Unprotected
left main stem stenting in elderly patients
Ajay Jain, Jonathan Hill
St Bartholomew’s Hospital and London Chest Hospital, London, UK
Correspondence: Dr Jonathan Hill, St Bartholomew’s Hospital,
London,
UK.
E-mail: hillj@nhlbi.nih.gov
Introduction
We present a case which outlines the management decisions regarding
coronary revascularization in elderly patients with chronic symptomatic
coronary artery disease. We discuss the implications of ischemia-guided
revascularization and aggressive percutaneous strategies in patients
with concomitant noncardiac risk factors.
Case
An 84-year-old Caucasian woman presented with a 9-month history
of CCS class 3 angina. Apart from her age, her only cardiac risk
factor was hyperlipidemia, which was well controlled on hMG-CoA
reductase therapy. Medication at the time of presentation included
bisoprolol, amlodipine, isosorbide dinitrate, and atorvastatin.
Despite this treatment her symptoms were severely limiting her
normal daily activities.
Pertinent medical history included severe cervical and thoracic
osteoarthritis associated with moderate kyphoscoliosis, and continued
warfarin therapy for recurrent deep venous thrombosis. She was
also treated for hypothyroidism. Initial examination confirmed
kyphoscoliosis with severely reduced movements of the cervical
spine with limited flexion and extension. Cardiovascular examination
was unremarkable; respiratory examination, however, revealed poor
chest expansion with markedly reduced FEV1 and FVC related to
kyphoscoliosis. ECG was normal. Transthoracic echocardiography
showed well-preserved left ventricular function with no regional
wall motion abnormality. Mild mitral and tricuspid regurgitation
was noted. Thallium myocardial perfusion imaging with adenosine
stress showed reduced tracer uptake in the anterior wall after
stress, consistent with reversible ischemia. Coronary angiography
revealed a left main stem equivalent stenosis with tight proximal
stenoses of the left anterior descending and left circumflex coronary
arteries. The distal portions of these vessels were both normal.
Minor disease only was seen in the nondominant right coronary
artery. The left ventriculogram was normal.
Referral for surgical revascularization was made, but surgery
was refused on the grounds of high peri- and postoperative risk
assessment related to impaired respiratory function, difficult
intubation and high probability of prolonged postoperative intensive
care. Despite additional medical therapy, the patient remained
severely limited.
Following extensive counseling the patient then underwent unprotected
elective angioplasty with placement of two stents. Prior to the
procedure the anticoagulation regime was switched to heparin.
Abciximab infusion was commenced at the start of the procedure
following elective placement of an intra-aortic balloon pump.
Two wires were passed into the distal LAD and Cx vessels and the
LAD lesion was directly stented with a 3.5 x 15 mm slotted tube
stent, whilst the Cx lesion was predilated prior to placement
of a 3.5 x 20 mm stent. Following the procedure the patient was
commenced on clopidogrel. The patient made an uneventful recovery
and was discharged after 5 days. After 6 months, coronary angiography
revealed no instent restenosis, and a subsequent myocardial perfusion
scan showed complete resolution of the anterior wall defect.
Discussion
Invasive vs medical therapy in elderly patients
with coronary artery disease
Randomized trials for treatment of coronary artery disease have
traditionally concentrated on a younger target population, excluding
patients over 75 years of age. Findings from these trials may
not be directly relevant to very elderly patients in whom the
risk of complications from invasive treatment is significantly
higher. In addition, as in this case, noncardiac risk factors,
such as impaired respiratory function and high anesthetic risk,
have led to the exclusion of such patients from clinical trials.
The patient population over 75 years of age is the fastest-growing
age group and therefore requires well-defined management strategies
based on evidence from randomized trials. The TIME investigators[1]
recently reported the results of a prospective, randomized, multicenter
study in patients over 75 years of age. Comparison was made between
an invasive strategy of cardiac catheterization followed by percutaneous
or surgical intervention, and a noninvasive strategy of optimized
medical therapy. The primary end point assessed quality of life
indices, which included the incidence of major adverse cardiac
events. In both groups a reduction in angina score and an increase
in quality of life were reported, but these changes were significantly
better in the invasively treated group. Nearly half of the patients
treated noninvasively experienced major adverse cardiac events,
whereas in the invasive group this was reduced to 1 in 5 (P <
0.0001). This would strongly support an invasive strategy in patients
over 75 years of age, who despite many comorbid risk factors,
often derive the greatest symptomatic benefit from aggressive
revascularization. The method of revascularization should be dictated
by the preoperative risk assessment and the feasibility of a percutaneous
approach, and age should no longer be a bar to aggressive revascularization.[2,3]
Unprotected left main stem angioplasty
The feasibility and safety of unprotected left main stem
stenting have continued to improve in recent years. Improvements
in stent technology, better adjuvant therapies such as glycoprotein
Iib/IIIa receptor blockade, and improved treatments for restenosis
have all made a percutaneous revascularization strategy a more
attractive option than cardiac surgery with its higher complication
rate, especially in more elderly patients. With good case selection
and the elective use of supportive devices such as intra-aortic
balloon pumping, the long-term outcome even in elderly patients
is increasingly favorable.
Tan et al[4] recently reported results from
279 consecutive patients who underwent unprotected left main stem
angioplasty between 1993 and 1998. Forty-six percent of these
patients were inoperable or were of high surgical risk, as in
the case described here; 13.7% of patients died in hospital. Cardiac
mortality after 1 year was 20.2%: low ejection fraction, impaired
renal function, severe mitral valve disease, myocardial infarction
or shock, and lesion calcification were all independent predictors
of mortality. In a low-risk subset of patients <65 years old
with well-preserved left ventricular function and no adverse risk
factors, there were no periprocedural deaths and 1-year mortality
was 3.4%. A percutaneous strategy may be appropriate for highly
symptomatic inoperable patients, the decision based on objective
evidence of ischemic comorbidity and procedural risk rather than
on biological age.
Choussat et al[5] reported the immediate and
mid-term results of unprotected left main stem stenting in 92
patients out of 6006 patients undergoing coronary angioplasty.
The average age of the patients was 74.3 years. The reported angiographic
success rate was 100%, with no patients requiring emergency bypass
surgery. Four patients died during their hospital stay and a further
six deaths occurred over the next 6 months of follow-up. One-year
actuarial survival was 89%, with 85% reported at 3 years. There
are many more reports of the success of a percutaneous approach
to revascularization in an increasingly elderly population.[6,7]
Conclusions
This case outlines treatment strategies in elderly patients with
chronic symptomatic coronary artery disease and accumulating evidence
in support of an invasive vs. an optimized medical approach. In
addition, the feasibility of unprotected left main stem stenting
is now well reported and there is a growing body of evidence to
support an aggressive percutaneous strategy in selected patients.
REFERENCES
-
Comment in:
Trial of invasive versus medical therapy
in elderly patients with chronic symptomatic coronary-artery
disease (TIME): a randomised trial.
The TIME Investigators.
BACKGROUND: Since previous randomised treatment trials in coronary
disease have focused on patients younger than 75 years of age,
their findings might not apply to the elderly population in
whom the cardiac risk profile, risk of intervention, and comorbidities
are increased. We aimed to assess quality of life and outcome
of elderly patients with coronary disease after medical or revascularisation
therapy. METHODS: In this randomised, prospective, multicentre
trial, we enrolled patients aged 75 years or older with chronic
angina of at least Canadian Cardiac Society class II despite
at least two antianginal drugs. Patients were randomly assigned
coronary angiography and revascularisation or optimised medical
therapy. The primary endpoint was quality of life after 6 months,
as assessed by questionnaire and the presence of major adverse
cardiac events (death, non-fatal myocardial infarction, or hospital
admission for acute coronary syndrome with or without the need
for revascularisation). Analysis was by intention to treat.
FINDINGS: 150 patients were assigned medical therapy and 155
invasive therapy. Two protocol violators in each group were
not included in the analysis. After 6 months, angina severity
decreased and measures of quality of life increased in both
treatment groups; however, these improvements were significantly
greater after revascularisation. Major adverse cardiac events
occurred in 72 (49%) of patients in the medical group and 29
(19%) in the invasive group (p<0.0001). INTERPRETATION: Patients
aged 75 years or older with angina despite standard drug therapy
benefit more from revascularisation than from optimised medical
therapy in terms of symptom relief and quality of life. Therefore,
these patients should be offered invasive assessment despite
their high risk profile followed by revascularisation if feasible.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 11583747 [PubMed - indexed for MEDLINE]
-
Invasive treatment for coronary artery disease
in the elderly.
Gold S, Wong WF, Schatz IJ, Blanchette PL.
Department of Medicine, John A. Burns School of Medicine, University
of Hawaii, Honolulu.
The widespread availability of coronary artery bypass grafting
and percutaneous transluminal coronary angioplasty presents
important treatment options for the older patient. The findings
from a number of surgical series of coronary artery bypass grafting
and percutaneous transluminal coronary angioplasty are summarized.
Certain trends are evident. Perioperative mortality, cardiovascular
morbidity, and other complications, while declining, remain
somewhat higher in elderly patients. However, the impact of
age alone is slight. In both coronary artery bypass grafting
and percutaneous transluminal coronary angioplasty, complications
are more closely correlated with the presence of serious concomitant
disease. Long-term survival and pain relief after coronary artery
bypass grafting are excellent in older patients, and percutaneous
transluminal coronary angioplasty may be the treatment of choice
in some elderly patients with coronary artery disease. As in
younger patients, prolongation of survival should not be the
exclusive goal. Rather, a focus on quality of life and freedom
from dependency should be seriously considered.
Publication Types:
PMID: 2043011 [PubMed - indexed for MEDLINE]
-
Myocardial revascularisation in the elderly:
complementary roles for coronary angioplasty and bypass grafting.
Violaris AG, Angelini GD.
Thoraxcentrum, Erasmus University, Rotterdam, The Netherlands.
Coronary artery disease is a common finding, responsible for
substantial morbidity and mortality in the elderly. Despite
this, there is a general reluctance to refer elderly patients
for further investigation as the perceived risks are thought
to outweight any potential benefit. This is not however borne
out by the available evidence, which suggests that revascularisation
procedures carry little additional risk in appropriately selected
elderly patients. Chronological age per se should, therefore,
no longer be a bar to myocardial revascularisation.
Publication Types:
PMID: 8021050 [PubMed - indexed for MEDLINE]
-
Long-term clinical outcomes after unprotected
left main trunk percutaneous revascularization in 279 patients.
Tan WA, Tamai H, Park SJ, Plokker HW, Nobuyoshi M, Suzuki
T, Colombo A, Macaya C, Holmes DR Jr, Cohen DJ, Whitlow PL,
Ellis SG; ULTIMA Investigators.
Pittsburgh Vascular Institute, UPMC Shadyside, Pittsburgh, PA,
USA.
BACKGROUND: Percutaneous coronary revascularization (PCI) has
been increasingly applied to unprotected left main trunk (LMT)
lesions, with varied long-term success. This study attempts
to define the predictors of outcome in this population. METHODS
AND RESULTS: Two hundred seventy-nine consecutive patients who
had LMT PCI at 1 of 25 sites between 1993 and 1998 were studied.
Forty-six percent of these patients were deemed inoperable or
at high surgical risk. Thirty-eight patients (13.7%) died in
hospital, and the rest were followed up for a mean of 19 months.
The 1-year incidence was 24.2% for all-cause mortality, 20.2%
for cardiac mortality, 9.8% for myocardial infarction, and 9.4%
for CABG. Independent correlates of all-cause mortality were
left ventricular ejection fraction </=30%, mitral regurgitation
grade 3 or 4, presentation with myocardial infarction and shock,
creatinine >/=2.0 mg/dL, and severe lesion calcification.
For the 32% of patients <65 years old with left ventricular
ejection fraction >30% and without shock, the prevalence
of these adverse risk factors was low. No periprocedural deaths
were observed in this low-risk subset, and the 1-year mortality
was only 3.4%. CONCLUSIONS: Patients undergoing unprotected
LMT PCI have frequent serious comorbidities and consequently
have high event rates. PCI may be an alternative to CABG for
a select proportion of elective patients and may also be appropriate
for highly symptomatic inoperable patients. Meticulous follow-up
of hospital survivors is required because of the rather high
mortality during the first few months after treatment.
Publication Types:
- Clinical Trial
- Multicenter Study
PMID: 11581137 [PubMed - indexed for MEDLINE]
-
[Percutaneous angioplasty of unprotected
left main coronary disease with implantation of systematic stenting.
Immediate and mid-term results]
[Article in French]
Choussat R, Black AJ, Jordan C, Farah B, Fajadet J, Marco
J.
Unite de cardiologie interventionnelle, clinique Pasteur, Toulouse.
The authors report the immediate and medium term results of
percutaneous angioplasty of unprotected left main coronary disease
with systematic stenting. Between March 1994 and December 1998,
out of 6,006 patients undergoing coronary angioplasty, 92 had
significant unprotected left main stem disease. The majority
of patients was male (74 men, 80%) with an average age of 74.3
+/- 8.1 years. Between March 1994 and October 1996, only patients
with a surgical contraindication were treated by angioplasty
(n = 39). After October 1996, the indications were extended
to patients who did not have surgical contraindications (n =
53). During the hospital phase, 4 patients (4%) died (ventricular
arrhythmia: 1, cardiogenic shock: 2, gastro-intestinal haemorrhage:
1). No non-fatal infarction with or without Q waves were observed,
and no emergency coronary bypass surgical procedures were required.
The angiographic success rate was 100%. During follow-up (7.3
+/- 5.8 months), 6 other patients died, 13 required a repeat
coronary angioplasty, 4 for restenosis of the left main coronary
artery, and 2 underwent coronary bypass surgery. The actuarial
survival rate was 89 +/- 5% at 1 year and 85 +/- 17% at 3 years.
Percutaneous angioplasty for unprotected left main coronary
disease with systematic stenting was performed with acceptable
hospital and medium term results.
PMID: 11004969 [PubMed - indexed for MEDLINE]
-
Treatment of intractable angina in a nonagenarian
patient by direct coronary stenting.
Byrne J, Cotton JM, Wainwright RJ.
Department of Cardiology, King's College Hospital, Bessemer
Road, London SE5 9RS, UK. jonathan.byrne@kcl.ac.uk
BACKGROUND: A 91-year-old man presented with a 6-month history
of exertional angina. As he was already on maximally tolerated
medical therapy, we decided to perform coronary angiography,
which revealed severe stenosis of the distal main stem coronary
artery, OUTCOME: The lesion was crossed with an intra-coronary
wire, and a stent placed to cover the distal main stem lesion,
without prior balloon dilatation. The result was satisfactory
and he remains symptom-free at 6-month follow-up. CONCLUSION:
Treatment of left main stem lesions with percutaneous intervention
may be an acceptable alternative to surgery in high-risk elderly
patients. Since percutaneous coronary angioplasty can be performed
on very elderly patients with a high degree of success, the
decision to investigate and treat should not be based solely
on biological age.
PMID: 11509314 [PubMed - indexed for MEDLINE]
-
Coronary stenting of unprotected left main
stem stenoses in elderly patients unsuitable for coronary surgery.
Davies CH, Banning AP, Channon KM, Ormerod OJ.
Department of Cardiology, John Radcliffe Hospital, Oxford, UK.
We describe five patients with severe unstable angina refractory
to medical management in whom coronary angiography demonstrated
a severe stenosis of the left main stem. Due to severe co-existing
illnesses bypass surgery was deemed inappropriate. Angioplasty
to the left main stem stenosis followed by stent deployment
was performed. All five patients were successfully discharged
from hospital.
PMID: 9363497 [PubMed - indexed for MEDLINE]
|
Books,