Intrrnutional Journal of Cardiology. 37 (1992) 33-39 il;’ IS92 Elsevier Science Publishers B.V. All rights resewed
CARD10
33 0167-5273/92/$05.00
01527
Percutaneous transluminal coronary angioplasty in patients more than 75 years old: early and long-term results Philippe Buffet, Nicolas Danchin, Yves Juilliere, Luc Feldmann, Pierre Yves Marie, Christine Selton-Suty, Joseph Anconina and Fraqois Cherrier Department of Cardiology, SenYce de Cardiologie B. CHU Nancy-Brahois. Vandoeuc,re-l~.~-Nancy. France (Received
17 March
1992; revision
accepted
17 May 1992)
Buffet P, Danchin N, Juilliere Y, Feldmann L, Marie PY, Selton-Suty C, Anconina J, Cherrier F. Percutaneous transluminal coronary angioplasty in patients more than 75 years old: early and long-term results. Int J Cardiol 1992;37:33-39. Over 4 yr, 102 consecutive patients more than 75 yr old (56 men, 46 women; mean age 78 + 3 years, range: 76-89 years) underwent 120 percutaneous transluminal coronary angioplasty procedures. At baseline, 86% had severe angina1 symptoms (Canadian class III or IV>, 43% had a history of prior myocardial infarction; 61% had multivessel coronary artery disease, and mean left ventricular ejection fraction was 60 + 11%. Calcifications were observed on 66% of the dilated arteries. A total of 158 vessels (1.3 vessel per procedure) were attempted: 1 vessel in 89 procedures (74%), 2 vessels in 24 (20%) and 3 vessels in 7 (6%). The primary success rate was 80% per lesion (126/158) and 77% per procedure (92/120). Complications included 3 deaths (3%), 9 Q-wave infarctions (7.5%) and there was no emergency coronary bypass surgery. The primary success rate was significantly related to the absence of coronary calcifications on the dilated segment (88% versus 75%, p < 0.05) and to the initial patency of the dilated artery (subtotal stenosis: 83% versus total occlusion: 53%, p < 0.05).Follow-up data were obtained in the 79 consecutive patients with a duration of follow-up exceeding 8 months. The mean duration of follow-up was 23 _t 13 months (range 8 to 61 months). No patient was lost to follow-up; 11 patients died (cardiac causes: 7), 2 had a non-fatal infarction, 7 had aortocoronary bypass surgery and 18 had repeat percutaneous transluminal coronary angioplasty. Long-term survival (Kaplan-Meier method) was 83% at 4 yr. Among the 65 survivors, 73% were totally asymptomatic, 23% had Canadian Class I or II angina; 92% remained treated with oral antianginal medications. Although the initial results of percutaneous transluminal coronary angioplasty in very elderly patients are less favorable than in younger patients, the procedure has an acceptable risk in these very symptomatic patients and, when successful, brings sustained long-term symptomatic improvement. Key words: Coronary angioplasty in the elderly
Introduction Correspondence to: P. Buffet, M.D., Dept. of Cardiology, Service de Cardiologie B. CHU Nancy-Brabois, 54500 Vandoeuvre-l&s-Nancy, France. Fax 83-44-04-16.
Elderly patients with severe angina1 symptoms are more and more frequently referred for coro-
34
nary angiography. In such patients, the risk of coronary bypass surgery procedures is high [1,2] and percutaneous transluminal coronary angioplasty might constitute a valuable therapeutic option. However, few data are available regarding the factors influencing the procedural success rates or the impact of procedural success on long-term survival in very elderly patients [3,41. The present study documents the results of percutaneous transluminal coronary angioplasty in a consecutive series of highly symptomatic patients more than 75 yr old. Materials
and Methods
Patients The study population comprises all patients aged over 75 years who underwent a coronary angioplasty procedure in our laboratory between January 1986 and August 1990. Patients with coronary angioplasty in the acute stage of myocardial infarction (< 48 h from the beginning of symptoms) were excluded.
Follow-up Follow-up data were obtained from a detailed questionnaire sent to all presumably living patients after information on the patients’ status had been obtained from their referring physicians. In patients with repeat coronary angiography during follow-up, the presence of a residual stenosis > 50% at the site initially dilated was considered a restenosis, regardless of the patients’ symptoms. Statistical analysis Factors related to the immediate results of the angioplasty procedures were analyzed with Student’s unpaired t-tests for continuous variables and with chi-square tests (Yates correction) for discrete variables. Long-term survival was calculated according to the Kaplan-Meier method. For all tests, p values < 0.05 were considered significant. Results
Angioplasty procedure
Patients (Table 1)
All procedures were performed using the femoral approach with steerable balloon catheters [.5]. The patients were premeditated with aspirin (250 mg) and heparin (10000 units) immediately after insertion of the arterial sheath. Primary success per lesion was defined as a reduction of > 20% of intraluminal diameter stenosis, with a residual stenosis < 50% and absence of complications (death, myocardial infarction or emergency coronary surgery). Primary success per procedure was defined as a reduction of > 20% of intraluminal diameter stenosis with a residual stenosis < 50% of all attempted lesions, and absence of complications. All cineangiograms were reviewed by two observers and percentage diameter stenosis and presence of coronary calcifications were determined visually. Calcifications were defined as the presence of linear densities at the site of the stenosis, before injection of contrast medium.
During the study period, among 2270 coronary angioplasties, 120 were performed in 102 patients over 75 yr of age (56 men, 46 women, mean age 78 f 3 yr, range: 76-89 yr). There were 102 primary procedures and 18 re-angioplasties for restenosis or progression of coronary artery disease. These 120 procedures were performed in 68 men and 52 women. At the time of the procedure (Table l), 86% had Canadian Class III or IV angina; 43% had a history of previous myocardial infarction; 61% had multivessel coronary artery disease (2 50% reduction of intraluminal diameter); mean left ventricular ejection fraction was 60 -I 11%. Immediate results Coronary angioplasty was attempted on a total of 158 segments (1.3 segment per procedure). The lesions dilated were located on the left ante-
TABLE
I
Coronary angioplasty in patients more than 75 yr old: demographic. clinical and angiographic parameters before percutaneous transluminal coronary angioplasty (n = 120).
6X/52
56/44
89 31 52
74 26 43
17 103 92
14 X6 76
47 40 33 drug therapy 5 Xl 34
39 33 28
Male/female Age > 75 yr > X0 yr Previous MI Angina class CCS II11 KS III-IV Unstable angina No. of diseased vessels
1 7 3 No. of anti-angina] I 2 3 CCS = Canadian farction.
%
No.
Parameters
cardiovascular
4 68 28 society;
MI = myocardial
in-
rior descending or diagonal branch in 99 cases, on the left circumflex in 29 cases, on the right coronary artery in 29 cases and on a saphenous graft to the left circumflex in 1 case. Calcifications were visible in 104 of the dilated segments (66%). One lesion was attempted in 84 procedures, 2 lesions in 24 procedures and 3 lesions in 7 procedures. There were 143 subtotal stenoses and 15 complete coronary artery occlusions. The primary success rate was 80% per lesion (126/158) and 77% per procedure (92/120). There were 3 in-hospital deaths (1 sudden death, 6 h after an initially successful angioplasty of the left circumflex; 2 deaths of cardiogenic shock, 48 h after failed angioplasty of the proximal left anterior descending coronary artery complicated by acute anterior wall myocardial infarction). Nine patients (7.5%) developed a Q-wave myocardial infarction and 4 additional patients had a non-Q wave myocardial infarction (cardiac enzymes > twice the upper limit of normal). There was no emergency coronary bypass surgery. In addition, 2 patients had surgery for a local complication at the puncture site (femoral hematoma: 1; lower limb ischemia: 1).
Acute occlusion occurred in 15 lesions (10%): 8 were treated with the combined use of thrombolysis and repeat angioplasty, 4 of them successfully ( < 50% residual stenosis without myocardial infarction). Angioplasty failures (32 lesions) were caused by: inability to cross a total occlusion (n = 7); inability to cross the stenosis with the guide-wire or balloon (n = 8); inability to dilate the stenosis (residual stenosis > 50%) (n = 6); occurrence of a permanent total occlusion (n = 11). Five patients with a failed angioplasty procedure underwent elective coronary bypass surgery during their initial hospital stay. Only two variables were significantly correlated with the primary success rate (Table 2): the absence of calcifications on the dilated segment (88% vs 75%, p < 0.05) and the presence of a
TABLE
2
Coronary angioplasty in patients more than 75 yr old: parameters influencing angiographic success rate. Lesion (n = 158)
Global success rate Males Females Previous MI yes no Angina stable unstable Coronary calcifications yes no No. of diseased vessels one-VD multi-VD Dilated artery LAD LCX RCA Total occlusion yes no
P
No.
C/r
126/15X 72/Y2 54/hfJ
x0 7x XI
47/64 79/94
73 x4
NS
33/3x 93/120
X7 77
NS
7x/ I04 4x/54
75 XX
< 0.05
37/47 x9/111
7’) 80
NS
Xl/99 21/30 24/29
87 70 x3
NS
x/15 118/143
53 X3
< 0.01
NS
LAD = left anterior descending coronary artery; LCx = left circumflex coronary artery: MI = myocardial infarction; RCA = right coronary artery; VD = vessel disease.
36
subtotal stenosis versus total coronary (83% vs 53%, p < 0.05). Long-term
occlusion
follow-up
In order to pass the critical period of postangioplasty restenosis, only the 79 patients with a follow-up period 2 6 months were evaluated. The mean follow-up period was 23 k 13 months (range: 6 to 61 months). No patient was lost to follow-up. During follow-up, in addition to the 3 patients who died during their initial hospital stay, 11 patients (14%) died, 7 of whom of cardiac causes (sudden death: 1; elective coronary surgery: 1; acute myocardial infarction: 5). Of the 7 cardiac deaths, 6 occurred during the first 6 months following angioplasty. Three patients sustained a non-fatal myocardial infarction, and 7 underwent elective coronary bypass surgery, including the 5 patients with coronary bypass surgery during their initial hospital stay. Of the 35 patients with repeat coronary angiography (46%), 22 (62%) had an angiographic restenosis; 15 underwent reangioplasty and 7, who were symptom-free with medical treatment, did not. Of the 65 survivors, 47 (73%) were symptomfree, and 15 (23%) had Canadian class I or II angina; 59 patients (91%) were feeling well or very well. Long-term survival was 88 &-4% at 1 yr and 83 + 6% at 4 yr (Fig. 1). For the whole group,
SURVIVALI%1
Fig. 2. Coronary angioplasty in patients more than 75 yr old: long-term event-free survival (without myocardial infarction. elective coronary artery bypass graft or re-angioplasty for restenosis).
survival without cardiac event (death, infarction, coronary bypass, re-angioplasty) was 60 k 5% at 1 yr and 51 * 7% at 4 yr (Fig. 2). Follow-up events are reported in Table 3, and more events were noted in the group with failed angioplasty. In patients more than 80 yr of age (n = 23), 2-yr survival was 81% (Table 4). Discussion
The number of angioplasty procedures in elderly patients has increased consistently over the years. In a recent study [4], 18% of the patients treated with coronary angioplasty were aged 75 yr or more. The characteristics of coronary heart disease are distinct in the elderly, with a higher frequency of female patients, unstable angina, multivessel disease and coronary calcifications [3,4,6-91, so that the results of PTCA in younger patients cannot be extrapolated to this specific population. Early success rate
0%’
0
0.5
1
1.5
2
2.5
3
3.5
I 4
YEARS
Fig. 1. Coronary angioplasty in patients more than 75 yr old: long-term overall survival (n = 79). n = number of patients available for follow-up at each time point.
Although the initial NHLBI registry [lo] showed a lower success rate in patients over 65 yr of age, most more recent studies have shown that the primary success rate in such patients was not much different from that observed in younger
TABLE
3
Coronary angioplasty in patients more than 75 yr old: longterm results in patients with success and with failure of the procedure ftr= 79). Mean follow-up = 2?+ 13 months (S-61 months). Statistical analysis performed on follow-up data only. Success ,I = 59
Failure n = 20
P
No
Q
No.
96
Death periprocedural follow up
0 6
10
3 5
15 29
= 0.06
Non-fatal Ml periprocedural follow up Elective CABG
0 1 2
0 10 3
9 2 5
45 10 29
NS = 0.01
23
h/l?
50
=0.06
75
< 0.01
Angina at follow-up
(II = 65) 12/53 Total number of nonperiprocedural events during follow-up (death, MI. elective CABG or re-PTCA 24
40
15
CABG = coronary artery bypass graft; MI = myocardial infarction: PTCA = percutaneous transluminal coronary angioplasty.
patients [6,9,11,13,14]. Imburgia et al. [3], however, described results similar to ours, with a lower success rate in patients more than 75 yr TABLE
Complication
Coronary angioplasty in patients more than and long-term results in the group of patients old (31 PTCA procedures).
75 yr old: acute more than 80 yr
No.
cr,
23 0 3 0
74
Acute results
Long-term results (n = 23 pts) (mean follow-up = 21 it 13 months) Death 4 Non-fatal Ml 1 Angina at follow-up 5/19 re-PTCA 6/19
IO
17 4 27 31
CABG = coronary artery bypass graft; MI = myocardial infarction: PTCA = percutaneous transluminal coronary angioplasty.
rate
Major complications (death. acute myocardial infarction), though remaining at an acceptable level, particularly when compared to coronary bypass surgery [1,2], are more frequent in the elderly [3,4,14,151, and should be kept in mind before indications of angioplasty are taken in these patients. This finding might be due to the presence of more advanced and severe disease in these patients, particularly to more diffuse involvement of the coronary arteries. In addition, a number of elderly patients treated with coronary angioplasty are considered poor surgical candidates, Significantly, the rate of emergency coronary bypass surgery after failed angioplasty is usually lower after 7.5 yr of age [4,151; in our series, no patient underwent emergency coronary bypass surgery, whereas the rate of emergency surgery for our whole angioplasty population during the same time period was 3% [16]. In addition, some series [3,81 have reported a high rate of extracardiac complications, such as bleeding or hematomas at the puncture site. Long-term
3
Primary success Death Acute MI Emergency CABG
old, particularly when coronary calcifications were noted and in case of recanalisation of complete coronary occlusions.
results
Long-term survival in our patients (83% at 4 yr) compares with the figures reported in previous series [4,17,181 and appears quite satisfactory. The need for subsequent repeat revascularisation procedures, however, is not unusual, including approximately 10% of surgical procedures [17,19]. Most of these procedures take place within 1 yr of the initial angioplasty and correspond either to cases of failed angioplasty (generally coronary artery bypass graft) or restenosis (re-angioplasty). More debate exists regarding the evolution of residual angina. Although a vast majority of our patients remains asymptomatic at follow-up, a finding similar to that of Jenkins et al. [17], several series have reported a high incidence of recurrent angina [3,4], raising the issue of restenosis in this population. Because of the lack
38
of systematic repeat angiography in series of elderly patients, little reliable information is available regarding this subject; Jackman et al. [20] noted a 31% restenosis rate in a short series of patients more than 80 yr old and Macaya et al. 171 a 44% restenosis rate in patients aged 65 yr or more. These figures do not seem different from those found in younger populations [21]. Percutaneous transluminal coronary in patients older than 80 years
angioplasty
Five studies have assessed coronary angioplasty in patients more than 80 yr old [19,20,22,24]. The primary success rate ranges from 67 to 93%, with a procedural mortality rate ranging from 2 to 19%. The long-term survival rates are satisfactory, ranging from 90% at 1 yr [20] to 75% at 2 yr [19]. Our own data are in accordance with these results, which, considering the severity of the disease in these patients appear quite acceptable. Conclusion
Although the immediate complication rate of coronary angioplasty in elderly patients appears higher than in younger ones, our results suggest that the procedure is quite effective in most patients and brings long-term relief of symptoms with an excellent long-term survival; however, repeat revascularisation procedures are often necessary within 1 yr of the initial angioplasty. Coronary angioplasty appears a valuable therapeutic alternative to coronary bypass surgery in very elderly people suffering from severe angina1 symptoms. References 1 Naunheim KS, Kern MJ, McBride LR, Fiore AC, Willman UL, Kaiser GC. Coronary artery bypass surgery in patients aged 80 years or older. Am J Cardiol 1987;59:804-807. 2 Rose DM, Gelbfisch J. Jacobowitz IJ. Kramer M. Acinapura A, Cunningham JN. Analysis of morbidity and mortality in patients 70 years of age and over undergoing isolated coronary artery bypass surgery. Am Heart J 1985;110:341-346. 3 Imburgia M, King TR, Soffer AO. Rich MW, Krone RJ.
Salimi A. Early results and long-term oucome of percutaneous transluminal coronary angioplasty in patients age 75 years or older. Am J Cardiol 1989;63:1127-1129. 4’ Thompson RC, Holmes DR, Gersh BJ. Mock MB, Bailey KR. Percutaneous transluminal coronary angioplasty in the elderly: early and long term results. J Am Coil Cardiol 1991;17:124s-1250. 5 Simpson JB. Bairn DS, Robert EW, Harrison DC. A new catheter system for coronary angioplasty. Am J Cardiol 1982;49:1216-1222. 6 Bonnier JJRM. Michels HR, El Gamal M. PTCA in patients older than 75 years (abstract). Eur Heart J 1989; 10fsuppl 1):79. F. Iniguez A, Zarco P. Long-term 7 Macaya C. Alfonson clinical and angiographic follow-up of percutaneous transluminal coronary angioplasty in patients 2 65 years of age. Am J Cardiol 1990;66:1513-1515. RR, et al. PTCA in 8 McGrath MA. Peet GI, Mildenberger elderly patients: in-hospital events (abstract). Circulation 1990;82(suppl 3):609. 9 Mills TJ, Smith HC, Vlietstra RE. PTCA in the elderly: results and expectations. Geriatrics 1989;44:71-79. 10 Mock MB. Holmes DR. Vlietstra RE et a!. Percutaneous transluminal coronary angioplasty (percutaneous transluminal coronary angioplasty) in the elderly patient: experience in the NHLBI PTCA registry. Am J Cardiol 1984;53:89C91C. 11 Jung SC, Ligon RM, Webb DL, McCallister BD. Coronary angioplasty in patients over the age of 70: an analysis of early and late results and influence of experience on outcome (abstract). J Am Coil Cardiol 1990;15:34A. R, Simpfendorfer C. Zeiler Arnold A et al. 12 Raymond Coronary angioplasty in the elderly patient: short and longterm results (abstract). J Am Coil Cardiol lY91;17:64A. 13 Ten Berg JM, Bal ET, Tlon RM, Mast EG, Ernst JMPG, Plokker HWM. What is the long term benefit of PTCA in patients over 75 years of age? (abstract). Eur Heart J 1991;12:383. N. Immediate outcome of PTCA in 14 Colle JP. Delarche patients aged 75 years and older, compared with younger (abstract). Eur Heart J 1991;12;382. BD, McConahay DR et al. Re15 Bedotto JB, Rutherford sults of multivessel percutaneous transluminal coronary angioplasty in persons aged 65 years and older. Am J Cardiol 1991:67:1051-1055. 16 Buffet Ph, Danchin N, Villemot JP et al. Early and longterm outcome after emergency coronary artery bypass surgery after failed coronary angioplasty. Circulation 1991:84(suppl 111):254-259. 17 Jenkins GM, Midei MG. Dowger B et al. PTCA in the very elderly: long term follow-up (abstract). Circulation 1990;82(suppI 111):739. 18 De Jaegere P, De Feyter P, Van Domburg R, Suryapranata H. Van den Brand M, Serruys PW. Immediate and long term results of percutaneous coronary angioplasty in patients aged 70 and over. Br Heart J 1992:138-143.
39 19 Good TH, Calkins M, Ligon R, McCallister BD. Hartzler GD. PTCA in the ultra elderly (abstract). Circulation 1987;76(suppl IVb464. 70 Jackman JD, Navetta FI, Smith JE et al. Percutaneous transluminal coronary angioplasty in octogenerians as an effective therapy for angina pectoris. Am J Cardiol 1991:68:116-119. 21 McBride W. Lange RA, Hillis LD. Restenosis after successful coronary angioplasty. N Engl _I Med 1988:318: 1374-1377.
22 Kern MJ. Deligonul U, Galan K et al. Percutaneous transluminal coronary angioplasty in octogenerians. Am J Cardiol 1988;61:457-458. 23 Rizo-Patron C. Hamad N, Paulus R, Garcia J. Beard E. Percutaneous transluminal coronary angioplasty in octogenerians with unstable coronary syndromes. Am J Cardiol 3990;66:857-858. 24 Jeroudi MD, Kleiman NS, Minor ST et al. Percutaneous transluminal coronary angioplasty in octogenerians. Ann Intern Med 1990:113:423-428.
CARD10
33 0167-5273/92/$05.00
01527
Percutaneous transluminal coronary angioplasty in patients more than 75 years old: early and long-term results Philippe Buffet, Nicolas Danchin, Yves Juilliere, Luc Feldmann, Pierre Yves Marie, Christine Selton-Suty, Joseph Anconina and Fraqois Cherrier Department of Cardiology, SenYce de Cardiologie B. CHU Nancy-Brahois. Vandoeuc,re-l~.~-Nancy. France (Received
17 March
1992; revision
accepted
17 May 1992)
Buffet P, Danchin N, Juilliere Y, Feldmann L, Marie PY, Selton-Suty C, Anconina J, Cherrier F. Percutaneous transluminal coronary angioplasty in patients more than 75 years old: early and long-term results. Int J Cardiol 1992;37:33-39. Over 4 yr, 102 consecutive patients more than 75 yr old (56 men, 46 women; mean age 78 + 3 years, range: 76-89 years) underwent 120 percutaneous transluminal coronary angioplasty procedures. At baseline, 86% had severe angina1 symptoms (Canadian class III or IV>, 43% had a history of prior myocardial infarction; 61% had multivessel coronary artery disease, and mean left ventricular ejection fraction was 60 + 11%. Calcifications were observed on 66% of the dilated arteries. A total of 158 vessels (1.3 vessel per procedure) were attempted: 1 vessel in 89 procedures (74%), 2 vessels in 24 (20%) and 3 vessels in 7 (6%). The primary success rate was 80% per lesion (126/158) and 77% per procedure (92/120). Complications included 3 deaths (3%), 9 Q-wave infarctions (7.5%) and there was no emergency coronary bypass surgery. The primary success rate was significantly related to the absence of coronary calcifications on the dilated segment (88% versus 75%, p < 0.05) and to the initial patency of the dilated artery (subtotal stenosis: 83% versus total occlusion: 53%, p < 0.05).Follow-up data were obtained in the 79 consecutive patients with a duration of follow-up exceeding 8 months. The mean duration of follow-up was 23 _t 13 months (range 8 to 61 months). No patient was lost to follow-up; 11 patients died (cardiac causes: 7), 2 had a non-fatal infarction, 7 had aortocoronary bypass surgery and 18 had repeat percutaneous transluminal coronary angioplasty. Long-term survival (Kaplan-Meier method) was 83% at 4 yr. Among the 65 survivors, 73% were totally asymptomatic, 23% had Canadian Class I or II angina; 92% remained treated with oral antianginal medications. Although the initial results of percutaneous transluminal coronary angioplasty in very elderly patients are less favorable than in younger patients, the procedure has an acceptable risk in these very symptomatic patients and, when successful, brings sustained long-term symptomatic improvement. Key words: Coronary angioplasty in the elderly
Introduction Correspondence to: P. Buffet, M.D., Dept. of Cardiology, Service de Cardiologie B. CHU Nancy-Brabois, 54500 Vandoeuvre-l&s-Nancy, France. Fax 83-44-04-16.
Elderly patients with severe angina1 symptoms are more and more frequently referred for coro-
34
nary angiography. In such patients, the risk of coronary bypass surgery procedures is high [1,2] and percutaneous transluminal coronary angioplasty might constitute a valuable therapeutic option. However, few data are available regarding the factors influencing the procedural success rates or the impact of procedural success on long-term survival in very elderly patients [3,41. The present study documents the results of percutaneous transluminal coronary angioplasty in a consecutive series of highly symptomatic patients more than 75 yr old. Materials
and Methods
Patients The study population comprises all patients aged over 75 years who underwent a coronary angioplasty procedure in our laboratory between January 1986 and August 1990. Patients with coronary angioplasty in the acute stage of myocardial infarction (< 48 h from the beginning of symptoms) were excluded.
Follow-up Follow-up data were obtained from a detailed questionnaire sent to all presumably living patients after information on the patients’ status had been obtained from their referring physicians. In patients with repeat coronary angiography during follow-up, the presence of a residual stenosis > 50% at the site initially dilated was considered a restenosis, regardless of the patients’ symptoms. Statistical analysis Factors related to the immediate results of the angioplasty procedures were analyzed with Student’s unpaired t-tests for continuous variables and with chi-square tests (Yates correction) for discrete variables. Long-term survival was calculated according to the Kaplan-Meier method. For all tests, p values < 0.05 were considered significant. Results
Angioplasty procedure
Patients (Table 1)
All procedures were performed using the femoral approach with steerable balloon catheters [.5]. The patients were premeditated with aspirin (250 mg) and heparin (10000 units) immediately after insertion of the arterial sheath. Primary success per lesion was defined as a reduction of > 20% of intraluminal diameter stenosis, with a residual stenosis < 50% and absence of complications (death, myocardial infarction or emergency coronary surgery). Primary success per procedure was defined as a reduction of > 20% of intraluminal diameter stenosis with a residual stenosis < 50% of all attempted lesions, and absence of complications. All cineangiograms were reviewed by two observers and percentage diameter stenosis and presence of coronary calcifications were determined visually. Calcifications were defined as the presence of linear densities at the site of the stenosis, before injection of contrast medium.
During the study period, among 2270 coronary angioplasties, 120 were performed in 102 patients over 75 yr of age (56 men, 46 women, mean age 78 f 3 yr, range: 76-89 yr). There were 102 primary procedures and 18 re-angioplasties for restenosis or progression of coronary artery disease. These 120 procedures were performed in 68 men and 52 women. At the time of the procedure (Table l), 86% had Canadian Class III or IV angina; 43% had a history of previous myocardial infarction; 61% had multivessel coronary artery disease (2 50% reduction of intraluminal diameter); mean left ventricular ejection fraction was 60 -I 11%. Immediate results Coronary angioplasty was attempted on a total of 158 segments (1.3 segment per procedure). The lesions dilated were located on the left ante-
TABLE
I
Coronary angioplasty in patients more than 75 yr old: demographic. clinical and angiographic parameters before percutaneous transluminal coronary angioplasty (n = 120).
6X/52
56/44
89 31 52
74 26 43
17 103 92
14 X6 76
47 40 33 drug therapy 5 Xl 34
39 33 28
Male/female Age > 75 yr > X0 yr Previous MI Angina class CCS II11 KS III-IV Unstable angina No. of diseased vessels
1 7 3 No. of anti-angina] I 2 3 CCS = Canadian farction.
%
No.
Parameters
cardiovascular
4 68 28 society;
MI = myocardial
in-
rior descending or diagonal branch in 99 cases, on the left circumflex in 29 cases, on the right coronary artery in 29 cases and on a saphenous graft to the left circumflex in 1 case. Calcifications were visible in 104 of the dilated segments (66%). One lesion was attempted in 84 procedures, 2 lesions in 24 procedures and 3 lesions in 7 procedures. There were 143 subtotal stenoses and 15 complete coronary artery occlusions. The primary success rate was 80% per lesion (126/158) and 77% per procedure (92/120). There were 3 in-hospital deaths (1 sudden death, 6 h after an initially successful angioplasty of the left circumflex; 2 deaths of cardiogenic shock, 48 h after failed angioplasty of the proximal left anterior descending coronary artery complicated by acute anterior wall myocardial infarction). Nine patients (7.5%) developed a Q-wave myocardial infarction and 4 additional patients had a non-Q wave myocardial infarction (cardiac enzymes > twice the upper limit of normal). There was no emergency coronary bypass surgery. In addition, 2 patients had surgery for a local complication at the puncture site (femoral hematoma: 1; lower limb ischemia: 1).
Acute occlusion occurred in 15 lesions (10%): 8 were treated with the combined use of thrombolysis and repeat angioplasty, 4 of them successfully ( < 50% residual stenosis without myocardial infarction). Angioplasty failures (32 lesions) were caused by: inability to cross a total occlusion (n = 7); inability to cross the stenosis with the guide-wire or balloon (n = 8); inability to dilate the stenosis (residual stenosis > 50%) (n = 6); occurrence of a permanent total occlusion (n = 11). Five patients with a failed angioplasty procedure underwent elective coronary bypass surgery during their initial hospital stay. Only two variables were significantly correlated with the primary success rate (Table 2): the absence of calcifications on the dilated segment (88% vs 75%, p < 0.05) and the presence of a
TABLE
2
Coronary angioplasty in patients more than 75 yr old: parameters influencing angiographic success rate. Lesion (n = 158)
Global success rate Males Females Previous MI yes no Angina stable unstable Coronary calcifications yes no No. of diseased vessels one-VD multi-VD Dilated artery LAD LCX RCA Total occlusion yes no
P
No.
C/r
126/15X 72/Y2 54/hfJ
x0 7x XI
47/64 79/94
73 x4
NS
33/3x 93/120
X7 77
NS
7x/ I04 4x/54
75 XX
< 0.05
37/47 x9/111
7’) 80
NS
Xl/99 21/30 24/29
87 70 x3
NS
x/15 118/143
53 X3
< 0.01
NS
LAD = left anterior descending coronary artery; LCx = left circumflex coronary artery: MI = myocardial infarction; RCA = right coronary artery; VD = vessel disease.
36
subtotal stenosis versus total coronary (83% vs 53%, p < 0.05). Long-term
occlusion
follow-up
In order to pass the critical period of postangioplasty restenosis, only the 79 patients with a follow-up period 2 6 months were evaluated. The mean follow-up period was 23 k 13 months (range: 6 to 61 months). No patient was lost to follow-up. During follow-up, in addition to the 3 patients who died during their initial hospital stay, 11 patients (14%) died, 7 of whom of cardiac causes (sudden death: 1; elective coronary surgery: 1; acute myocardial infarction: 5). Of the 7 cardiac deaths, 6 occurred during the first 6 months following angioplasty. Three patients sustained a non-fatal myocardial infarction, and 7 underwent elective coronary bypass surgery, including the 5 patients with coronary bypass surgery during their initial hospital stay. Of the 35 patients with repeat coronary angiography (46%), 22 (62%) had an angiographic restenosis; 15 underwent reangioplasty and 7, who were symptom-free with medical treatment, did not. Of the 65 survivors, 47 (73%) were symptomfree, and 15 (23%) had Canadian class I or II angina; 59 patients (91%) were feeling well or very well. Long-term survival was 88 &-4% at 1 yr and 83 + 6% at 4 yr (Fig. 1). For the whole group,
SURVIVALI%1
Fig. 2. Coronary angioplasty in patients more than 75 yr old: long-term event-free survival (without myocardial infarction. elective coronary artery bypass graft or re-angioplasty for restenosis).
survival without cardiac event (death, infarction, coronary bypass, re-angioplasty) was 60 k 5% at 1 yr and 51 * 7% at 4 yr (Fig. 2). Follow-up events are reported in Table 3, and more events were noted in the group with failed angioplasty. In patients more than 80 yr of age (n = 23), 2-yr survival was 81% (Table 4). Discussion
The number of angioplasty procedures in elderly patients has increased consistently over the years. In a recent study [4], 18% of the patients treated with coronary angioplasty were aged 75 yr or more. The characteristics of coronary heart disease are distinct in the elderly, with a higher frequency of female patients, unstable angina, multivessel disease and coronary calcifications [3,4,6-91, so that the results of PTCA in younger patients cannot be extrapolated to this specific population. Early success rate
0%’
0
0.5
1
1.5
2
2.5
3
3.5
I 4
YEARS
Fig. 1. Coronary angioplasty in patients more than 75 yr old: long-term overall survival (n = 79). n = number of patients available for follow-up at each time point.
Although the initial NHLBI registry [lo] showed a lower success rate in patients over 65 yr of age, most more recent studies have shown that the primary success rate in such patients was not much different from that observed in younger
TABLE
3
Coronary angioplasty in patients more than 75 yr old: longterm results in patients with success and with failure of the procedure ftr= 79). Mean follow-up = 2?+ 13 months (S-61 months). Statistical analysis performed on follow-up data only. Success ,I = 59
Failure n = 20
P
No
Q
No.
96
Death periprocedural follow up
0 6
10
3 5
15 29
= 0.06
Non-fatal Ml periprocedural follow up Elective CABG
0 1 2
0 10 3
9 2 5
45 10 29
NS = 0.01
23
h/l?
50
=0.06
75
< 0.01
Angina at follow-up
(II = 65) 12/53 Total number of nonperiprocedural events during follow-up (death, MI. elective CABG or re-PTCA 24
40
15
CABG = coronary artery bypass graft; MI = myocardial infarction: PTCA = percutaneous transluminal coronary angioplasty.
patients [6,9,11,13,14]. Imburgia et al. [3], however, described results similar to ours, with a lower success rate in patients more than 75 yr TABLE
Complication
Coronary angioplasty in patients more than and long-term results in the group of patients old (31 PTCA procedures).
75 yr old: acute more than 80 yr
No.
cr,
23 0 3 0
74
Acute results
Long-term results (n = 23 pts) (mean follow-up = 21 it 13 months) Death 4 Non-fatal Ml 1 Angina at follow-up 5/19 re-PTCA 6/19
IO
17 4 27 31
CABG = coronary artery bypass graft; MI = myocardial infarction: PTCA = percutaneous transluminal coronary angioplasty.
rate
Major complications (death. acute myocardial infarction), though remaining at an acceptable level, particularly when compared to coronary bypass surgery [1,2], are more frequent in the elderly [3,4,14,151, and should be kept in mind before indications of angioplasty are taken in these patients. This finding might be due to the presence of more advanced and severe disease in these patients, particularly to more diffuse involvement of the coronary arteries. In addition, a number of elderly patients treated with coronary angioplasty are considered poor surgical candidates, Significantly, the rate of emergency coronary bypass surgery after failed angioplasty is usually lower after 7.5 yr of age [4,151; in our series, no patient underwent emergency coronary bypass surgery, whereas the rate of emergency surgery for our whole angioplasty population during the same time period was 3% [16]. In addition, some series [3,81 have reported a high rate of extracardiac complications, such as bleeding or hematomas at the puncture site. Long-term
3
Primary success Death Acute MI Emergency CABG
old, particularly when coronary calcifications were noted and in case of recanalisation of complete coronary occlusions.
results
Long-term survival in our patients (83% at 4 yr) compares with the figures reported in previous series [4,17,181 and appears quite satisfactory. The need for subsequent repeat revascularisation procedures, however, is not unusual, including approximately 10% of surgical procedures [17,19]. Most of these procedures take place within 1 yr of the initial angioplasty and correspond either to cases of failed angioplasty (generally coronary artery bypass graft) or restenosis (re-angioplasty). More debate exists regarding the evolution of residual angina. Although a vast majority of our patients remains asymptomatic at follow-up, a finding similar to that of Jenkins et al. [17], several series have reported a high incidence of recurrent angina [3,4], raising the issue of restenosis in this population. Because of the lack
38
of systematic repeat angiography in series of elderly patients, little reliable information is available regarding this subject; Jackman et al. [20] noted a 31% restenosis rate in a short series of patients more than 80 yr old and Macaya et al. 171 a 44% restenosis rate in patients aged 65 yr or more. These figures do not seem different from those found in younger populations [21]. Percutaneous transluminal coronary in patients older than 80 years
angioplasty
Five studies have assessed coronary angioplasty in patients more than 80 yr old [19,20,22,24]. The primary success rate ranges from 67 to 93%, with a procedural mortality rate ranging from 2 to 19%. The long-term survival rates are satisfactory, ranging from 90% at 1 yr [20] to 75% at 2 yr [19]. Our own data are in accordance with these results, which, considering the severity of the disease in these patients appear quite acceptable. Conclusion
Although the immediate complication rate of coronary angioplasty in elderly patients appears higher than in younger ones, our results suggest that the procedure is quite effective in most patients and brings long-term relief of symptoms with an excellent long-term survival; however, repeat revascularisation procedures are often necessary within 1 yr of the initial angioplasty. Coronary angioplasty appears a valuable therapeutic alternative to coronary bypass surgery in very elderly people suffering from severe angina1 symptoms. References 1 Naunheim KS, Kern MJ, McBride LR, Fiore AC, Willman UL, Kaiser GC. Coronary artery bypass surgery in patients aged 80 years or older. Am J Cardiol 1987;59:804-807. 2 Rose DM, Gelbfisch J. Jacobowitz IJ. Kramer M. Acinapura A, Cunningham JN. Analysis of morbidity and mortality in patients 70 years of age and over undergoing isolated coronary artery bypass surgery. Am Heart J 1985;110:341-346. 3 Imburgia M, King TR, Soffer AO. Rich MW, Krone RJ.
Salimi A. Early results and long-term oucome of percutaneous transluminal coronary angioplasty in patients age 75 years or older. Am J Cardiol 1989;63:1127-1129. 4’ Thompson RC, Holmes DR, Gersh BJ. Mock MB, Bailey KR. Percutaneous transluminal coronary angioplasty in the elderly: early and long term results. J Am Coil Cardiol 1991;17:124s-1250. 5 Simpson JB. Bairn DS, Robert EW, Harrison DC. A new catheter system for coronary angioplasty. Am J Cardiol 1982;49:1216-1222. 6 Bonnier JJRM. Michels HR, El Gamal M. PTCA in patients older than 75 years (abstract). Eur Heart J 1989; 10fsuppl 1):79. F. Iniguez A, Zarco P. Long-term 7 Macaya C. Alfonson clinical and angiographic follow-up of percutaneous transluminal coronary angioplasty in patients 2 65 years of age. Am J Cardiol 1990;66:1513-1515. RR, et al. PTCA in 8 McGrath MA. Peet GI, Mildenberger elderly patients: in-hospital events (abstract). Circulation 1990;82(suppl 3):609. 9 Mills TJ, Smith HC, Vlietstra RE. PTCA in the elderly: results and expectations. Geriatrics 1989;44:71-79. 10 Mock MB. Holmes DR. Vlietstra RE et a!. Percutaneous transluminal coronary angioplasty (percutaneous transluminal coronary angioplasty) in the elderly patient: experience in the NHLBI PTCA registry. Am J Cardiol 1984;53:89C91C. 11 Jung SC, Ligon RM, Webb DL, McCallister BD. Coronary angioplasty in patients over the age of 70: an analysis of early and late results and influence of experience on outcome (abstract). J Am Coil Cardiol 1990;15:34A. R, Simpfendorfer C. Zeiler Arnold A et al. 12 Raymond Coronary angioplasty in the elderly patient: short and longterm results (abstract). J Am Coil Cardiol lY91;17:64A. 13 Ten Berg JM, Bal ET, Tlon RM, Mast EG, Ernst JMPG, Plokker HWM. What is the long term benefit of PTCA in patients over 75 years of age? (abstract). Eur Heart J 1991;12:383. N. Immediate outcome of PTCA in 14 Colle JP. Delarche patients aged 75 years and older, compared with younger (abstract). Eur Heart J 1991;12;382. BD, McConahay DR et al. Re15 Bedotto JB, Rutherford sults of multivessel percutaneous transluminal coronary angioplasty in persons aged 65 years and older. Am J Cardiol 1991:67:1051-1055. 16 Buffet Ph, Danchin N, Villemot JP et al. Early and longterm outcome after emergency coronary artery bypass surgery after failed coronary angioplasty. Circulation 1991:84(suppl 111):254-259. 17 Jenkins GM, Midei MG. Dowger B et al. PTCA in the very elderly: long term follow-up (abstract). Circulation 1990;82(suppI 111):739. 18 De Jaegere P, De Feyter P, Van Domburg R, Suryapranata H. Van den Brand M, Serruys PW. Immediate and long term results of percutaneous coronary angioplasty in patients aged 70 and over. Br Heart J 1992:138-143.
39 19 Good TH, Calkins M, Ligon R, McCallister BD. Hartzler GD. PTCA in the ultra elderly (abstract). Circulation 1987;76(suppl IVb464. 70 Jackman JD, Navetta FI, Smith JE et al. Percutaneous transluminal coronary angioplasty in octogenerians as an effective therapy for angina pectoris. Am J Cardiol 1991:68:116-119. 21 McBride W. Lange RA, Hillis LD. Restenosis after successful coronary angioplasty. N Engl _I Med 1988:318: 1374-1377.
22 Kern MJ. Deligonul U, Galan K et al. Percutaneous transluminal coronary angioplasty in octogenerians. Am J Cardiol 1988;61:457-458. 23 Rizo-Patron C. Hamad N, Paulus R, Garcia J. Beard E. Percutaneous transluminal coronary angioplasty in octogenerians with unstable coronary syndromes. Am J Cardiol 3990;66:857-858. 24 Jeroudi MD, Kleiman NS, Minor ST et al. Percutaneous transluminal coronary angioplasty in octogenerians. Ann Intern Med 1990:113:423-428.
