Coronary angioplasty of age or older

in patients

eighty

years

Percutaneous transluminal coronary angioplasty (PTCA) was performed on 58 lesions in 53 patients 80 years of age or older with unstable angina. Most patients had previous myocardial infarction, abnormal left ventricular contraction patterns, and multivessel coronary disease. In most (48) patients only one vessel was dilated. PTCA was successful in 48 (82.8%) lesions, but complications were frequent. Eight patients died, six after anatomically successful PTCA (three with cardiac complications, two with noncardiac complications, and one with both cardiac and noncardiac complications). Two patients died after unsuccessful PTCA (one of cardiac complications and one of noncardiac complications), and 11 patients with PTCA were alive with significant complications (all noncardiac). Twenty-nine patients had successful PTCA with no complications; 40 (74.5%) patients were discharged with clinically successful PTCA. It is concluded that PTCA is feasible in patients 80 years of age or older but that both cardiac and noncardiac complications are common in this group of very fragile patients. (AM HEART J 1992;124:13.)

Jose 0. Santana, MD, Jacob I. Haft, MD, Nelson S. LaMarche, MD, and Jonathan E. Goldstein, MD. Newark, NJ

Percutaneous t,ransluminal coronary angioplasty (PTCA) offers an important alternative for myocardial revascularization in elderly patients, in whom risk of coronary bypass surgery is high’ and in whom the benefits of a less extensive procedure are attractive. Data on the outcome of elderly patients with unstable angina who have had PTCA are limited, because most large studies have been performed with patients who have a mean age ranging from 50 to 55 years, and those studies on the “elderly” have included patients as young as 65,70, or 75 years.“-7 Recently a few reports of PTCA in those patients 80 years of age or older have appeared,“l’ mainly as abstracts.‘l-l’l An important concern is that very advanced age might increase the morbidity and mortality rates of this procedure. To evaluate the efficacy and safety of PTCA in the very elderly, we performed a retrospective review of all the patients 80 years of age or older who underwent PTCA in our institution between January 1987 and August 1990.

From Received

the Department for publication

of (‘ardiology, March

St. Michael’s 5. 1991;

Reprint requests: Jacob I. Haft, MD, ment of Cardiology. 268 King Rlvd., 41127353

accepted

Medical Jan.

St. Michael’s Medical Newark. N.J 07102.

Center.

6, 1992. Center.

Depart-

METHODS

The recordsof2007 angioplasty proceduresperformed at St. Michael’s Medical Center from January 1987to August 1990 were retrospectively reviewed, and 61 patients 80 years of ageor older were selectedfor further study. Adequate clinical and angioplasty data were available on 53 patients. Eight were excluded becauseof unavailability of charts or films; none died in the catheterization laboratory. The femoral artery approach was used for all except one patient, on whomright arm catheterization wasperformed. The maj0rit.y of patients were premeditated with diphenhydramine hydrochloride (Benadryl) or meperidinehydrochloride (Demerolj intramuscularly. During the procedure all patients received 10,000units heparin intravenously, and nitroglycerin and calcium channel blockers were used to control episodesof blood pressureelevation and/or coronary artery spasm.All patients were monitored in an intensive care unit setting and were administered full-dose heparin for 18to 24 hours after the procedure unlesscomplications occurred. Antiplatelet agents were used in all casesunlesscontraindicated. No attempt wasmadeto treat all visible lesionsin all patients, and only the most critical lesionswere dilated. Left ventricular function was evaluated in most patients from the left ventriculogram in the right anterior oblique projection with three surfacesconsidered:anterior (anterior basaland anterior lateral), inferior (inferior basal and inferior apical), and apical. The number is included in thosefew caseswith ejection fraction by mugascan.Angioplasty wasconsideredsuccessfulwhen residual diameter stenosiswas no more than SO”;,. The

13

14

Santana

et al.

Table I. Patient percent

characteristics male, 35.8”~ 1

(mean age, 84 t 2.6 years; No. of patients

Vessel lesions 1 Vessel 2 Vessel 3 Vessel Previous myocardial infarction Recent ((5 days) Previous CABG Previous PTCA Unstable angina Congestive heart failure Patients with diabetes mellitus Patients with hypertension Neurologic events Left ventriculogram Normal 1 Abnormal surface 2 Abnormal surfaces 3 Abnormal surfaces CANG,

Coronary

artery

bypass

Percentage

- __-.

9 17

27 29 7 3 3 53 11 7 ‘6

4 13/51 25/51

10/51 3/51

-

Table II. PTCA

procedures and results __~~. ~~ _ ~.______ I -Vessel PT(‘A LAD LC’S RCA RJ Graii 2-\‘essel P’lY‘A LAD + LCS LAD + RCA LCX + RCA 1-Vessel PTCA In l-vessel disease In Z-vessel disease In Zvessel disease ‘L-Vessel PTCA In Z-vessel disease In :I-vessel disease Total vessels subjected to PTCA (8 TOi Successful (anatomicl I ‘nsuccessful (5 TOI

16 ,Wl.li’ ::, 1 5 -j iY.4 ’ I j

Y/9 fl(JU',

I

14il7 (82.4’, I 25/“7 (92.6’, 1 X/l7 (17.7’# t L’!27 (7.41, ) ,jX

-LG5X (82.X’ < J IO/58 (17.“‘, 1 !H.fi’, TC)I

surgery.

outcome of these patients was evaluated, and complications during or after the procedure were divided into two categories: cardiac and noncardiac.

RESULTS Angioplasty was performed in 53 patients (19 [35.8Cl] men) (Table I). While receiving maximal medical therapy, all had unstable angina characterized as prolonged chest pain, either at rest or with minimal exertion. Seventeen (32.1 ‘i, ) had two-vessel disease and 27 (50.gc0) had three-vessel disease. Three had previous angioplasty, and three had coronary artery bypass surgery. Twenty-nine patients had previous myocardial infarction; in seven patients the myocardial infarction had occurred within the &day period preceding angioplasty, and they had continued to have postinfarction angina. Eleven patients had at least one episode of congestive heart failure. Study of the left ventriculograms in 51 patients showed one abnormal surface in 25 (49’( 1, two abnormal surfaces in 10 (19.6”0), and three abnormal surfaces in three (5.9 “h ). Fifty-eight lesions in the 53 patients were subjected to PTCA: the left anterior descending coronary artery in 31 patients, the left circumflex coronary artery in 12, the right coronary artery in 13, the ramus intermedius in one, and a saphenous vein graft in one. Although 83.0’~ of’ the patients had multivessel disease, the procedure was aimed at a single vessel (the most critical lesion) in 48 (90.6%) patients and at two vessels in five (9.4’; ) patients. Forty-eight (82.BCr) of the attempted le-

sions were successfully dilated; eight lesions in seven patients could not be crossed, and two lesions closed at 1 hour and at 24 hours, respectively (Table II). Five of the 10 unsuccessful PTCAs were in totally occluded vessels (p < 0.01). Significant complications occurred in 20 (37.7 ’ I i of the 53 patients, including eight (15.1”( ) who died (Table III). Of the six patier& wit,h cardiac complications, five died. Two had Q-wave myocardial infarction; one of these died 48 hours after PTCA with venbricular tachycardia and multiple noncardiac complications, and one survived. Pulmonary edema developed in two other patients; both died with ventricular t,achycardia within 24 to 48 hours after the procedure. Ventricular tachycardia developed in two other patients at 18 and 72 hours after the procedure, respectively, and they could not be resuscitated. Among the 15 patient,s with noncardiac complications, four died (one patient who died also had cardiac complications). Hematoma developed at the access site in eight patients, seven patients required blood transfusion, and two patients required surgical repair of a pseudoaneurysm. Respiratory failure setondary to pneumonia developed in one (1.8’, 1. Two (3.6c; ) experienced renal failure and underwent dialysis. Three (5.7 (( ) experienced gastrointestinal bleeding and died; one of these also had ischemic colitis, renal failure, sepsis, and myocardial infarction. Another patient died of urosepsis.

Volume Number

Table

-

124 1

PTCA outcome in very elderly patients

Table

III. Complications No. (If patients

Percentage

--~___Total patients wit,h complications (‘ardiac complications M:iocardiJ infarction Ventricu1.n tachycardia Pulmonary edema Death

20 ci* ‘I* 5* 2 :,*

15* N~mcacdiac complications Hematoma at access site 8 Respiratctry failure 1 Renal failure 2* Gastrointestinal bleeding 3* Sepsis 2* Death 4* .-__ -1rwludes the me patient with both cardiac and noncardiac

37.7 11.3

9.4 28.3

IV. Clinical outcome

Patients alive with successful PTCA With significant cardiac complications With significant noncardiac complications With no complications Patients alive with unsuccessful PTCA Patients died after procedure Successful PTCA with cardiac complications Unsuccessful PTCA with cardiac complications Successful PTCA with noncardiac complications Unsuccessful PTCA with noncardiac complications *Includes

15

the me patient

40/53 (xdc; ) 0 11 (20.8”C ) 29 (54.7”r) 5/53 (9.4”C ) 8153 (15.17 1 4* (75’;)

with both cardiac and noncardiac

1 (1.97 :