Results of Multivessel Percutaneous Transluminal Coronary Angioplasty in Persons Aged 65 Years and Older John B. Bedotto, MD, Barry D. Rutherford, MD, David R. McConahay, MD, Warren L. Johnson, MD, Lee V. Giorgi, MD, Thomas M. Shimshak, MD, James H. O’Keefe, MD, Robert W. Ligon, MA, and Geoffrey 0. Hartzler, MD
Between 1981 and lSSO,l,373 patients, aged ~66 years (mean 71.2 f 4.9), underwent 1,640 muttivessei percutaneous transtuminai coronary angioptasty (PTCA) procedures. Df these, 224 patients (13.6%) had a feft ventricufar ejection fraction 140% 412 (26.1%) had prior coronary artery bypass grafting (CABG) and 46 (2.9%) had left main artery diiatation. Df the 1,640 PTCA procedures, 697 were in patients with 2vessel disease and 943 were in patients with 3vessei disease. A mean 3.5 tesions were dilated per patient, with an overall angiographii success rate of 96%. Complete revascutarization was achieved in 667 (62%). A total of 62 patients (3.2%) had a major in-hospital complication: 27 patknts(1.6%)died,24(1.4%) had a Q-wave myocardii infarction, and 14 (0.8%) underwent emergent CABG. Stepwise logistic regression analysts identified ejection fraction 540% (p lO.OOl), 3-vessel disease (p lO.Ol), female gender (p 50.02), and PTCA between 1981 and 1966 (p rO.05) as independent prediiors of 1,373patknts,1,023 have mortalfty.Dfthe been foRowed for 21 year (mean follow-up 32.5 f 21.3 months). There were 166 (15.2%) late deaths,81(7.9%) recucrenf myocardiii intarctions, and 162 (15.8%) coronary artery bypass operatfons. Actuarial survival, computed from the time of hospital discharge, was 92% at 1 year, 86% at 3 years and 78% at 5 years. Repeat PTCA was required in 371 patients (36.3%). Survival was better in those with 2versus3-vesseldisease (p 10.006) and in those with complete versus partial revascularization (p 10.001). These data indiite that muftivessei PTCA is an effective and safe alternative to
From the Mid America Heart Institute, St. Luke’s Hospital, Kansas City, Missouri. Manuscript received October 10, 1990; revised manuscript received January 18, 1991, and accepted January 21. Address for reprints: Geoffrey 0. Hartzler, MD, Medical Plaza II20,432O Wornall Road, Kansas City, Missouri 64111.
CABG in oider patients with symptomatic coronary artery disease. (AmJ Cardid lSS1;67:1061-1065)
he number of elderly patients in the general population with symptomatic coronary artery diseaseis increasing.l The frequency with which coronary artery bypass grafting (CABG) is used to treat ischemic heart diseasein the aged is also increasing.*S Although CABG is effective in relieving angina, enthusiasmhas been tempered by the higher morbidity and mortality in this population.2-18 Because of increasedprocedural risks with CABG in the elderly, percutaneous transluminal coronary angioplasty (PTCA) would be an attractive alternative method for myocardial revascularization. Multivessel dilatation and advanced age, however, also have been shown to increase the risk of PTCA.19y20 Previousreports on PTCA in the elderly have included small numbers of patients who underwent primarily l-vessel dilatation.20-25This report describesthe acute and long-term results of multivessel angioplasty in 1,373 patients 265 years of age over a 1O-year period.
T
METHODS
Since 1981, details of the clinical profile, angiographic results and follow-up of all patients treated with PTCA by a group of cardiologists at the Mid America Heart Institute were prospectivelyentered into a computerized database. All patients 265 years old who underwent PTCA in 2 or 3 major epicardial vessels were identified and included in the study. Only patients undergoing emergency angioplasty for acute myocardial infarction were excluded from analysis. Angioplasty protocok Routine premeditations included 325 mg of oral aspirin (1 to 3/day), 75 mg of oral dipyridamole administered 3 times/day, 5 mg of sublingual isosorbide dinitrate, 75 mg of intravenous lidocaine and 5 mg of intravenous verapamil. After placement of a femoral arterial sheath, 10,000 U of heparin were administered intravenously. An additional Patients
MULTIVESSEL PTCA 1051
TABLE I Patient Characteristics AgesWs)
Total no. of procedures Male gender Mean age (yrs) LVEF 540% Prior CABG Left main PTCA No. of coronary arteries narrowed 270% in diameter
2 3
265
65-69
70-74
75-79
280
1,640 1,147 (70%) 71 224(14%) 412 (25%)
717
517 365 (71%) 72
295 179(61%) 77
111 64 (58%) 82
47(16%)
18(16%)
539 (75%) 67 95 (13%)
64(12%)
48 (3%)
195 (27%) 28 (4%)
140 (27%) 13 (3%)
68 (23%) 5 (2%)
9 (8%) 2 (2%)
697 (43%) 943 (57%)
315(44%) 402 (56%)
229 (44%) 288 (56%)
115 (39%) 180(61%)
38 (34%) 73 (66%)
1,236 (75%) 404 (25%)
539 (75%) 178 (25%)
384 (74%) 133 (26%)
226 (77%) 69 (23%)
87 (78%) 24 (22%)
No. of coronary arteries having F’TCA
2 3 CABG = coronary
artery bypass grafting;
LVEF = left ventricular
ejection fraction;
PTCA = percutaneous
5,000 U of heparin were administered hourly during the angioplasty procedure and continued as an intravenous infusion for 18 to 24 hours after the procedure. A low-molecular-weight dextran infusion was variably used, depending on operator preference.In general, patients continued to receive aspirin, dipyridamole and a calcium channel antagonist for 3 to 6 months. Coronary angioplasty was performed with a variety of over-the-wire and fmed-wire devices. An attempt was made to revascularize all patients completely by dilating all significant potentially bypassable stenoses supplying viable myocardium during a single procedure. Followup: Long-term follow-up data were collected prospectively by office evaluation, mailed questionnaires, and telephone interviews. Definltknsr Multivessel diseasewas defined as a diameter stenosis of 170% in 2 or 3 major epicardial vessels.Dilatation within >2 of the 3 major coronary arteries qualified as multivessel angioplasty. A dilatation was considered successfulif the luminal diameter stenosiswas reduced to 540% in multiple angiographic projections. In-hospital complications included Q-wave myocardial infarction, emergent CABG, procedural TABLE II Complications Ages(~6
Myocardial infarction Urgent CABG Death
Total No. (n = 1,640)
65-69 (n = 717)
70-74
74-79
280
(n = 517)
(n = 295)
(n = 111)
24(1.4%)
9(1.2%)
9(1.7%)
3(1.0%)
3(2.7%)
14 (0.8%)
7 (0.9%)
5 (0.9%)
2 (0.6%)
0 (0.0%)
27 (1.6%)
6 (0.8%)
9 (1.7%)
5 (1.6%)
7 (6.3%)
CABG = coronary
1052
artery bypass grafting;
THE AMERICAN
JOURNAL
No. = number of procedures.
OF CARDIOLOGY
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67
transluminal
coronary
angioplasty.
death or in-hospital death related to the performanceof the angioplasty procedure. Statistical analysis: All data are expressedas the mean f 1 standard deviation. Stepwise logistic regression analysis was used to identify variables that correlated with in-hospital complications. Long-term and event-free survival were computed from the time of hospital discharge with the Kaplan-Meier actuarial method. RESULTS clinkal duuacteristksr Between January 1981 and July 1990, 1,373 patients aged 265 years underwent 1,640 elective multivessel angioplasties. Clinical and angiographic characteristics are listed in Table I. This group included 224 patients (13.6%) with poor left ventricular function (ejection fraction 80 years), prior CABG, diabetes, poor left ventricular function, left main coronary artery disease,number of diseased vessels(2 versus3), years during which PTCA was performed (1981 to 1985, 1986 to 1990) and unstable angina. Poor left ventricular function (p SO.OOl), 3-vessel disease(p lO.Ol), female gender (p 50.02) and performance of the PTCA procedure between 1981 and 1985 (p 50.05) were independent predictors of mortality. Unstable angina (p = 0.07) and the absence of prior CABG (p = 0.08) approached statistical sign& cance as predictors of in-hospital mortality. Follow-up (Fire 1): In 1,206of the 1,373 patients, > 1 year had lapsed from the time of their PTCA. Of these, 183 (15%) were lost to follow-up, leaving 1,023 hospital survivors for analysis. During follow-up (mean 32.5 f 21.3 months), there were 8 1 (7.9%) myocardial infarctions (mean time to infarction, 20.3 f 23.1 months), 162 (15.8%) coronary artery bypassprocedures(mean time to CABG, 12.2 f
,
11
TABLE III Complications
in “High-Risk”
Subsets
t
14.6 months) and 156 (15.2%) deaths. Repeat PTCA was required in 371 patients (36.3%) at 10.9 f 15.4 months. There were 172 PTCA proceduresfor restenosis alone, 120 for both restenosisand diseaseprogression at sites not previously dilated, 37 for disease progressionalone, 17 for patients undergoing a staged procedure, and 4 for acute closure. Twenty-one patients underwent repeat PTCA at other institutions for unknown reasons.A repeat revascularization procedure (PTCA or CABG) was required in 463 patients (45.3%). Angina1 status was New York Heart Association class I or II in 77% and class III or IV in 23% at the time of last follow-up. Actuarial survival was 92% at 1 year, 86% at 3 years and 78% at 5 years. Event-free survival (free of myocardial infarction, CABG or death) was 81% at 1 year, 69% at 3 years and 56% at 5 years. Patients with 3- versus 2-vesselcoronary artery disease(p rO.008) and incomplete versuscomplete (p ~0.001) revascularization had poorer long-term survival rates. DISCUSSION
The average life expectancy in the United States is increasing. By 1987, 12.2% of the population was >65 years of age and, by 1990, 3.0% (7.4 million) were ->80 years old.26Approximately 50 to 60% of persons
100 90 30 70 s 60 5 ; 60 (d * 40 30 20 10 0 0
U
12
13
24
30
36
42
43
64
80
ml.
flGUREl.ActwuidswhdofpathtsfohmdLlyem (A).Ewnt+ee~umdvalofpathtsfolowd
21 yew(B).
MULTIVESSEL F’TCA 1053
TABLE IV Coronary Artery Bypass Grafting in the Elderly: Morbidity and Mortality Hosp. F-k.
Mean Age bwe)
222 88 60 5,070 674 38 597 1,086 75
77 (75-88) 75 78 (75-86) 165 73 82 (80-89) 73 (70-87) 68 (65-84) 72 (70-79)
No. of Reference
Year
Horvath et al4
1990 1989 1988 1988 1987 1986 1985 1983 1982
Grondin et al5 Rich et al* Loop et al3 Dorros et allo Tsai et aI” Montague et aI2 Gersh et all4 Hochberget alI5 CVA = cerebrovascular
accident;
Hosp. = hospital;
MI = myocardial
infarction;
CABG.*,3,‘1,14
PTCA has been an increasingly used method of revascularizing the elderly. In addition to advanced age, other clinical variables noted more frequently in the elderly, such as depressedleft ventricular function, left main coronary artery diseaseand 3-vesseldisease,also increase the risk of PTCA.19 This report demonstrates that technical successrates (96%) in the elderly are comparable to those of multivessel PTCA in younger patients.28-3* Additionally, despite a large number of patients with depressed left ventricular function (13.6%), prior CABG (25.1%) and left main artery dilatation (2.9%), multivessel PTCA can be performed with relatively low morbidity and mortality rates in patients 165 years old. When PTCA is performed in patients aged 280 years, however, the risk of death and myocardial infarction increasessubstantially. In elderly patients undergoing multivessel PTCA, poor left ventricular function, 3-vesseldiseaseand female gender were identified as independent predictors of procedural and in-hospital mortality. Becausethe incidence of depressedleft ventricular function, 3-vessel disease and female gender also increased as age increased, increasing age itself did not adversely affect survival. When compared with younger patients, however, age 170 years has been shown to increaseprocedural mortality.31 Unstable angina (p = 0.07) and the THE AMERICAN
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OF CARDIOLOGY
VOLUME
10.8 10.2 3.3 2.3 7.4 5.2 2.7 5.2 12
4.1 3 5 1 7.1 0 1.5 5
CVA (%)
Reop. (W
Stay (days)
2.3 6.8 0 2.7 4.2 2 2 2.7
-
10 11 12 23 11 13 18
5 5 5 3.6 12 3.5 5.3
Reap. = reoperation.
>65 have coronary artery diseaseand constitute most patients hospitalized for acute myocardial infarction.1~27 Elderly Americans represent an increasing proportion of patients undergoing CABG in the United States2J In the last decade,severalstudies have reported on the morbidity and mortality of CABG in the elderly.2-18The risk of death in older patients undergoing CABG in the last 10 years ranges from 2.3 to 12% (Table IV). The risk of serious complication ranges from 14 to 65%. Although the elderly have a higher incidence of left main and 3-vesselcoronary artery disease,depressedleft ventricular function and associated medical illnesses,age has been shown to be an independent risk factor for morbidity and mortality after
1054
Mortality cw
67
absenceof prior CABG (p = 0.08) may also increase the risk of multivesselPTCA in the elderly.32Multivesse1PTCA performed during the first 5 years of operator experience was also found to influence outcome adversely; this change was likely due to increasing operator experience and improvements in angioplasty technology. FoMow-up: Although 36% of patients required a repeat PTCA, only 16% ultimately required CABG, and most patients (77%) had New York Heart Association class I or II angina at last follow-up. In addition, although this study involved a large number of high-risk patients, actuarial survival rates of 92% and 78% at 1 and 5 years, respectively, are similar to those reported for elderly patients undergoing CABG.4Ji*33 The number of diseasedvesselsand the degree of revascularization had an important effect on long-term survival. The importance of complete revascularization after CABG is well documented.34v35 Reports on the clinical importance of complete revascularization after PTCA are conflicting. Previousstudieshave shown that if revascularization is only partial after multivessel PTCA, the frequency of recurrent angina and the need for CABG increases.28-31 Our data demonstrate that the ability to provide complete revascularization importantly influences long-term survival after multivessel PTCA as well. CiinicaI impIieatiensr These data indicate that multivessel PTCA is a safe and effective alternative to CABG for the treatment of elderly patients with symptomatic coronary artery disease.In addition to the lower morbidity and mortality rates when PTCA is compared with CABG, a shorter duration of hospitalization and decreasedcost are additional advantages.36 Study limitations: This is a nonrandomized, consecutive caseanalysis of a large number of elderly patients who underwent multivessel PTCA at a single institution. Although a direct comparison with surgical results cannot be made, these data suggest that future randomized trials comparing CABG to PTCA should not exclude elderly patients. In addition, 15% of patients MAY 15, 1991
were lost to follow-up over the lo-year period, which may have influenced our long-term results. Acknowkdgmdz We gratefully acknowledge Susan Spaude for help in data collection and collation, and Kelly Williams for help in preparation of the manuscript.
19. Hartzler GO, Rutherford BD, McConahay DR, JohnsonWL, Giorgi LV. “High risk” percutaneoustransluminal coronary angioplasty. Am J Cordial 1988;61:33G-37G. 20. Mock MB, Holmes DR Jr, Vlietstra RE, Gersch BJ, Detre KM, Kelsey SF, OrszulakTA, Schaff HV, PiehlerJM, Van RadenMJ, PassamaniER, Kent KM, Gruentzig AR. Percutaneoustransluminal coronary angioplasty (PTCA) in the elderly patient: experience in the National Heart, Lung, and Blood Institute Pf’CA registry. Am J Cordial 1984;53:89C-91C. 21. Rich JJ, Crispino CM, Saporito JJ, Domat I, Cooper WM. Percutaneous transluminal coronary angioplasty in patients 80 years of age and older. Am J Cordial 1990;65:675-676.
REFERENCES 1. Moritz DJ, Ostfeld AM. The epidemiology and demography of aging. In: Hazzard WR, Andrea R, Bierman EL, Blass JP, eds. Principles of Geriatric Medicine and Gerontology. New York: McGraw Hill, 1990:146-156. 2. Montague NT III, KouchoukcsNT, Wilson TAS, BennettAL III, Knott HW, Lochridge SK, Erath HG Jr, Clayton OW. Morbidity and mortality of coronary bypass grafting in patients 70 years of age and older. Ann Thoroc Surg 1985;39:552-557. 3. Loop FD, Lytle BW, CcsgroveDM, GoormasticM, Taylor PC, Gelding LAR, Stewart RW, Gill CC. Coronary artery bypassgraft surgery in the elderly. Clew Clin J Med 1988;55:23-34.
4. Horvath KA, DiSeaa VJ, Peigh PS, Couper GS, Collins JJ Jr, Cohn LH. Favorable results of coronary bypassgrafting in patients older than 75 years. J Thoroc Cordkwosc Surg 1990;99:92-96.
5. Grondin CM, Thornton JC, EngleJC, SchreiberH, CrossFS. Cardiic surgery in septuagenarians:is there a difference in mortality and morbidity? J Thoroc Cwdiouosc Surg 1989;98:908-914. 6. Naunhein KS, Kern MJ, McBride LR, PenningtonDC, Barrier HB, Kanter KR, Fiore AC, Willman VL, Kaiir CC. Coronary artery bypass surgery in patients aged 80 years or older. Am J Cordiol 1987;59:804-807. 7. EdmundsLH Jr, StephensonLW, Edie RN, Ratcliffe MB. Open-heart surgery in octogenarians.N Engl J Med 1988;319:131-136. 8. Rich MW, Keller AJ, SchechtmanKB, Marshall WC Jr, KouchoukosNT. Morbidity and mortality of coronary artery bypasssurgery in patients75 yearsof age or older. Ann Thoroc Surg 1988;46:638-644. 9. Saklanha RF, Raman J, EsmoreDS, Spratt PM, Farnsworts AE, Chang VP, ShanahanMX. Myocardial revascularisationin patientsover seventyfive years.J Cardicuasc Surg 1988;29:624-628.
10. Dorms G, Lewin RF, Daley P, Assa J. Coronary artery bypasssurgery in patientsover age 70 years: report from the Milwaukee cardiovasculardata registry. Clin Cordial 1981;10:377-382. 11. Homeffer PJ, Gardner TJ, Manolio TA, Hoff SJ, Rykiel MF, PearsonTA, Gott VL, BaumgartnerWA, Borkon AM, Watkins L, Reitz BA. The effect of age on outcome after coronary bypass surgery. Circulation 1987;76(supplV): V-6-V- 12. 12. Tsai TP, Matloff JM, Gray RJ, Chaux A, Kass RM, Lee ME, Czer LSC. Cardiac surgery in the octogenarian. J Thoroc Cordiouarc Surg 1986;91: 924-928. 13. Ennabli K, Pelletier LC. Morbidity and mortality of coronary artery surgery after the age of 70 years. Ann Thoroc Surg 1986;42:197-200.
14. Gersh BJ, Kronmal RA, Frye RL, Schaff HV, Ryan TJ, GossclinAJ, Kaiser CC, Killip T 3d. Coronary arteriography and coronary bypasssurgery:morbidity and mortality in patients ages 65 years or older. A report from the Coronary Artery Surgery Study. Circulation 1983;67:483-491. 15. Hochberg MS, Levine FH, Daggett WM. Akins CW, Austen WC, Buckley MJ. Isolated coronary artery bypassgrafting in patientsseventyyears of age and older: early and late results. J Thoroc Cordiovosc Surg 1982;84:219-223. 16. Hamby RI, Wisoff BG, Kolker P, Hartatein M. Intractable anginapectorisin the 65 to 79 year age group: a surgical approach. Chest 1973;64:46-50. 17. Garcia JM, Cheanvechai C, Effler DB. Myocardial revasculariaation in patients aged 65 and older. Cordiouasc C/in 1975:7:83-91. 18. Smith JM, Lindsay WC, Lillehei RC, Nicoloff DM. Cardiac surgery in geriatric patients. Surgery 1976;80:443-448.
22. Holt GW, Sugrue DD, BresnahanJF, Vhetstra RE, BresnahanDR, Reeder GS, Holmes DR Jr. Resultsof percutaneoustransluminal coronary angioplasty for unstableangina pectoris in patients 70 years of age and older. Am J Cordial 1988;61:994-997. 23. Simpfendorfer C, RaymondR, SchraiderJ, Badhwar K, Dorosti K, France I,
Hollman J, Whitlow P. Early and long-term resultsof percutaneoustransluminal coronary angioplasty in patients 70 years of age and older with angina pectoris. Am J Cordial 1988;62:959-961.
24. Dorms G, Lewin RF, Mathiak LM. Percutaneoustransluminal coronary angioplasty in patients over the age of 70 years. Cordiol Clin 1989;7:805-812. 25. Kern MJ, Deligonul U, Galan K, Zelman R, Gabliani G, Bell ST, Bodet J, Naunheim K, VandormaelM. Percutaneoustransluminalcoronary angioplastyin octogenarians.Am J Cordiol 1988;61:457-458. 26. Bureau of Census.United Statespopulation estimates,by age,sex,and race: 1980-1987.Current populationreports.SeriesP-25,no. 1022.Washington,DC.: Government Printing Oflice, 1988. 27. Wenger NK, Furberg CD, Pitt E. Coronary heart diseasein the elderly: review of current knowledge and research recommendations.In: Wenger NK, Furberg CD, Pitt E, eds. Coronary Heart Diseasein the Elderly. New York: Elsevier SciencePublishing, 1986:l-7. 28. Mabin TA, Holmes DR Jr, Smith HC, Vlietstra RE, Rccder GS, Bresnahan JF, Bove AA, Hammer LN, Elveback LR, Orszulak TA. Follow-up clinical results in patients undergoingpercutaneoustransluminal coronary angioplasty. Circulation 1985;71:754-760. 29. Deligonul U, Vandormael MC, Kern MJ, Zelman R, Galan K, Chaitman BR. Coronary angioplasty:a therapeuticoption for symptomaticpatientswith two and three vesselcoronary disease.J Am Co11 Cordiol 1988;l I:1 173-l 179. 30. Finci L, Meier B. De Bruyne R, Steffenino G, Divernois J, RutishauserW. Angiographic follow-up after multivessel percutaneoustransluminal coronary angioplasty.Am J Cordial 1987;60:467-470. 31. O’Keefe JH Jr, Rutherford BD, McConahay DR. JohnsonWL Jr, Giorgi LV, Ligon RW, ShimshakTM, Hartzler GO. Multivessel coronary angioplasty from 1980to 1989:proceduralresultsand long-termoutcome.J Am Co11Cordial 1990;16:1097-1102. 32. de Feyter PJ, Suryapranata H, Serruys PW, Beatt K, van Domburg R, van den Brand M, Tijssen JJ, Azar AJ, Hugenholtz PG. Coronary angioplasty for unstable angina: immediate and late results in 200 consecutivepatients with identification of risk factors for unfavorable early and late outcome.J Am Coil Cardiol 1988;12:324-333. 33. Gersh BJ, Kronmal RA, Schaff HV, Frye RL, Ryan TJ, Mock MB, Myers WO, Athearn MW, GosselinAJ, Kaiser CC, BourassaMC, Killip T III, and the Participants in the Coronary Artery Surgery Study. Comparison of coronary artery bypasssurgery and medical therapy in patients65 years of ageor older. A nonrandomizedstudy from the Coronary Artery Surgery Study (CASS) registry. N Engl J Med 1985;313:217-224. 34. JonesEL, Craver JM, Guyton RA, BoneDK, Hatcher CR Jr, Ricchwald N. Importanceof completerevascularizationin performanceof the coronary bypass operation. Am J Cordial 1983;51:7-12. 35. Laurie GM, Morris CC Jr, Silvers A, Wagner WF, Baron AE, Beltangady SS, GlaeserDH, ChapmanDW. The influence of residual diseaseafter coronary artery bypasson the S-yearsurvival rate of 1274menwith coronary artery disease. Circulation 1982;66:717-723. 36. ReederGS, Krishan I, Nobrega FT. NaessensJ, Kelly M, ChristiansonJB, McAfec MK. Is percutaneouscoronary angioplasty less expensivethan bypass surgery? N Engl J Med 1984;311:1157-1162.
MULTIVESSEL F’TCA 1055
Between 1981 and lSSO,l,373 patients, aged ~66 years (mean 71.2 f 4.9), underwent 1,640 muttivessei percutaneous transtuminai coronary angioptasty (PTCA) procedures. Df these, 224 patients (13.6%) had a feft ventricufar ejection fraction 140% 412 (26.1%) had prior coronary artery bypass grafting (CABG) and 46 (2.9%) had left main artery diiatation. Df the 1,640 PTCA procedures, 697 were in patients with 2vessel disease and 943 were in patients with 3vessei disease. A mean 3.5 tesions were dilated per patient, with an overall angiographii success rate of 96%. Complete revascutarization was achieved in 667 (62%). A total of 62 patients (3.2%) had a major in-hospital complication: 27 patknts(1.6%)died,24(1.4%) had a Q-wave myocardii infarction, and 14 (0.8%) underwent emergent CABG. Stepwise logistic regression analysts identified ejection fraction 540% (p lO.OOl), 3-vessel disease (p lO.Ol), female gender (p 50.02), and PTCA between 1981 and 1966 (p rO.05) as independent prediiors of 1,373patknts,1,023 have mortalfty.Dfthe been foRowed for 21 year (mean follow-up 32.5 f 21.3 months). There were 166 (15.2%) late deaths,81(7.9%) recucrenf myocardiii intarctions, and 162 (15.8%) coronary artery bypass operatfons. Actuarial survival, computed from the time of hospital discharge, was 92% at 1 year, 86% at 3 years and 78% at 5 years. Repeat PTCA was required in 371 patients (36.3%). Survival was better in those with 2versus3-vesseldisease (p 10.006) and in those with complete versus partial revascularization (p 10.001). These data indiite that muftivessei PTCA is an effective and safe alternative to
From the Mid America Heart Institute, St. Luke’s Hospital, Kansas City, Missouri. Manuscript received October 10, 1990; revised manuscript received January 18, 1991, and accepted January 21. Address for reprints: Geoffrey 0. Hartzler, MD, Medical Plaza II20,432O Wornall Road, Kansas City, Missouri 64111.
CABG in oider patients with symptomatic coronary artery disease. (AmJ Cardid lSS1;67:1061-1065)
he number of elderly patients in the general population with symptomatic coronary artery diseaseis increasing.l The frequency with which coronary artery bypass grafting (CABG) is used to treat ischemic heart diseasein the aged is also increasing.*S Although CABG is effective in relieving angina, enthusiasmhas been tempered by the higher morbidity and mortality in this population.2-18 Because of increasedprocedural risks with CABG in the elderly, percutaneous transluminal coronary angioplasty (PTCA) would be an attractive alternative method for myocardial revascularization. Multivessel dilatation and advanced age, however, also have been shown to increase the risk of PTCA.19y20 Previousreports on PTCA in the elderly have included small numbers of patients who underwent primarily l-vessel dilatation.20-25This report describesthe acute and long-term results of multivessel angioplasty in 1,373 patients 265 years of age over a 1O-year period.
T
METHODS
Since 1981, details of the clinical profile, angiographic results and follow-up of all patients treated with PTCA by a group of cardiologists at the Mid America Heart Institute were prospectivelyentered into a computerized database. All patients 265 years old who underwent PTCA in 2 or 3 major epicardial vessels were identified and included in the study. Only patients undergoing emergency angioplasty for acute myocardial infarction were excluded from analysis. Angioplasty protocok Routine premeditations included 325 mg of oral aspirin (1 to 3/day), 75 mg of oral dipyridamole administered 3 times/day, 5 mg of sublingual isosorbide dinitrate, 75 mg of intravenous lidocaine and 5 mg of intravenous verapamil. After placement of a femoral arterial sheath, 10,000 U of heparin were administered intravenously. An additional Patients
MULTIVESSEL PTCA 1051
TABLE I Patient Characteristics AgesWs)
Total no. of procedures Male gender Mean age (yrs) LVEF 540% Prior CABG Left main PTCA No. of coronary arteries narrowed 270% in diameter
2 3
265
65-69
70-74
75-79
280
1,640 1,147 (70%) 71 224(14%) 412 (25%)
717
517 365 (71%) 72
295 179(61%) 77
111 64 (58%) 82
47(16%)
18(16%)
539 (75%) 67 95 (13%)
64(12%)
48 (3%)
195 (27%) 28 (4%)
140 (27%) 13 (3%)
68 (23%) 5 (2%)
9 (8%) 2 (2%)
697 (43%) 943 (57%)
315(44%) 402 (56%)
229 (44%) 288 (56%)
115 (39%) 180(61%)
38 (34%) 73 (66%)
1,236 (75%) 404 (25%)
539 (75%) 178 (25%)
384 (74%) 133 (26%)
226 (77%) 69 (23%)
87 (78%) 24 (22%)
No. of coronary arteries having F’TCA
2 3 CABG = coronary
artery bypass grafting;
LVEF = left ventricular
ejection fraction;
PTCA = percutaneous
5,000 U of heparin were administered hourly during the angioplasty procedure and continued as an intravenous infusion for 18 to 24 hours after the procedure. A low-molecular-weight dextran infusion was variably used, depending on operator preference.In general, patients continued to receive aspirin, dipyridamole and a calcium channel antagonist for 3 to 6 months. Coronary angioplasty was performed with a variety of over-the-wire and fmed-wire devices. An attempt was made to revascularize all patients completely by dilating all significant potentially bypassable stenoses supplying viable myocardium during a single procedure. Followup: Long-term follow-up data were collected prospectively by office evaluation, mailed questionnaires, and telephone interviews. Definltknsr Multivessel diseasewas defined as a diameter stenosis of 170% in 2 or 3 major epicardial vessels.Dilatation within >2 of the 3 major coronary arteries qualified as multivessel angioplasty. A dilatation was considered successfulif the luminal diameter stenosiswas reduced to 540% in multiple angiographic projections. In-hospital complications included Q-wave myocardial infarction, emergent CABG, procedural TABLE II Complications Ages(~6
Myocardial infarction Urgent CABG Death
Total No. (n = 1,640)
65-69 (n = 717)
70-74
74-79
280
(n = 517)
(n = 295)
(n = 111)
24(1.4%)
9(1.2%)
9(1.7%)
3(1.0%)
3(2.7%)
14 (0.8%)
7 (0.9%)
5 (0.9%)
2 (0.6%)
0 (0.0%)
27 (1.6%)
6 (0.8%)
9 (1.7%)
5 (1.6%)
7 (6.3%)
CABG = coronary
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transluminal
coronary
angioplasty.
death or in-hospital death related to the performanceof the angioplasty procedure. Statistical analysis: All data are expressedas the mean f 1 standard deviation. Stepwise logistic regression analysis was used to identify variables that correlated with in-hospital complications. Long-term and event-free survival were computed from the time of hospital discharge with the Kaplan-Meier actuarial method. RESULTS clinkal duuacteristksr Between January 1981 and July 1990, 1,373 patients aged 265 years underwent 1,640 elective multivessel angioplasties. Clinical and angiographic characteristics are listed in Table I. This group included 224 patients (13.6%) with poor left ventricular function (ejection fraction 80 years), prior CABG, diabetes, poor left ventricular function, left main coronary artery disease,number of diseased vessels(2 versus3), years during which PTCA was performed (1981 to 1985, 1986 to 1990) and unstable angina. Poor left ventricular function (p SO.OOl), 3-vessel disease(p lO.Ol), female gender (p 50.02) and performance of the PTCA procedure between 1981 and 1985 (p 50.05) were independent predictors of mortality. Unstable angina (p = 0.07) and the absence of prior CABG (p = 0.08) approached statistical sign& cance as predictors of in-hospital mortality. Follow-up (Fire 1): In 1,206of the 1,373 patients, > 1 year had lapsed from the time of their PTCA. Of these, 183 (15%) were lost to follow-up, leaving 1,023 hospital survivors for analysis. During follow-up (mean 32.5 f 21.3 months), there were 8 1 (7.9%) myocardial infarctions (mean time to infarction, 20.3 f 23.1 months), 162 (15.8%) coronary artery bypassprocedures(mean time to CABG, 12.2 f
,
11
TABLE III Complications
in “High-Risk”
Subsets
t
14.6 months) and 156 (15.2%) deaths. Repeat PTCA was required in 371 patients (36.3%) at 10.9 f 15.4 months. There were 172 PTCA proceduresfor restenosis alone, 120 for both restenosisand diseaseprogression at sites not previously dilated, 37 for disease progressionalone, 17 for patients undergoing a staged procedure, and 4 for acute closure. Twenty-one patients underwent repeat PTCA at other institutions for unknown reasons.A repeat revascularization procedure (PTCA or CABG) was required in 463 patients (45.3%). Angina1 status was New York Heart Association class I or II in 77% and class III or IV in 23% at the time of last follow-up. Actuarial survival was 92% at 1 year, 86% at 3 years and 78% at 5 years. Event-free survival (free of myocardial infarction, CABG or death) was 81% at 1 year, 69% at 3 years and 56% at 5 years. Patients with 3- versus 2-vesselcoronary artery disease(p rO.008) and incomplete versuscomplete (p ~0.001) revascularization had poorer long-term survival rates. DISCUSSION
The average life expectancy in the United States is increasing. By 1987, 12.2% of the population was >65 years of age and, by 1990, 3.0% (7.4 million) were ->80 years old.26Approximately 50 to 60% of persons
100 90 30 70 s 60 5 ; 60 (d * 40 30 20 10 0 0
U
12
13
24
30
36
42
43
64
80
ml.
flGUREl.ActwuidswhdofpathtsfohmdLlyem (A).Ewnt+ee~umdvalofpathtsfolowd
21 yew(B).
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TABLE IV Coronary Artery Bypass Grafting in the Elderly: Morbidity and Mortality Hosp. F-k.
Mean Age bwe)
222 88 60 5,070 674 38 597 1,086 75
77 (75-88) 75 78 (75-86) 165 73 82 (80-89) 73 (70-87) 68 (65-84) 72 (70-79)
No. of Reference
Year
Horvath et al4
1990 1989 1988 1988 1987 1986 1985 1983 1982
Grondin et al5 Rich et al* Loop et al3 Dorros et allo Tsai et aI” Montague et aI2 Gersh et all4 Hochberget alI5 CVA = cerebrovascular
accident;
Hosp. = hospital;
MI = myocardial
infarction;
CABG.*,3,‘1,14
PTCA has been an increasingly used method of revascularizing the elderly. In addition to advanced age, other clinical variables noted more frequently in the elderly, such as depressedleft ventricular function, left main coronary artery diseaseand 3-vesseldisease,also increase the risk of PTCA.19 This report demonstrates that technical successrates (96%) in the elderly are comparable to those of multivessel PTCA in younger patients.28-3* Additionally, despite a large number of patients with depressed left ventricular function (13.6%), prior CABG (25.1%) and left main artery dilatation (2.9%), multivessel PTCA can be performed with relatively low morbidity and mortality rates in patients 165 years old. When PTCA is performed in patients aged 280 years, however, the risk of death and myocardial infarction increasessubstantially. In elderly patients undergoing multivessel PTCA, poor left ventricular function, 3-vesseldiseaseand female gender were identified as independent predictors of procedural and in-hospital mortality. Becausethe incidence of depressedleft ventricular function, 3-vessel disease and female gender also increased as age increased, increasing age itself did not adversely affect survival. When compared with younger patients, however, age 170 years has been shown to increaseprocedural mortality.31 Unstable angina (p = 0.07) and the THE AMERICAN
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10.8 10.2 3.3 2.3 7.4 5.2 2.7 5.2 12
4.1 3 5 1 7.1 0 1.5 5
CVA (%)
Reop. (W
Stay (days)
2.3 6.8 0 2.7 4.2 2 2 2.7
-
10 11 12 23 11 13 18
5 5 5 3.6 12 3.5 5.3
Reap. = reoperation.
>65 have coronary artery diseaseand constitute most patients hospitalized for acute myocardial infarction.1~27 Elderly Americans represent an increasing proportion of patients undergoing CABG in the United States2J In the last decade,severalstudies have reported on the morbidity and mortality of CABG in the elderly.2-18The risk of death in older patients undergoing CABG in the last 10 years ranges from 2.3 to 12% (Table IV). The risk of serious complication ranges from 14 to 65%. Although the elderly have a higher incidence of left main and 3-vesselcoronary artery disease,depressedleft ventricular function and associated medical illnesses,age has been shown to be an independent risk factor for morbidity and mortality after
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absenceof prior CABG (p = 0.08) may also increase the risk of multivesselPTCA in the elderly.32Multivesse1PTCA performed during the first 5 years of operator experience was also found to influence outcome adversely; this change was likely due to increasing operator experience and improvements in angioplasty technology. FoMow-up: Although 36% of patients required a repeat PTCA, only 16% ultimately required CABG, and most patients (77%) had New York Heart Association class I or II angina at last follow-up. In addition, although this study involved a large number of high-risk patients, actuarial survival rates of 92% and 78% at 1 and 5 years, respectively, are similar to those reported for elderly patients undergoing CABG.4Ji*33 The number of diseasedvesselsand the degree of revascularization had an important effect on long-term survival. The importance of complete revascularization after CABG is well documented.34v35 Reports on the clinical importance of complete revascularization after PTCA are conflicting. Previousstudieshave shown that if revascularization is only partial after multivessel PTCA, the frequency of recurrent angina and the need for CABG increases.28-31 Our data demonstrate that the ability to provide complete revascularization importantly influences long-term survival after multivessel PTCA as well. CiinicaI impIieatiensr These data indicate that multivessel PTCA is a safe and effective alternative to CABG for the treatment of elderly patients with symptomatic coronary artery disease.In addition to the lower morbidity and mortality rates when PTCA is compared with CABG, a shorter duration of hospitalization and decreasedcost are additional advantages.36 Study limitations: This is a nonrandomized, consecutive caseanalysis of a large number of elderly patients who underwent multivessel PTCA at a single institution. Although a direct comparison with surgical results cannot be made, these data suggest that future randomized trials comparing CABG to PTCA should not exclude elderly patients. In addition, 15% of patients MAY 15, 1991
were lost to follow-up over the lo-year period, which may have influenced our long-term results. Acknowkdgmdz We gratefully acknowledge Susan Spaude for help in data collection and collation, and Kelly Williams for help in preparation of the manuscript.
19. Hartzler GO, Rutherford BD, McConahay DR, JohnsonWL, Giorgi LV. “High risk” percutaneoustransluminal coronary angioplasty. Am J Cordial 1988;61:33G-37G. 20. Mock MB, Holmes DR Jr, Vlietstra RE, Gersch BJ, Detre KM, Kelsey SF, OrszulakTA, Schaff HV, PiehlerJM, Van RadenMJ, PassamaniER, Kent KM, Gruentzig AR. Percutaneoustransluminal coronary angioplasty (PTCA) in the elderly patient: experience in the National Heart, Lung, and Blood Institute Pf’CA registry. Am J Cordial 1984;53:89C-91C. 21. Rich JJ, Crispino CM, Saporito JJ, Domat I, Cooper WM. Percutaneous transluminal coronary angioplasty in patients 80 years of age and older. Am J Cordial 1990;65:675-676.
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22. Holt GW, Sugrue DD, BresnahanJF, Vhetstra RE, BresnahanDR, Reeder GS, Holmes DR Jr. Resultsof percutaneoustransluminal coronary angioplasty for unstableangina pectoris in patients 70 years of age and older. Am J Cordial 1988;61:994-997. 23. Simpfendorfer C, RaymondR, SchraiderJ, Badhwar K, Dorosti K, France I,
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