to require angioplasty for treatment of obstructive coronary disease. Angiography was carried out at admission, and patients were restudied 8 +/- 4 months (mean +/- SD) after the first angiogram. Ischemia-related stenoses were identified and classified as "complex" (irregular borders, overhanging edges, or thrombus) or "smooth" (absence of complex features). Stenosis progression (> or = 20% diameter reduction or new total occlusion) was assessed by automated edge detection. At initial angiography, there were 198 stenoses (> or = 50%, 102), of which 85 (54 complex and 31 smooth) were ischemia related. At restudy, 21 ischemia-related stenoses and 8 non-ischemia-related stenoses progressed (25% versus 7%, P = .001). Seventeen of the 21 ischemia-related stenoses that progressed developed into total occlusion compared with 3 of the 8 non-ischemia-related stenoses (P = .02). Changes in average stenosis severity and in absolute stenosis diameter were significantly larger in ischemia-related stenoses than in non-ischemia-related stenoses (P = .03). Eighteen (34%) complex stenoses progressed, compared with 3 (10%) smooth lesions (P = .02). During follow-up, 1 patient died (myocardial infarction) and 25 patients had nonfatal coronary events that were associated with progression of ischemia-related stenoses in 14 (56%).

CONCLUSIONS

In unstable angina patients who stabilize medically, subsequent short-term stenosis progression and coronary events are common. The unstable coronary lesion (particularly complex stenoses) is often not stabilized and will continue to progress over the ensuing months.

Differential progression of complex and smooth stenoses within the same coronary tree in men with stable coronary artery disease

OBJECTIVES

We sought to compare the evolution of complex and smooth stenoses within the same coronary tree in patients with stable coronary artery disease.

BACKGROUND

Progression of coronary stenosis has prognostic significance and may be influenced by local and systemic factors. Stenosis morphology is a determinant of disease progression, but no previous study has systematically assessed progression of complex and smooth stenoses within the same patient.

METHODS

We studied 50 men with stable angina who 1) had one complex coronary stenosis and one smooth stenosis in different noninfarct-related coronary vessels at initial coronary angiography, and 2) had a second angiogram after a median interval of 9 months (range 3 to 24). Patients with lesions > or = 10 mm long, at a major branching point or with > 85% diameter reduction were not included. Coronary lesions were measured quantitatively from comparable end-diastolic frames. Stenosis morphology was determined qualitatively by two independent observers.

RESULTS

All patients remained in stable condition during follow-up. Progression, defined as an increase in diameter stenosis by > or = 15% was seen in only eight complex stenosis (16%) but in no smooth lesions (p < 0.01). The severity of complex stenoses changed more than that of corresponding smooth stenoses (mean +/- 1 SD 5.8 +/- 13% vs. -0.06 +/- 6%, p < 0.01). On average, the annual rate of growth was 11.4 +/- 28% and 1.5 +/- 14% for complex and smooth lesions, respectively (p < 0.01).

CONCLUSIONS

Few coronary stenoses progress rapidly in stable angina. Complex and smooth coronary stenoses progress at different rates within the same coronary tree. complex stenosis morphology itself is an important determinant of progression of stenosis in patients with apparently clinically stable coronary artery disease.

Identification of patients at high risk for adverse coronary events while awaiting routine coronary angioplasty

BACKGROUND

Identification of patients at risk for progression of coronary stenosis and adverse clinical events while awaiting coronary angioplasty is desirable.

OBJECTIVE

To determine the standard clinical or angiographic variables, or both, present at initial angiography associated with the development of adverse coronary events (unstable angina, myocardial infarction, and angiographic total coronary occlusion) in patients awaiting routine percutaneous transluminal coronary angioplasty (PTCA).

PATIENTS AND METHODS

Consecutive male patients on a waiting list for routine PTCA. Routine clinical details were obtained at initial angiography. Stenosis severity was measured using computerised angiography.

OUTCOME MEASURES

Development of one or more of myocardial infarction, unstable angina, or angiographic total coronary occlusion while awaiting PTCA were recorded as an adverse event.

RESULTS

Some 214 of 219 patients underwent a second angiogram. One had a fatal myocardial infarction and four (2%) were lost to follow up. Fifty patients (23%) developed one or more adverse events (myocardial infarction five, unstable angina 35, total coronary occlusion 23) at a median (range) interval of 8 (3-25) months. Twenty (57%) of the 35 patients with unstable angina developed adverse events compared with 30 (17%) of the 180 with stable angina (P = 0.0001). Plasma triglyceride concentration was 2.6 (1.2) mmol/l in patients with adverse coronary events compared with 2.2 (1.1) mmol/l in those without such events (P < 0.05). Patients with adverse events were younger than those without (54 (9) years v 58 (9) years, P < 0.01). The relative risk of an adverse event in patients with unstable angina and increased plasma triglyceride concentrations was 6.9 compared with those presenting with stable angina and a normal triglyceride concentration (P < 0.02).

CONCLUSIONS

The study shows that adverse events are not uncommon in patients awaiting PTCA. Patients at high risk for adverse events may be predicted by the presence of acute coronary syndrome, increased concentration of plasma triglyceride, and younger age at the time of the first angiogram.

Restenosis presented with unstable angina and myocardial infarction: one explanation for late cardiac events following directional coronary atherectomy

Three cases of restenosis after directional coronary atherectomy (DCA) presented with unstable angina and then myocardial infarction. Two of them were complicated with malignant ventricular dysrhythmia. A total or subtotal thrombotic occlusion at the DCA site was shown. This fulminating course of restenosis could partially explain the higher late cardiac morbidity and mortality after DCA than after percutaneous transluminal balloon angioplasty.

Unstable angina: role of silent ischemia and total ischemic time (silent plus painful ischemia), a 6-year follow-up

To assess the long-term prognostic significance of total ischemic time (silent plus painful ischemia) and silent ischemia in patients with unstable angina whose condition stabilized with medical treatment, 76 patients were studied. All patients underwent Holter ambulatory electrocardiographic (ECG) monitoring for greater than or equal to 48 h beginning within the 1st 12 h of the hospital stay. Forty-three patients (Group A) had a total ischemic time greater than or equal to 60 min, whereas 33 patients (Group B) had a total ischemic time less than 60 min. More than 78% of the ischemic episodes in patients in Group A and 62% of those in Group B were silent (p less than 0.05); nine patients in Group A and six in Group B had only silent episodes. Patients in Group A frequently showed three-vessel disease (65% vs. 18%, p less than 0.01), angiographic findings of subtotal occlusion of the coronary arteries (TIMI grade I) (76.7% vs. 42.4%, p less than 0.01) and ischemic alterations in the rest ECG (51.2% vs. 30.3%, p less than 0.05). During a 6-year follow-up period, 15 patients in Group A and 8 in Group B experienced myocardial infarction (p less than 0.05); 9 patients in Group A and 4 in Group B required coronary artery surgery (p less than 0.05) and 10 patients in Group A and 4 in Group B died of cardiac causes (p less than 0.01). Multivariate analysis showed three-vessel disease to be the most important predictor of cardiac mortality and morbidity (p = 0.025); it was followed in predictive power by a total ischemic time greater than or equal to 60 min and by left ventricular dysfunction. The presence of silent ischemia was not shown to be an independent predictor of long-term morbidity and mortality. In conclusion, patients with unstable angina and a total ischemic time greater than or equal to 60 min frequently have silent ischemic episodes on Holter ECG monitoring, a greater extent of coronary atherosclerosis and ischemic alterations of the rest ECG. The long-term prognosis of patients with unstable angina whose condition stabilizes with medical treatment depends on the extent of coronary atherosclerosis and on the longer duration of total ischemic time but not on the presence of silent ischemia.

Same-day angioplasty and diagnostic catheterization: safe and effective but riskier in unstable angina

Percutaneous transluminal coronary angioplasty was performed at the time of the diagnostic catheterization in 188 patients (215 lesions) at a University Hospital in order to assess the efficacy of this approach and the potential role it should play in the evaluation and treatment of patients. Patients either presented for diagnostic catheterization for evaluation of stable coronary disease (79 patients) or for unstable or new onset anginal symptoms (109 patients). Lesions were graded as to whether they were simple or complex; and post angioplasty films were reviewed for success rate, and degree of revascularization. Patients who were referred for stable anginal symptoms had a slightly higher success rate (91%) compared to those who were referred for new onset or more unstable symptomatology (85%, p = ns). Additionally, lesions morphology was judged to be more complex in unstable patients, as 67% had complex lesions with the presence of thrombus or ulcerated plaque in 56% of these stenoses. Angioplasty success was high for simple lesions in all patients, but was most unfavorable for complex stenoses in patients who presented with unstable symptoms (81% success rate). In patients who presented with new onset or unstable symptoms multivessel disease was present in 69% and angioplasty was more often geared at dilating a culprit stenosis leaving only 49% of these patients with complete revascularization. On the other hand, in 76% of those patients who presented with stable angina complete revascularization was a common outcome. Length of hospital stay was considerably shorter at 2.9 +/- 0.8 days in those patients who presented with stable symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for progression of atherosclerosis six months after balloon angioplasty of coronary stenosis

To assess the possible progression of coronary artery disease after percutaneous transluminal coronary angioplasty (PTCA) and its relation to risk factors and restenosis, 124 patients who underwent a first successful PTCA were studied. All had routine follow-up angiography 5 to 8 months after PTCA. Restenosis was defined as a 30% decrease in diameter stenosis or a return to greater than 50% stenosis, and progression (in any nondilated site) as a 20% decrease in diameter stenosis, assessed by a video-densitometric computer-assisted technique. Univariate and multivariate analysis with respect to progression was carried out for age, sex, initial unstable angina, previous myocardial infarction, diabetes mellitus, hypertension, hypercholesterolemia (greater than or equal to 6.2 mmol), smoking habits, Jenkins' score, dilated artery and restenosis. Forty-one patients (33%) had restenosis, and 23 (19%) had evidence of progression; 20 (87%) of these latter patients had restenosis and 3 (13%) did not. Univariate correlates of progression were: previous myocardial infarction (p less than 0.05), higher Jenkins' score (p less than 0.0003) and restenosis (p less than 0.0001). Restenosis was the only multivariate correlate (p less than 0.00003). Progression at routine angiography after PTCA is not rare, and appears to be related to both the initial extent of coronary artery disease and restenosis.

Significance of spontaneous obstruction of high degree coronary artery stenoses between diagnostic angiography and later percutaneous transluminal coronary angioplasty

Among 265 patients with severe coronary artery stenoses amenable to percutaneous transluminal coronary angioplasty, 13 (5%) developed new total coronary occlusion of the vessel to be dilated during the period between diagnostic coronary angiography and repeat coronary angiography at the time of the operation. Time from diagnostic to "therapeutic" angiography (76 +/- 74 vs 31 +/- 31 days, p less than 0.0001), degree of coronary stenosis on diagnostic angiography (85 +/- 7 vs 80 +/- 8%, p less than 0.05) and impaired coronary flow distal to the narrowing (Thrombolysis in Myocardial Infarction grade 2: 38 vs 10%, p less than 0.01) were the only variables related to the occurrence of spontaneous coronary occlusion. The clinical course of the patients who developed new total coronary occlusion was remarkably favorable. Twelve of the 13 patients had unchanged or improved anginal symptoms. The electrocardiogram at rest remained unchanged in 11 patients and there was no transmural myocardial infarction. Eight patients had 2 ventriculograms and the mean ejection fraction remained unchanged (only 2 patients had greater than 5% decrease in ejection fraction between the 2 examinations). Spontaneous occlusion of high degree coronary artery stenoses is not unusual and is usually well tolerated, presumably due to the development of collateral circulation.

Coronary angioplasty in patients with unstable angina pectoris: is there a role for thrombolysis?

Management of unstable angina has evolved progressively, and coronary angioplasty has recently been shown to be an effective treatment strategy for unstable angina. However, the procedure-related major complication rate is higher when compared with that for angioplasty in stable angina. The underlying pathophysiology may explain this higher complication rate. Rupture of an atherosclerotic plaque associated with thrombus formation is frequent in the pathogenesis of unstable angina. These processes lead to a critical reduction in myocardial blood supply, and coronary angioplasty may effectively interrupt this process. In contrast, coronary angioplasty itself may cause further injury of the already ulcerated intima, have the potential to intensify the ongoing thrombogenic process and lead to an increased frequency of abrupt closure of the artery during the procedure. Therefore, intracoronary streptokinase was used in the procedure in those patients with abrupt closure of the artery immediately after dilation to attempt to improve the immediate result. Coronary angioplasty was attempted in 200 consecutive patients with unstable angina. Initial success in crossing the obstructed artery was achieved in 196 patients; however, an abrupt closure immediately after dilation occurred in 21 of these patients. Of these 21 patients, 12 were also treated with intracoronary streptokinase, and successful dilation was achieved in 9 patients without evidence of necrosis or the need for emergency bypass surgery. Of the remaining nine patients, four successfully underwent redilation with a larger-sized balloon, four underwent urgent surgery (one death postoperatively) and one was treated conventionally. Final success was achieved in 188 patients (94%) without death, the need for emergency surgery or evidence of myocardial necrosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Progression of coronary artery disease after percutaneous transluminal coronary angioplasty

Thirty-nine patients underwent coronary arteriography 1 to 20 months (mean 7 months) after percutaneous transluminal coronary angioplasty (PTCA). At the time of the repeat study, 35 patients (90%) had recurrent angina or myocardial infarction, and 4 patients (10%) were asymptomatic. Restenosis, defined as greater than 50% loss of PTCA gained diameter, was found in 19 patients (49%). In addition, 20 patients had new lesions or marked progression of existing lesions (defined as greater than 20% or increasing greater than 20% obstruction in coronary diameter) in the previously normal or mildly diseased coronary segments. The new or progressive lesions occurred both in patients with restenosis at the PTCA site (nine of 19) and in patients without restenosis (11 of 20). New or progressive lesions tended to occur more commonly in the artery on which PTCA was performed (13 of 40) than in the artery that did not have PTCA (10 of 77) (p less than 0.02 by chi 2). In arteries that had PTCA, new or progressive lesions occurred more often in the segment proximal to the angioplasty site (seven of 13 or 54%) than in the peri-PTCA segment (two of 13 or 15%) and in the segments distal to it (four of 13 or 31%), but this observation did not reach statistical significance. No other clinical, angiographic, or PTCA procedure variables affected the occurrence of new or progressive lesions. In patients with recurrent angina or myocardial infarction after PTCA, both restenosis and new or progressive lesions are common. New lesions or marked progression of existing lesions tended to occur in the vessel subjected to PTCA.(ABSTRACT TRUNCATED AT 250 WORDS)

Late thrombotic occlusion of saphenous vein grafts: successful recanalization using thrombolytic therapy

We report two cases in which thrombosis was the primary cause of vein graft occlusion many years after bypass surgery. Both displayed minimal thrombolysis immediately after a selective infusion of streptokinase but were patent when reimaged hours later. Such therapy may be helpful when graft occlusions are associated with a large volume of thrombus.

Mechanical thrombectomy: a comparison of two rotational devices and balloon angioplasty in subacute canine femoral thrombosis

In this study, two prototype rotational devices were compared to balloon angioplasty in a canine model of subacute arterial thrombosis. Radiographic 2- to 8-day-old total thrombotic occlusions were produced in 30 canine femoral arteries. A high-speed rotating device with a cutting tip was used in 18 arteries. Successful opening occurred in every case, with a residual percent diameter stenosis at 45 +/- 25%. Vessel perforation was seen in 6 of the 18 arteries. A noncutting rotational thrombectomy catheter was used in six arteries. Radiographic patency was established in two of six (residual stenosis 86 +/- 28%), with one perforation with the use of the noncutting thrombectomy catheter. Balloon angioplasty reestablished radiographic patency in three of six arteries (residual stenosis 77 +/- 2%). No perforations were seen with balloon dilation, but radiographic distal emboli were always observed. No radiographic emboli were observed with either of the rotational devices. We conclude that subacute arterial thromboses are easily opened with an abrasive-tipped rotating angioplasty device. Although perforations are relatively common with this prototype equipment, design changes may produce a clinically useful angioplasty device.

Risk of preangioplasty occlusion and myocardial infarction in one-vessel-disease patients scheduled for percutaneous transluminal coronary angioplasty

Coronary occlusion or myocardial infarction occurred in 50 of 394 (13%) one-vessel-disease patients awaiting percutaneous transluminal coronary angioplasty (PTCA). To identify risk factors for these events, we first matched the 37 patients who demonstrated occlusion on the immediate preangioplasty repeat angiogram with 37 patients who did not. Matching was based on the time interval between angiograms, the date of the procedure, and the site of the lesion. Preangioplasty occlusion patients did differ from controls by age (47 +/- 11 vs 54 +/- 8 years, P less than .01), smoking status (34/37 vs 24/37, P less than .01), and angina class (2.6 +/- 1.0 vs 2.3 +/- 0.7, P less than .10) at the time of the first angiogram. Second, we pooled the data of the 37 preangioplasty occlusion patients with those of the 13 patients with preangioplasty myocardial infarction. The 50 cases with complication (coronary occlusion or myocardial infarction) were younger (47 +/- 12 vs 54 +/- 8 years, P less than .01), more often smokers (42/50 vs 24/37, P less than .05), and more symptomatic (2.7 +/- 0.8 vs 2.3 +/- 0.7, P less than .05) than the 37 controls. This study suggests that young smokers with severe angina are at high risk of preangioplasty occlusion and/or myocardial infarction; prompt management of these patients, when considered for PTCA, seems advisable.