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J Am Coll Cardiol, 1999; 33:73-78
© 1999 by the American College of Cardiology Foundation
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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{dagger}, Peter Ganz, MD, FACC*, Scott Kinlay, MBBS*, John Strony, MD, FACC{ddagger}, 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
{dagger} Department of Medicine, St. Louis University, St. Louis, Missouri, USA
{ddagger} 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


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
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

Percutaneous coronary revascularization procedures are now widely applied to treat acute coronary syndromes. Much attention has centered on the acute results and associated complications of these procedures (1–16), but few studies

See page 79(17–24) have focused on predictors of enduring clinical success during the ensuing 6 months, a more relevant end point inclinical practice. Long-term success is clearly reduced when major ischemic complications occur at the time of the initial procedure (2,3). The predictors of 6 month clinical outcome among successfully treated patients without in-hospital complications remain uncertain, however. We utilized data from the recent Hirulog Angioplasty Study (25) to examine the predictors of clinical outcome at 6 months following successful percutaneous coronary revascularization.


   Methods
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 Abstract
 Methods
Results
 Discussion
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Study population.   In the Hirulog Angioplasty Study 4,098 patients undergoing conventional balloon angioplasty for the treatment of unstable angina between March 24, 1993 and July 15, 1994 were randomized to treatment with heparin or bivalirudin in a double-blind fashion for 18 to 24 h (25). Unstable angina was defined as angina of new onset, crescendo angina, rest pain or angina within 2 weeks of a myocardial infarction (MI).

Hospital outcome was analyzed for all 4,098 patients. In this substudy, 6-month clinical outcome was analyzed for the 3,899 of 4,098 patients (95%) who underwent successful coronary intervention without a major ischemic complication in-hospital. Because bivalirudin did not produce a significant treatment effect in the study (25), all patients were combined as a single group for the purposes of this analysis.

Definitions.   Major ischemic complications were defined as in-hospital death, MI or emergent coronary artery bypass graft surgery (CABG). The definition of MI was a rise in the total serum creatine kinase (CK) concentration above twice the upper limit of normal with an MB fraction of at least 4.0% in association with either ischemic chest pain lasting longer than 30 min, or a new two-step Q wave change (according to the Minnesota code) (26), persistent ST segment or T wave changes or a new left bundle branch block. Reelevation of the total or CK-MB to above the previous nadir in association with ischemic chest pain or the defined ischemic electrocardiographic changes was also classified as reinfarction. Event-free survival at 6 months was defined as freedom from major adverse cardiac events (MACE), defined as death, MI or repeat revascularization.

A procedure was defined as successful if it was performed without a major in-hospital ischemic complication. Abrupt vessel closure (AVC) included both threatened and established closure. Threatened closure after initially successful dilation of the target lesion was defined as a recurrent stenosis of more than 50% with flow less than Thrombolysis in Myocardial Infarction trial (TIMI) grade 3 (27) requiring intracoronary stenting, thrombolytic therapy or repeat cardiac catheterization (28,29). Established AVC after initially successful dilation was defined as total or subtotal occlusion of the target lesion with impaired flow to TIMI grade 0 or 1 (2). "Complicated" AVC was defined as threatened or established closure that led to a major in-hospital ischemic complication. "Uncomplicated" AVC was a closure that was successfully reversed without a resultant major in-hospital ischemic complication. In the angiographic analysis, thrombus was defined as a filling defect, haze or ulceration at the lesion site, or a total occlusion.

Data collection.   Clinical follow-up was obtained at 3 and 6 months postprocedure. Measurement of the total CK was performed at 8 and 16 h after angioplasty, with MB determinations done if the total CK was elevated. Of 4,098 patients in the trial, 4,068 (99%) had at least one CK measurement after angioplasty. All data were submitted to the data coordinating center (ClinTrials Research, Research Triangle Park, NC) and were verified for accuracy against source documents by clinical monitors from ClinTrials.

Angiograms were reviewed at the core angiographic laboratory by experienced angiographers blinded to treatment assignment using electronic digital calipers according to previously validated methods (30). Of 4,098 patients in the trial, 4,056 (99%) had films reviewed at the core laboratory. Angiograms were analyzed on 368 of the 378 (97%) patients who experienced AVC during the study.

Statistical analysis.   Categorical variables were compared using Fisher exact test or Pearson chi-square test where appropriate. Student t test was used to compare continuous variables between groups. Logistic regression, incorporating univariates with at least borderline significance (p < 0.10), was used to determine predictors of ischemic complications during the 6 months after successful angioplasty. Statistical analysis was performed using SPSS. Baseline data were unavailable on 3 of 4,098 patients (0.1%) who underwent angioplasty, and follow-up data were incomplete for 195 patients (5%). Angiographic data for 42 patients (1%) were unavailable.


   Results
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 Results
Discussion
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Clinical and angiographic characteristics.   Of 4,098 patients undergoing angioplasty in the trial, 83% had unstable angina and 17% had post-MI angina (Table 1). Rest angina occurred in 64%. Multivessel coronary disease was identified in 47%, and 17% underwent multilesion angioplasty (Table 2).


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  		Table 1 Baseline Clinical Characteristics for 4,098 Patients Undergoing Coronary Angioplasty for Unstable or Postinfarction Angina

 

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  		Table 2 Baseline Angiographic Characteristics of 4,056 Patients with Core Laboratory Analysis

 
Hospital outcome.   Angioplasty was successful without a major in-hospital ischemic complication in 3,899 of 4,098 patients (95%). Death occurred in 13 (0.3%), MI in 145 (4%), emergency CABG in 70 (2%) and at least one of these major complications occurred in 199 patients (5%). The majority of complications followed an episode of abrupt vessel closure, but not all AVCs resulted in a major ischemic event. Of the 4,098 patients in the study, 378 patients (9%) experienced a total of 397 episodes of AVC. Although the milder form of "threatened" vessel closure predominated (240 of 397 episodes [60%]), both threatened and established closure sharply increased the likelihood of major ischemic complications. Death, MI or emergency CABG occurred in 71 of 3,720 patients (2%) without vessel closure, in 48 of 240 (20%) with threatened closure and in 80 of 138 (58%) with established closure (p < 0.001). Thus, by definition 128 of 378 patients with threatened or established closure sustained "complicated" AVC, while the remaining 250 patients had "uncomplicated" AVC (Fig. 1).



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  		Figure 1 Flow diagram of patients’ in-hospital course in the Hirulog Angioplasty Study. AVC = abrupt vessel closure. *"Uncomplicated" abrupt vessel closure indicates that the abrupt closure event did not result in a major ischemic complication (death, myocardial infarction or emergent coronary artery bypass graft surgery). {dagger}"Complicated" abrupt vessel closure indicates that the abrupt closure event did result in a major ischemic complication (death, myocardial infarction or emergent coronary artery bypass graft surgery).

 
Abrupt closure was managed with emergency stent placement in 31% of patients with complicated AVC, as compared with 44% of patients with uncomplicated AVC (p = 0.01). Filling defects were detected during the procedure in 20% of patients with complicated AVC and in 16% of those with uncomplicated AVC, compared with only 3% of patients never sustaining closure (p < 0.001).

Among the 3,899 patients with successful angioplasty, 155 (4%) developed an elevation of the CK to greater than twice the upper limit of normal without ischemic symptoms or electrocardiographic changes. These were not classified as MI events according to the predetermined definition. Asymptomatic elevations of CK were detected in 139 of 3,649 (0.4%) successful procedures without an episode of threatened or established AVC, compared with 16 of 250 (6%) procedures with uncomplicated AVC (p = 0.04).

Follow-up after successful angioplasty.   Clinical status at 6 months was available for 3,704 of the 3,899 patients (95%) with successful index procedures. The rate of follow-up was equal for those with and without AVC (both 95%) during the index procedure. Patients without follow-up were younger (59 ± 12 vs. 62 ± 11 years; p < 0.001) and had a lower prevalence of prior angioplasty (17% vs. 27%; p = 0.002) compared to those with follow-up. Otherwise the two groups were similar.

Major adverse cardiac events occurred by 6 months in 825 of 3,704 (22%) patients, including death in 44 (1%), MI in 82 (2%) and repeat revascularization in 770 (21%). Clinical and angiographic predictors of an increased incidence of MACE in follow-up (Table 3) included AVC (p < 0.001), requirement for stent placement during the index procedure (p < 0.001), multilesion angioplasty (p < 0.001), diabetes (p = 0.02), angioplasty of the left anterior descending artery (p = 0.02), unstable angina as opposed to post-MI angina (p = 0.03) and a smaller postprocedural luminal diameter (p = 0.04). There was also a trend for increased MACE among patients who had undergone prior angioplasty (p = 0.08). Lesion length, reference diameter, final percent stenosis, residual stenosis of greater than 50%, persistent dissection at completion of the procedure and asymptomatic elevation of the CK were not statistically significantly associated with increased events in follow-up. In a multivariable analysis incorporating the univariable predictors, AVC was the strongest independent predictor of MACE at 6 months (p < 0.001; odds ratio [95% confidence interval] = 3.6 [2.5 to 5.1]), while multilesion angioplasty, target lesion in the left anterior descending artery and diabetes also remained independent predictors.


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  		Table 3 Predictors of Major Ischemic Events in Follow-up in 3,899 Patients Without In-Hospital Complications

 
Of 238 patients with complete follow-up who had sustained uncomplicated AVC during the index procedure, 105 (44%) experienced an adverse clinical event by 6 months, compared with 720 of the 3,466 successful patients (21%) who had no AVC during angioplasty (p < 0.001; Table 4). The higher event rate in the uncomplicated AVC cohort was driven by a doubling of the rate of repeat revascularization (44% vs. 19%; p < 0.001), whereas death and MI were not increased.


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  		Table 4 Cumulative Rates of Major Adverse Cardiac Events at Six Months Follow-up Among 3,899 Patients Without In-Hospital Complications

 
The 250 patients with uncomplicated AVC were less likely to have undergone prior angioplasty than the 3,649 successfully treated patients without abrupt closure (21% vs. 27%; p = 0.05), but otherwise the two groups shared similar clinical characteristics. By contrast, angiographic analysis suggested that the lesions treated in patients with uncomplicated AVC were significantly more complex than those in the other successfully treated patients. These lesions were less often type A (24% vs. 33%; p = 0.001) or discrete (74% vs. 81%; p = 0.01), they had a higher prevalence of filling defects (5% vs. 2%; p = 0.01) or features suggestive of thrombus at baseline (21% vs. 13%; p = 0.001) and they had more severe stenoses at the target site (74 ± 15% vs. 71 ± 16%; p = 0.001). During the procedure, patients with uncomplicated closure sustained more dissections (45% vs. 20%; p < 0.001), required more stents (45% vs. 0.2%; p < 0.001) and had a higher incidence of a residual stenosis greater than 50% by core angiographic analysis (15% vs. 9%; p = 0.002).


   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
In this study involving over 4,000 patients with unstable or post-MI angina treated with conventional balloon angioplasty, the most powerful predictor of clinical outcome during the 6 months following an otherwise successful procedure was an episode of AVC. The 9% incidence of AVC in the current study is higher than commonly reported and reflects the inclusion of "threatened" along with established closure in our prespecified definition. Of the 378 patients with threatened or established AVC, 250 (66%) were successfully treated without an in-hospital major ischemic event using repeat balloon angioplasty or stenting, and were therefore considered "uncomplicated" by current definitions. Nevertheless, this group of successfully "salvaged" patients experienced a significant increase in MACE during 6 months of follow-up when compared to patients who did not sustain closure or other complications during the index hospitalization (44% vs. 21%; p < 0.001). Diabetes, multivessel angioplasty and angioplasty of the left anterior descending artery were also independent predictors of adverse outcome at 6 months, consistent with the well established increased rate of restenosis in such patients (19,31,32).

The prognostic significance of transient vessel closure during angioplasty has previously been suggested by data from the 1985–1986 National Heart, Lung and Blood Institute Registry. At 2 years of follow-up, patients with successfully reversed AVC had reduced survival (92% vs. 96%) and increased repeat revascularization rates (42% vs. 31%) compared to those without transient occlusion (2). Tanaglia also documented an increased rate of death, MI and repeat angioplasty by 1 year among patients salvaged from abrupt closure at Duke (33).

Repeat revascularization procedures accounted for the large increase in adverse events among patients with uncomplicated AVC in the present study (44% vs. 19% among those without AVC; p < 0.001). This 44% rate is higher than the 13% incidence at 1 year observed by Abdelmeguid in a smaller group of 88 patients with transient vessel closure (34). However, Abdelmeguid’s single center, retrospective analysis excluded patients treated with bailout stenting, which was required in 44% of our patients with uncomplicated AVC, despite being officially discouraged by the study. The decision to deploy a stent may have reflected more complicated vessel disruption, portending a higher risk prognosis than for AVC manageable with repeat balloon angioplasty alone. Abdelmeguid’s report was also not restricted to patients with unstable angina. The 1-year repeat revascularization rate of only 11% among patients without AVC in Abdelmeguid’s study contrasts with the 20% to 28% incidence at 6 months observed in the Hirulog study and many other recent multicenter trials of balloon angioplasty for unstable angina (22,35,36), suggesting possible differences in the patient populations.

Several explanations for the adverse prognostic significance of uncomplicated AVC are possible. Patients with "uncomplicated" AVC had more complex target lesions and achieved less optimal postprocedural angiographic results than patients who had successful angioplasty with no abrupt closure event. Unplanned stenting was also required in 44% of patients with "uncomplicated" AVC. Bailout stenting is highly successful in the acute setting, but it is accompanied by higher rates of subacute thrombosis and restenosis than after elective stenting (21,37–40). Periprocedural myonecrosis also occurred significantly more frequently following "uncomplicated" AVC. Even minor elevations of the CK after coronary intervention have been found by some investigators to predict reduced event-free survival (34,41–43).

The significant increase in the rate of MACE among patients with uncomplicated AVC cannot be fully explained by adverse morphologic features or more complex interventions, however. In the present study, neither lesion morphology nor elevation of the CK to above twice the upper limit of normal among patients with successful angioplasty was predictive of MACE at 6 months. In addition, multivariable analysis demonstrated that the AVC event itself was the most powerful independent predictor of MACE in follow-up, with an odds ratio of 3.6. Thus, although clinical and angiographic characteristics are important in assessing patients’ risk following angioplasty, the occurrence of transient coronary occlusion during the procedure appears to have a significant impact on outcome independent of these other data.

Limitations.   This was a retrospective analysis of subgroups from the Hirulog Angioplasty Trial, which was limited to patients with unstable angina and was completed prior to widespread use of glycoprotein IIb/IIIa inhibitors in coronary intervention. The prognostic implications of "uncomplicated" AVC may be different in stable angina or when IIb/IIIa antagonists are utilized. Elevation of the CK was detected in only 0.4% of non-AVC patients and 6% of AVC patients following successful angioplasty, possibly reflecting less stringent surveillance than in some other studies. Stricter surveillance and routine measurement of the CK-MB isoform may have uncovered a greater prognostic significance of enzyme elevation. Given the high prevalence of salvage stenting among patients with uncomplicated abrupt vessel closure, these results cannot necessarily be extrapolated to a population with transient occlusion that can be reversed with balloon angioplasty alone.

Conclusions.   Abrupt vessel closure during angioplasty for unstable or post-MI angina has a significant, independent, adverse effect on clinical outcome at 6 months. This holds true even when the closure does not cause a major ischemic event acutely, and is thus traditionally considered "uncomplicated" by the operator at the time of the procedure. Abrupt closure may thus serve as a general marker that incorporates unfavorable clinical characteristics, adverse features of the lesion or a less satisfactory angiographic result when the closure is salvaged. Fortunately, such uncomplicated abrupt closure events do not appear to increase subsequent rates of myocardial infarction or death. They do portend a significant increase in the need for repeat revascularization by 6 months, however. As interventional techniques are applied to more severely ill patients with increasingly complex coronary artery disease, the potential exists for the rates of transient or established vessel closure to rise. Acute complication rates may not reflect these instances of transient occlusion, because two thirds of such events can be reversed using the current interventional armamentarium without a recognized major ischemic event. Nevertheless, our analysis suggests that these salvaged patients constitute a population at higher risk for subsequent ischemic events. Thus, in approaching increasingly difficult scenarios for coronary intervention, techniques designed to reduce rates of abrupt closure should be applied when possible, and the potential medical and economic implications of even transient occlusion should be considered prior to attempts at percutaneous revascularization.


   Footnotes
 
This study was supported by a grant from Biogen, Inc., Cambridge, Massachusetts.


   References
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 Discussion
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G. W. Stone, R. Mehran, G. Dangas, A. J. Lansky, R. Kornowski, and M. B. Leon
Differential Impact on Survival of Electrocardiographic Q-Wave Versus Enzymatic Myocardial Infarction After Percutaneous Intervention: A Device-Specific Analysis of 7147 Patients
Circulation, August 7, 2001; 104(6): 642 - 647.
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S. E. Kimmel, A. R. Localio, C. Brensinger, C. Miles, J. Hirshfeld, H. L. Haber, and B. L. Strom
Effects of Coronary Stents on Cardiovascular Outcomes in Broad-Based Clinical Practice
Arch Intern Med, September 25, 2000; 160(17): 2593 - 2599.
[Abstract] [Full Text] [PDF]

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