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Percutaneous transluminal coronary angioplasty in patients 80 years of age and older
electrocardiogram correlates closely with infarct size.5 patients without these electrocardiographic abnormaliThis analysis, however, tested and extended a clinical ties have only a 16% probability of having LV thrombus observation that patients with Q waves in I or aVL after present. anterior myocardial infarction had significant post-AM1 LV distortion, presumably due to anterolateral extension 1. Weinrich DJ, Burke JF, Paulette FJ. Left ventricular thrombi complicating or expansion and distortion of the infarct zone. This ob- acute myocardial infarction. Long-term followup with serial echocardiography. servation is supported not only by the direct association of Ann Intern Med 1984;100:789~794. 2. Lamas GA, Vaughan DE, Pfeffer MA. Left ventricular thrombus formation lateral Q waves with high sphericity index and qualitative after first anterior wall acute myocardial infarction. Am JCardio//988.62;3/-35. LV distortion, but also by its association with secondary 3. Lamas GA, Pfeffer MA. Increased left ventricular volumes following mywarinfarction in man. Am Heart J 1986;11:30-35. effects of LV distortion such as increased LV volumes. di4.al Lamas GA, Vaughan DE, Parisi AF, Pfeffer MA. Effects of left ventricular This simple electrocardiographic finding may have some shape and exercise capacity after anterior wall acute myocardial infarction. Am J clinical application. Both echocardiographic studies6 as Cardiol 1989:63:1167m/ 173. 5. Ideker RE, Wagner GS, Ruth WK, Alonso DR, Bishop SP, Bloor CM, Fallon well as our own prior analysis2 have emphasized that LV JT, Gottlieb GJ, Hackel DB, Phillips HR, Reimer KA, Roark SF, Rogers WJ, thrombi are present in patients who have had large ante- Savage RM, White RD, S&ester RH. Evaluation of a QRS scoring s&m for rior AMIs resulting in distorted left ventricles. Thus, estimating myocardial infarct size. II. Correlation with quantitative anatomic for anterior infarcts. Am J Cardiol 1982;46:1604-1614. while anterior wall AM1 patients with a Q in I or in aVL findings 6. Meltzer RS, Visser CA, Foster V. Intracardiac thrombi and systemic embalishow a >50% chance of having developed LV thrombus, zation. Ann Intern Med 1986;304:689m698.
Percutaneous Transluminal 80 Years of Age and Older
Coronary
Angioplasty
J. Jeffrey Rich, MD, Charles M. Crispino, MD, J. Justin Saporito, and William M. Cooper, MD
in Patients
MD, lmad
Domat,
MD,
lderly patients undergoing percutaneous transE luminal coronary angioplasty (PTCA) are thought to be at an increased risk for complications and mortality.
before admission. Five of the 22 (23%) patients were hospitalized because of acute myocardial infarction. PTCA wasperformed becausethesepatients had develMore experience, improved technique and careful patient opedpostinfarction angina. Only 3 of the 22patients had selection have resulted in higher successrates for elderly 3-vesseldiseaseor serial lesionsin >I vessel. The repatients in recent years. Coronary artery bypass grafting maining 32 of the 54 patients were treated medically. has a higher operative morbidity and mortality in the Twenty-fve (78%) of the patients in this group had New elderly than in younger patients with comparative dis- York Heart Association class ZZZor IV angina before ease.’ However, elderly patients undergoing PTCA have admission.Diagnosis upon admission was acute myobeen reported to be at a risk similar to that in younger cardial infarction for 1I (34%) of thesepatients. Threepatients.2m5 Angioplasty, therefore, can play a role in the vesseldiseaseor serial lesionsin >I vesselwasfound in treatment of coronary artery disease in some elderly pa- 22 of the 32 patients (69%). tients. As the percentage of the elderly in our population The femoral artery approach was used in 27 proceincreases it is important to continue to evaluate their dures in 22 patients undergoingPTCA. The angioplastindications for interventional procedures. Although stud- ies were performed by 9 different cardiologists using ies2-4support the efficacy of PTCA in patients >65 years steerableguidewires and balloon-catheter systems.All of age, only 1 study has examined the role of PTCA in patients receivedintravenous heparin; intravenous or inoctogenarians.6 Accordingly, we reviewed the results of tracoronary nitroglycerin was administered at the disPTCA in octogenarians at our institution over a 14- cretion of the operator. SuccessfulPTCA wasdefined as month period. a decreasein diameter narrowing from 170 to X30%. Between March I987 and May 1988, over 5,000 pa- Failure of PTCA wasdefined as an inability to crossor tients underwent cardiac catheterization at our institu- dilate the stenotic area due to technical or clinical reation with over 1,500 of these undergoing PTCA. Sixtysonsand mortality in the procedure was defined assudone patients (28 men, 33 women) were aged 80 to 88 den cardiac death or subsequentin-hospital death. Five years (mean 82). They wereevaluatedfor unstableangi- patients underwent stagedmultivessel PTCA and 3 had salvage PTCA. Salvage PTCA is angioplasty done on na (n = 38), myocardial infarction (n = 16) and valvular heart disease(n = 7). Fifteen of thesepatients had a patients who are not surgical candidates, have failed history of myocardial infarction 13 months before ad- intensive medical therapy and usually have significant mission.Of the 54patients evaluatedfor coronary artery left ventricular dysfunction. Complicationsof theprocedisease,22 underwent PTCA. All of these 22 patients dure were defined as postprocedure myocardial infarchad New York Heart Association classZZZor IV angina tion, acute pulmonary edema, dysrhythmias, coronary artery dissection, hematoma, neurologic events,cholesFrom the Department of Medicine, Divisions of Internal Medicine and terol embolization and death. Cardiology, Shadyside Hospital, 5230 Centre Avenue, Pittsburgh, Follow-up was achieved in all patients by direct Pennsylvania 15232. Manuscript received August 4,1989; revised manphysician-to-physician contact. Patients’ status was deuscript received and accepted October 24, 1989.
THE AMERICAN
JOURNAL
OF CARDIOLOGY
MARCH
1. 1990
675
TABLE I Location Who Underwent Angioplasty
of Coronary Percutaneous
Artery Occlusions of Patients Transluminal Coronary
No.
No.
No.
Successful
Failed
Attempted
bypasssurgery. During the follow-up period no patient had a myocardial infarction and none was hospitalized for cardiac reasonsexcept for the previously mentioned patients who undemtent surgery.
Several studies have shown there is a role for PTCA in the elderly patient with coronary artery disease. ComparRight coronary artery 10 1 11 atively little has been reported concerning PTCA in octoLeft circumflex 1 0 1 genarians. Kern et al6 reported a 19% procedural mortaliLeft anterior descending 13 2 15 ty rate and a 38% complication rate in their series of Diagonal 1 0 1 patients undergoing PTCA. Edmunds et al7 reviewed Obtuse marginal1 1 0 1 Obtuse marginal2 1 0 1 their results of octogenarians undergoing coronary artery Total 27 3 30 bypass surgery alone or with valve replacement. They reported an early mortality rate of 24% and a late mortaltermined in ofJice visits and direct telephoneconversa- ity rate of 12 to 24%. Complications occurred in about tion inquiring as to change of angina status or class, half of their patients. Our series of patients undergoing changes in medications and post-PTCA hospitaliza- PTCA had a high morbidity rate but a low mortality rate. However, our patient population was selected. When tions. In the 32 medically treatedpatients, 5 died asa result comparing the PTCA group to the medically treated of cardiogenic shock after myocardial infarction and 1 group in our series, the patients in the PTCA group had patient diedfrom complications of cholesterolemboliza- less extensive coronary artery disease, there were fewer tion after cardiac catheterization. The mortality rate of patients with a history of previous myocardial infarction this group was 19%. In the PTCA group, 24 of 27 proce- and there were fewer patients presenting with acute myodures were successful(89%). Twenty-six of the 30 coro- cardial infarction. These patients underwent PTCA benary artery lesiondilations attempted wereproximal left cause they were thought to have unstable angina caused anterior descending or right coronary artery stenoses by a single proximal coronary occlusion or because they (Table I). Post-PTCA myocardial infarction occurred in had postinfarct angina. Under these circumstances we 3patients. Onepatient who had nonsustainedventricular believe that PTCA can be successfully performed with tachycardia during PTCA was treated successfullywith low mortality and with an acceptable long-term outcome a lidocaine bolus and continuous infusion for 24 hours. in the octogenarian population. Attempted
Location
Acute pulmonary edema occurred in 2 patients. These patients were successfully treated and stablized with nitroglycerin, furosemide and morphine. One of thesepatients was also in the post-PTCA myocardial infarction group. Hematomas developed in 4 patients, 3 with the femoral artery approach and 1 with the brachial artery approach. None of thesepatients required surgical evacuation or blood transfusions, Two patients had transient ischemic attacks and 1 patient had a cerebrovascular accident with complete resolution. No patients who had undergone PTCA died while in the hospital and none had to undergo emergency coronary artery bypasssurgery. The average follow-up in the PTCA group was 11 months. Twenty of the 22 patients were still alive. One patient died during elective coronary artery bypasssurgery 1 month after PTCA. The secondpatient diedfrom complications of a stroke that occurred 3’/2months after PTCA, One patient who developed unstable angina 2 days after PTCA underwent successfulcoronary artery
676
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
65
1. Gersh BJ, Kronmal RA, Frye RL, Schaff HV, Ryan TJ, Gosselin AJ, Kaiser GC, Killip T. Coronary arteriography and coronary artery bypass surgery: morbidity and mortality in patients ages 65 years or older; a report from the Coronary Artery Surgery Study. Circulation 1983x57:483-491. 2. Mock MB, Holmes DR. Vlietstra RE, Gersh BJ, Detre KM, Kelsey SF, OrszulakTA, Schaff HV, Piehler JM, VanRaden MJ, Passamani ER, Kent JM, Gruentzig AR. Percutaneous transluminal coronary angioplasty (PTCA) in the elderly patient: experience in the National Heart, Lung, and Blood Institute PTCA Registry. Am J Cardiol 1984:53:89C-91 C. 3. Hoh GW, Sugrue.DD, Bresnahan JF, Vlietstra RE, Bresnahan DR, Reeder GS, Holmes DR. Results of percutaneous transluminal coronary angioplasty for unstable angina pectoris in patients 70 years of age and older. Am J Cardiol 1988$1:994-997. 4. Raizner AE, Hust RG, Lewis JM, Winters
WL, Batty JW, Roberts R. Transluminal coronary angioplasty in the elderly. Am J Cardiol 1986;57:29-32. 5. Faro RS, Golden MD, Javid H, Serry C, DeLaria GA, Monson D, Weinberg M, Hunber JA, Najati H. Coronary revasculariaation in septuagenarians. J
Thorac
Cardiovasc
Surg
1983:86:616-620.
6. Kern MJ, Deligonul U, Galan K, Zelman R, Gabliani G, Bell ST, Bodet J, Naunheim K, Vandormael M. Percutaneous transluminal coronary angioplasty in octogenarians. Am J Cardiol 1988,61:457-458. 7. Edmunds LH, Stephenson LW, Edie RN, Ratcliffe MB. Open-heart surgery in octogenarians. N Engl J .&fed 1988;319:131-136.
Percutaneous Transluminal 80 Years of Age and Older
Coronary
Angioplasty
J. Jeffrey Rich, MD, Charles M. Crispino, MD, J. Justin Saporito, and William M. Cooper, MD
in Patients
MD, lmad
Domat,
MD,
lderly patients undergoing percutaneous transE luminal coronary angioplasty (PTCA) are thought to be at an increased risk for complications and mortality.
before admission. Five of the 22 (23%) patients were hospitalized because of acute myocardial infarction. PTCA wasperformed becausethesepatients had develMore experience, improved technique and careful patient opedpostinfarction angina. Only 3 of the 22patients had selection have resulted in higher successrates for elderly 3-vesseldiseaseor serial lesionsin >I vessel. The repatients in recent years. Coronary artery bypass grafting maining 32 of the 54 patients were treated medically. has a higher operative morbidity and mortality in the Twenty-fve (78%) of the patients in this group had New elderly than in younger patients with comparative dis- York Heart Association class ZZZor IV angina before ease.’ However, elderly patients undergoing PTCA have admission.Diagnosis upon admission was acute myobeen reported to be at a risk similar to that in younger cardial infarction for 1I (34%) of thesepatients. Threepatients.2m5 Angioplasty, therefore, can play a role in the vesseldiseaseor serial lesionsin >I vesselwasfound in treatment of coronary artery disease in some elderly pa- 22 of the 32 patients (69%). tients. As the percentage of the elderly in our population The femoral artery approach was used in 27 proceincreases it is important to continue to evaluate their dures in 22 patients undergoingPTCA. The angioplastindications for interventional procedures. Although stud- ies were performed by 9 different cardiologists using ies2-4support the efficacy of PTCA in patients >65 years steerableguidewires and balloon-catheter systems.All of age, only 1 study has examined the role of PTCA in patients receivedintravenous heparin; intravenous or inoctogenarians.6 Accordingly, we reviewed the results of tracoronary nitroglycerin was administered at the disPTCA in octogenarians at our institution over a 14- cretion of the operator. SuccessfulPTCA wasdefined as month period. a decreasein diameter narrowing from 170 to X30%. Between March I987 and May 1988, over 5,000 pa- Failure of PTCA wasdefined as an inability to crossor tients underwent cardiac catheterization at our institu- dilate the stenotic area due to technical or clinical reation with over 1,500 of these undergoing PTCA. Sixtysonsand mortality in the procedure was defined assudone patients (28 men, 33 women) were aged 80 to 88 den cardiac death or subsequentin-hospital death. Five years (mean 82). They wereevaluatedfor unstableangi- patients underwent stagedmultivessel PTCA and 3 had salvage PTCA. Salvage PTCA is angioplasty done on na (n = 38), myocardial infarction (n = 16) and valvular heart disease(n = 7). Fifteen of thesepatients had a patients who are not surgical candidates, have failed history of myocardial infarction 13 months before ad- intensive medical therapy and usually have significant mission.Of the 54patients evaluatedfor coronary artery left ventricular dysfunction. Complicationsof theprocedisease,22 underwent PTCA. All of these 22 patients dure were defined as postprocedure myocardial infarchad New York Heart Association classZZZor IV angina tion, acute pulmonary edema, dysrhythmias, coronary artery dissection, hematoma, neurologic events,cholesFrom the Department of Medicine, Divisions of Internal Medicine and terol embolization and death. Cardiology, Shadyside Hospital, 5230 Centre Avenue, Pittsburgh, Follow-up was achieved in all patients by direct Pennsylvania 15232. Manuscript received August 4,1989; revised manphysician-to-physician contact. Patients’ status was deuscript received and accepted October 24, 1989.
THE AMERICAN
JOURNAL
OF CARDIOLOGY
MARCH
1. 1990
675
TABLE I Location Who Underwent Angioplasty
of Coronary Percutaneous
Artery Occlusions of Patients Transluminal Coronary
No.
No.
No.
Successful
Failed
Attempted
bypasssurgery. During the follow-up period no patient had a myocardial infarction and none was hospitalized for cardiac reasonsexcept for the previously mentioned patients who undemtent surgery.
Several studies have shown there is a role for PTCA in the elderly patient with coronary artery disease. ComparRight coronary artery 10 1 11 atively little has been reported concerning PTCA in octoLeft circumflex 1 0 1 genarians. Kern et al6 reported a 19% procedural mortaliLeft anterior descending 13 2 15 ty rate and a 38% complication rate in their series of Diagonal 1 0 1 patients undergoing PTCA. Edmunds et al7 reviewed Obtuse marginal1 1 0 1 Obtuse marginal2 1 0 1 their results of octogenarians undergoing coronary artery Total 27 3 30 bypass surgery alone or with valve replacement. They reported an early mortality rate of 24% and a late mortaltermined in ofJice visits and direct telephoneconversa- ity rate of 12 to 24%. Complications occurred in about tion inquiring as to change of angina status or class, half of their patients. Our series of patients undergoing changes in medications and post-PTCA hospitaliza- PTCA had a high morbidity rate but a low mortality rate. However, our patient population was selected. When tions. In the 32 medically treatedpatients, 5 died asa result comparing the PTCA group to the medically treated of cardiogenic shock after myocardial infarction and 1 group in our series, the patients in the PTCA group had patient diedfrom complications of cholesterolemboliza- less extensive coronary artery disease, there were fewer tion after cardiac catheterization. The mortality rate of patients with a history of previous myocardial infarction this group was 19%. In the PTCA group, 24 of 27 proce- and there were fewer patients presenting with acute myodures were successful(89%). Twenty-six of the 30 coro- cardial infarction. These patients underwent PTCA benary artery lesiondilations attempted wereproximal left cause they were thought to have unstable angina caused anterior descending or right coronary artery stenoses by a single proximal coronary occlusion or because they (Table I). Post-PTCA myocardial infarction occurred in had postinfarct angina. Under these circumstances we 3patients. Onepatient who had nonsustainedventricular believe that PTCA can be successfully performed with tachycardia during PTCA was treated successfullywith low mortality and with an acceptable long-term outcome a lidocaine bolus and continuous infusion for 24 hours. in the octogenarian population. Attempted
Location
Acute pulmonary edema occurred in 2 patients. These patients were successfully treated and stablized with nitroglycerin, furosemide and morphine. One of thesepatients was also in the post-PTCA myocardial infarction group. Hematomas developed in 4 patients, 3 with the femoral artery approach and 1 with the brachial artery approach. None of thesepatients required surgical evacuation or blood transfusions, Two patients had transient ischemic attacks and 1 patient had a cerebrovascular accident with complete resolution. No patients who had undergone PTCA died while in the hospital and none had to undergo emergency coronary artery bypasssurgery. The average follow-up in the PTCA group was 11 months. Twenty of the 22 patients were still alive. One patient died during elective coronary artery bypasssurgery 1 month after PTCA. The secondpatient diedfrom complications of a stroke that occurred 3’/2months after PTCA, One patient who developed unstable angina 2 days after PTCA underwent successfulcoronary artery
676
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
65
1. Gersh BJ, Kronmal RA, Frye RL, Schaff HV, Ryan TJ, Gosselin AJ, Kaiser GC, Killip T. Coronary arteriography and coronary artery bypass surgery: morbidity and mortality in patients ages 65 years or older; a report from the Coronary Artery Surgery Study. Circulation 1983x57:483-491. 2. Mock MB, Holmes DR. Vlietstra RE, Gersh BJ, Detre KM, Kelsey SF, OrszulakTA, Schaff HV, Piehler JM, VanRaden MJ, Passamani ER, Kent JM, Gruentzig AR. Percutaneous transluminal coronary angioplasty (PTCA) in the elderly patient: experience in the National Heart, Lung, and Blood Institute PTCA Registry. Am J Cardiol 1984:53:89C-91 C. 3. Hoh GW, Sugrue.DD, Bresnahan JF, Vlietstra RE, Bresnahan DR, Reeder GS, Holmes DR. Results of percutaneous transluminal coronary angioplasty for unstable angina pectoris in patients 70 years of age and older. Am J Cardiol 1988$1:994-997. 4. Raizner AE, Hust RG, Lewis JM, Winters
WL, Batty JW, Roberts R. Transluminal coronary angioplasty in the elderly. Am J Cardiol 1986;57:29-32. 5. Faro RS, Golden MD, Javid H, Serry C, DeLaria GA, Monson D, Weinberg M, Hunber JA, Najati H. Coronary revasculariaation in septuagenarians. J
Thorac
Cardiovasc
Surg
1983:86:616-620.
6. Kern MJ, Deligonul U, Galan K, Zelman R, Gabliani G, Bell ST, Bodet J, Naunheim K, Vandormael M. Percutaneous transluminal coronary angioplasty in octogenarians. Am J Cardiol 1988,61:457-458. 7. Edmunds LH, Stephenson LW, Edie RN, Ratcliffe MB. Open-heart surgery in octogenarians. N Engl J .&fed 1988;319:131-136.