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[Treatment of refractory unstable angina by transluminal coronary angioplasty]
V Baladier1, J P Metzger, C Le Feuvre
1Clinique cardiologique, hôpital Necker, Paris.
Insights
Percutaneous transluminal coronary angioplasty (PTCA) is valuable for refractory unstable angina but has higher acute risks. Long-term outcomes are similar to medically controlled cases, highlighting the importance of managing in-hospital complications.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Unstable angina refractory to maximal medical therapy presents a significant clinical challenge.
- Percutaneous transluminal coronary angioplasty (PTCA) is a potential intervention for such cases.
- Comparing outcomes of PTCA in refractory versus medically controlled unstable angina is crucial for treatment guidance.
Purpose of the Study:
- To evaluate the efficacy and safety of PTCA in patients with unstable angina resistant to medical treatment.
- To compare the results of PTCA in refractory unstable angina with those in medically controlled unstable angina.
- To identify prognostic factors associated with refractory unstable angina.
Main Methods:
- Retrospective study comparing 30 patients undergoing emergency PTCA for refractory unstable angina (Group I) with 30 medically controlled unstable angina patients (Group II).
- Patients were paired for age and dilated artery.
- Clinical and angiographic features, including left ventricular ejection fraction, lesion morphology (Ambrose classification, TIMI grading), and calcification, were analyzed.
Main Results:
- Angiographic characteristics were comparable between groups, except for a higher incidence of filling defects in Group I (30% vs. 10%).
- Group I experienced significantly more per-PTCA complications, including acute occlusions (23% vs. 13%), with higher in-hospital mortality and myocardial infarction rates.
- Long-term rates of restenosis, myocardial infarction, and death were similar between groups (average follow-up: 27 months).
Conclusions:
- Refractory unstable angina carries a poor prognosis primarily due to in-hospital morbidity.
- The presence of "filling defects" indicates a thrombotic process and is a poor prognostic factor.
- PTCA is a valuable treatment option for refractory unstable angina, but requires careful management of acute complications, potentially improved by advanced antithrombotic therapies.
Abstract:
The aim of this retrospective study was to assess the value of percutaneous transluminal coronary angioplasty (PTCA) in unstable angina refractory to maximal medical therapy. The results of this procedure in these patients were compared with the results in unstable angina controlled by medication before angioplasty. Between january 1987 and january 1993, 30 patients underwent emergency PTCA for refractory unstable angina (group I). The clinical and angiographic features were compared with these of 30 patients with medically controlled unstable angina, paired for age and dilated artery (group II). The left ventricular ejection fraction was compared in the two groups (58 and 57%). The morphology of the coronary lesions according to the Ambrose classification, TIMI grading, number of lesions, degree of stenosis and severity of coronary calcification were comparable in the two groups. However, in group I, there was a significantly higher number of filling defects (30% compared with 10%, p = 0.05) and a greater number of per-PTCA complications, especially acute occlusions (23 compared with 13%, NS) with 3 deaths and 2 myocardial infarctions (compared with 1 death and 2 myocardial infarctions in group II). At long term, the restenosis, myocardial infarction and secondary death rates were comparable in the two groups with an average follow-up of 27 +/- 18 months. The poor prognosis of refractory unstable angina is therefore related to morbidity in the hospital period. These results confirm the physiopathological importance of the thrombotic process in unstable angina; the presence of "filling defect" is a poor prognostic factor associated with resistance to medical therapy. Coronary angioplasty is a valuable technique in this context but carries a higher risk of acute complications which can be reduced by an optimal platelet antiaggregant and anticoagulant therapy and in future by the use of new antithrombotic agents.