2 1,2 percutaneous transluminal coronary angioplasty: PTCA 3, PTCA PTCA PTCA PTCA American Heart Association AHA 75%

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1 1 2 : Long-Term Prognosis in Patients With Single-Vessel or Double-Vessel Coronary Artery Disease: Does Successful Revascularization Achieved by Coronary Angioplasty Improve Late Outcome? Takanobu KAWAHARADA, Abstract Objectives. It is not clear whether revascularization by coronary angioplasty improves long-term prognosis in patients with stable angina, single- or double-vessel coronary artery disease. This study investigated the extent of late revascularization achieved by percutaneous transluminal coronary angioplasty PTCA and evaluated the long-term effect of revascularization in patients with coronary artery disease. Methods. This study reviewed 178 patients with single-vessel or double-vessel disease and significant coronary diameter stenosis American Heart Association classification, 75% or more stenosis, but excluded 35 patients with failed revascularization of the target vessels because of initial failed angioplasty n 14 or restenosis n 21. The remaining 143 patients were available for assessment. Revascularization was successful at follow-up angiography after the last angioplasty in 15 patients Group A. The remaining 38 patients received conservative medical therapy Group B. Kaplan-Meier survival curves were used to examine absolute survival difference. Results. One hundred forty-three patients mean age 64 9 years were followed-up for years. The patients were 7.6% male, 59.4% had myocardial infarction and 76.9% had single-vessel disease. Anatomical complete revascularization in the chronic phase was accomplished in 8 patients with singlevessel disease 97.6% and 11 patients with double-vessel disease 47.8%. The event-free survival rate was not significantly different between Group A and Group B 88.6% vs 84.2%, p. Cardiac survival rate decreased significantly in Group B compared to Group A 89.5% vs 99.%, p.1. This difference in survival rate was due to sudden cardiac death in Group B 7.9% vs %, p.5. Non-fatal myocardial infarctions occurred in seven patients 6.7% with revascularization and in one patient 2.6% with conservative medical therapy, but with no significant difference. Late successful revascularization improved cardiac survival rate in patients with proximal left anterior descending coronary artery involvement or singlevessel disease. Conclusions. Cardiac events decreased and long-term prognosis appeared to be a good possibility in patients with single- or double-vessel coronary artery disease if late successful revascularization of target vessel was accomplished. J Cardiol 23 Jul; 42 1 : 1 11 Key Words Coronary artery disease Angioplasty Death, sudden Prognosis Revascularization 1 2 : The Second Department of Internal Medicine, Kagoshima University School of Medicine, Kagoshima Address for correspondence: KAWAHARADA T, MD, The Second Department of Internal Medicine, Kagoshima University School of Medicine, Sakuragaoka , Kagoshima, Kagoshima Manuscript received October 21, 22; revised November 13, 22 and March 7, 23; accepted March 27, 23 1

2 2 1,2 percutaneous transluminal coronary angioplasty: PTCA 3, PTCA PTCA PTCA PTCA American Heart Association AHA 75% PTCA PTCA PTCA 38 2 Judkins AHA 75% PTCA Judkins AHA 5% PTCA 3 6 AHA 5% PTCA AHA 5% coronary artery bypass grafting: CABG PTCA PTCA PTCA PTCA 3 t 2 p.5 Kaplan- Meier Logrank p PTCA PTCA PTCA PTCA PTCA 14 1 PTCA 1 1 Fig. 1 PTCA PTCA 48 PTCA 2 8 PTCA 38

3 1 2 3 Fig. 1 Flow chart showing treatment of all patients Group A: With successful revascularization at follow-up angiography after the last angioplasty. Group B: With conservative medical therapy. PTCA percutaneous transluminal coronary angioplasty ; CHF congestive heart failure ; AMI acute myocardial infarction. Fig. 2 Flow chart showing treatment of patients with repeated angioplasty of the target vessels Abbreviation as in Fig. 1.

4 PTCA Fig % 59.4% % % 96.5% Table % vs 47.8% p.1 2 PTCA vs p.1 Target lesion revascularization % vs 3.5% p.5 PTCA 2 1 Table % vs 29.5% Table 3 Table 1 Patient characteristics Total number 143 Age yr, mean SD 64 9 Male 11 Old myocardial infarction 85 Angina pectoris 58 Single-vessel disease 11 Double-vessel disease 33 Follow-up yr, mean SD Cumulative event-free rate % 87.4 Cumulative survival rate % % vs 84.2% ; Fig % vs 89.5% p.1 ; Fig % Table 2 Outcome of coronary angioplasty Single-vessel disease n 82 Double-vessel disease n 23 p value Complete revascularization Target lesion revascularization Subsequent PTCA New stenotic lesion Residual stenosis Number of total PTCA Number of subsequent PTCA Continuous values are mean SD. : %. Complete revascularization : Success rate of complete anatomical revascularization. Subsequent PTCA : PTCA associated with new stenotic lesion and residual stenosis except for initial culprit lesion. Abbreviation as in Fig. 1.

5 1 2 5 Table 3 Comparison of patient characteristics in Groups A and B Group A n 15 Age yr, mean SD 63 1 Male % 72.4 Myocardial infarction % 63.8 Vessel number Single-vessel disease % 78.1 Double-vessel disease % 21.9 LAD % 68.6 RCA % 29.5 LCX % 25.7 LVEF %, mean SD Poor left ventricular function LVEF 4% % 4.8 High LDL 13 mg/dl % 55.2 Hypertension % 44.8 Diabetes mellitus % 24.8 Smoker % 53.3 Group B n p value LAD left anterior descending coronary artery ; RCA right coronary artery ; LCX left circumflex coronary artery ; LVEF left ventricular ejection fraction ; LDL low-density lipoprotein. Explanation of the groups as in Fig. 1. Fig. 3 Cumulative event-free rate left and cumulative cardiac survival rate right : CHF. : Cardiac sudden death. Explanation of the groups and abbreviation as in Fig. 1. Fig % Fig % 43% Fig % Fig % 18% Fig % Fig. 6

6 6 Fig. 4 Revascularization in patients with myocardial infarction according to culprit vessels SVD single-vessel disease ; DVD double-vessel disease ; Prox proximal stenotic lesion American Heart Association AHA class segment RCA#1, LAD#6, LCX#11 ; Distal distal stenotic lesion except for proximal lesion AHA class segment RCA#1, LAD#6, LCX#11 ; MI myocardial infarction; AP angina pectoris. Other abbreviations as in Fig. 1, Table Fig. 7 2 Fig. 8 Fig. 8 3 Fig % vs.95% p.1 7.9% vs % p.5 6.7% vs 2.6% CABG 2.6% vs.95% PTCA 1.5% vs % p.5 PTCA 8.6% vs %; Table % 13 9% 2

7 1 2 7 Fig. 5 Revascularization in patients with angina pectoris according to culprit vessels Abbreviations as in Figs. 1, 4, Table 3. Fig. 6 Classification of culprit vessels in patients receiving conservative therapy Abbreviations as in Figs. 1, 4, Table 3.

8 8 Fig. 7 Cardiac survival rate and single left or double right culprit vessels Cardiac survival rate was significantly higher in Group A than in Group B due to three sudden cardiac deaths in Group B. : CHF. : Cardiac sudden death. Explanation of the groups and abbreviation as in Fig. 1. Fig. 8 Cumulative cardiac survival rate with left or without right involvement of the proximal left anterior descending coronary artery : CHF. : Cardiac sudden death. Explanation of the groups and abbreviation as in Fig. 1. Fig. 9 Cumulative cardiac survival rate in patients with left anterior descending coronary artery diseases associated with myocardial infarction : CHF. : Cardiac sudden death. Explanation of the groups and abbreviation as in Fig % 6 1% 2 5% 6 75% 1 75%

9 1 2 9 Table 4 Comparison of events between Groups A and B Group A n 15 Group B n 38 p value Non cardiac death Cardiac death AMI CHF Sudden death Non fatal AMI New stenotic lesion Residual stenosis PTCA related MI Restenosis CABG Subsequent PTCA New stenotic lesion Residual stenosis : %. CABG coronary artery bypass grafting. Explanation of the groups and other abbreviations as in Figs. 1, PTCA 1 1,4 1 2 PTCA 4 PTCA 42% 59/14 PTCA CABG 1 PTCA 2 PTCA PTCA

10 % % % PTCA 2 PTCA ,16 PTCA PTCA PTCA PTCA 1 2 PTCA : 1 2 PTCA 3 6 PTCA : 75% PTCA Kaplan-Meier : % 59.4% 76.9% % % 88.6% vs 84.2% 99.% vs 89.5% p % vs % p.5 6.7% 2.6% : 1 2PTCA J Cardiol 23 Jul; 42 1 :1 11

11 Mark DB, Nelson CL, Califf RM, Harrell FE Jr, Lee KL, Jones RH, Fortin DF, Stack RS, Glower DD, Smith LR, DeLong ER, Smith PK, Reves JG, Jollis JG, Tcheng JE, Muhlbaier LH, Lowe JE, Phillips RH, Pryor DB : Continuing evaluation of therapy for coronary artery disease : Initial results from the era of coronary angioplasty. Circulation 1994; 89: RITA-2 trial participants : Coronary angioplasty versus medical therapy for angina : The second Randomized Intervention Treatment of Angina RITA-2 trial. Lancet 1997; 35: Parisi AF, Folland ED, Hartigan P, on behalf of the Veterans Affairs ACME Investigators : A comparison of angioplasty with medical therapy in the treatment of singlevessel coronary artery disease. N Engl J Med 1992 ; 326: Folland ED, Hartigan P, Parisi AF, on behalf of the Veterans Affairs ACME Investigators: Percutaneous transluminal coronary angioplasty versus medical therapy for stable angina pectoris : Outcomes for patients with doublevessel versus single-vessel coronary artery disease in a Veterans Affairs Cooperative Randomized trial. J Am Coll Cardiol 1997; 29 : Laudau C, Lange RA, Hillis LD : Percutaneous transluminal coronary angioplasty. N Engl J Med 1994 ; 33: Ryan TJ, Bauman WB, Kennedy JW, Kereiakes DJ, King SB, McCallister BD, Smith SC Jr, Ullyot DJ : Guidelines for percutaneous transluminal coronary angioplasty : A report of the American Heart Association/ American College of Cardiology Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures Committee on Percutaneous Transluminal Coronary Angioplasty. Circulation 1993 ; 88 : Vacek JL, Rosamond TL, Stites HW, Rowe SK, Robuck W, Dittmeier G, Beauchamp GD : Comparison of percutaneous transluminal coronary angioplasty versus coronary artery bypass grafting for multivessel coronary artery disease. Am J Cardiol 1992; 69 : Webb JG, Myler RK, Shaw RE, Anwar A, Murphy MC, Mooney JF, Mooney MR, Stertzer SH : Bidirectional crossover and late outcome after coronary angioplasty and bypass surgery 8 to 11 year follow-up. J Am Coll Cardiol 199; 16 : King SB, Schlumpf M : Ten-year completed follow-up of percutaneous transluminal angioplasty : The early Zurich experience. J Am Coll Cardiol 1993; 22: Perper JA, Kuller LH, Cooper M: Arteriosclerosis of coronary arteries in sudden, unexpected deaths. Circulation 1975; 52 Suppl : Davies MJ: Pathological view of sudden cardiac death. Br Heart J 1981; 45 : Warnes CA, Roberts WC : Sudden coronary death : Relation of amount and distribution of coronary narrowing at necropsy to previous symptoms of myocardial ischemia, left ventricular scarring and heart weight. Am J Cardiol 1984; 54 : Hillis LD, Cigarroa JE, Lange RA: Late revascularization reduces mortality in survivors of myocardial infarction. Cardiol Rev 1999 ; 7: Bourassa MG, Holubkov R, Yen W, Detre KM: Strategy of complete revascularization in patients with multivessel coronary artery disease a report from NHLBI PTCA Registry. Am J Cardiol 1992 ; 7 : Ohta H, Daida H, Ohashi S, Sunayama S, Fujiwara Y, Miyauchi K, Yokoi H, Yamaguchi H: Percutaneous trasluminal coronary angiplasty in patients with multivessel coronary disease : Dose complete revascularization improve the long-term survival? J Cardiol 1997 ; 29 : in Jpn with Eng abstr 16 Talley JD, Weintraub WS, Roubin GS, Douglas JS Jr, Anderson HV, JonesEL, Morris DC, Liberman HA, Craver JM, Guyton RA, King SB : Failed elective percutaneous transluminal coronary angioplasty requiring coronary artery bypass surgery: In-hospital and late clinical outcome at 5 years. Circulation 199; 82:

PTCA CABG 2PTCA & CABG 3 4 PTCA CABG 1 2 3PTCA & CABG 4 5 PTCA CABG follow-up Japanese Circulation Journal Vol. 64, Suppl. IV, 2000

PTCA CABG 2PTCA & CABG 3 4 PTCA CABG 1 2 3PTCA & CABG 4 5 PTCA CABG follow-up Japanese Circulation Journal Vol. 64, Suppl. IV, 2000 19981999 JR PTCACABG 1 2 PTCA 3 PTCA 4 OP-CABG MID-CAB PTCACABG 1 PTCA PTCA CABG 2 1 PTCA PTCA PTCA PTCA PTCA 2CABG CABG CABG CABG 3PTCA CABG Japanese Circulation Journal Vol. 64, Suppl. IV, 2000 1009