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CLINICAL STUDIES

Effect of transient abrupt vessel closure during otherwise successful angioplasty for unstable angina on clinical outcome at six months

Robert N. Piana, MD, FACC^*, Waqar H. Ahmed, MD, MS, FACC^*, Bernard Chaitman, MD, FACC, Peter Ganz, MD, FACC^*, Scott Kinlay, MBBS^*, John Strony, MD, FACC, Burt Adelman, MD, John A. Bittl, MD, FACC^|| on behalf of the Hirulog Angioplasty Study Investigators

^* Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
Department of Medicine, St. Louis University, St. Louis, Missouri, USA
Department of Medicine, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, USA
Biogen Inc., Cambridge, Massachusetts, USA
^|| Ocala Heart Institute, Ocala, Florida, USA

Manuscript received April 3, 1998; revised manuscript received July 7, 1998, accepted September 10, 1998.

Address for correspondence: Robert N. Piana, MD, Cardiovascular Division, Brigham & Women’s Hospital, Boston, Massachusetts 02115
RNPiana{at}BICS.BWH.Harvard.Edu

Objectives. The objective of this study was to identify predictors of major adverse cardiac events after successful coronary angioplasty.

Background. The acute complications of angioplasty are related to baseline clinical and angiographic variables, and early complications adversely affect long-term outcome. However, the predictors of enduring success after uncomplicated angioplasty are less well defined.

Methods. Of 4,098 patients undergoing angioplasty in the Hirulog Angioplasty Study, 3,899 (95%) had a successful procedure without in-hospital death, emergent bypass surgery or clinical evidence of myocardial infarction. Baseline and procedural variables for these 3,899 patients were examined.

Results. Major adverse cardiac events occurred in 22% of the patients with initially successful procedures at 6 months: death in 1%, myocardial infarction in 2% and repeat revascularization in 21%. Univariable predictors of increased events included successful salvage from abrupt vessel closure (p < 0.001), emergency stenting (p < 0.001), multilesion angioplasty (p < 0.001), diabetes (p = 0.02), target lesion in the left anterior descending artery (p = 0.02), unstable angina (p = 0.03) and smaller final luminal diameter (p = 0.04). There was a trend toward increased events among patients with prior angioplasty (p = 0.08), but asymptomatic elevation of the creatine kinase was not predictive (p = 0.5). In a multivariable model, abrupt vessel closure was the strongest independent predictor of major adverse cardiac events at 6 months (p < 0.001; odds ratio [95% confidence interval] = 3.6 [2.5 to 5.1]), while multivessel angioplasty, target lesion in the left anterior descending artery and diabetes also remained independent predictors (all p 0.02).

Conclusions. This analysis suggests that "uncomplicated" abrupt vessel closure is a powerful predictor of adverse clinical outcome following successful angioplasty. Improved techniques to reduce abrupt closure during angioplasty are thus urgently needed, and patients who experience "uncomplicated" closure require closer surveillance during follow-up.

Abbreviations and Acronyms   AVC = Abrupt vessel closure   CABG = Coronary artery bypass graft surgery   CK = Creatine kinase   MACE = Major adverse cardiac events   MI = myocardial infarction   TIMI = Thrombolysis in Myocardial Infarction trial

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