Circulation, Vol 82, 1193-1202, Copyright © 1990 by American Heart Association
SG Ellis, MG Vandormael, MJ Cowley, G DiSciascio, U Deligonul, EJ Topol and TM Bulle
To assess the likelihood of procedural success in patients with multivessel
coronary disease undergoing percutaneous coronary angioplasty, 350
consecutive patients (1,100 stenoses) from four clinical sites were
evaluated. Eighteen variables characterizing the severity and morphology of
each stenosis and 18 patient-related variables were assessed at a core
angiographic laboratory and at the clinical sites. Most patients had
Canadian Cardiovascular Society class III or IV angina (72%) and two-vessel
coronary disease (78%). Left ventricular function was generally well
preserved (mean ejection fraction, 58 +/- 12%; range, 18-85%) and 1.9 +/-
1.0 stenoses per patient had attempted percutaneous coronary angioplasty.
Procedural success (less than or equal to 50% final diameter stenosis in
one or more stenoses and no major ischemic complications) was achieved in
290 patients (82.8%), and an additional nine patients (2.6%) had a
reduction in diameter stenosis by 20% or more with a final diameter
stenosis 51-60% and were without major complications. Major ischemic
complications (death, myocardial infarction, or emergency bypass surgery)
occurred in 30 patients (8.6%). In-hospital mortality was 1.1%. Stepwise
regression analysis determined that a modified American College of
Cardiology/American Heart Association Task Force (ACC/AHA) classification
of the primary target stenosis (with type B prospectively divided into type
B1 [one type B characteristic] and type B2 [greater than or equal to two
type B characteristics]) and the presence of diabetes mellitus were the
only variables independently predictive of procedural outcome (target
stenosis modified ACC/AHA score; p less than 0.001 for both success and
complications; diabetes mellitus: p = 0.003 for success and p = 0.016 for
complications). Analysis of success and complications on a per stenosis
dilated basis showed, for type A stenoses, a 92% success and a 2%
complication rate; for type B1 stenoses, an 84% success and a 4%
complication rate; for type B2 stenoses, a 76% success and a 10%
complication rate; and for type C stenoses, a 61% success and a 21%
complication rate. The subdivision into types B1 and B2 provided
significantly more information in this clinically important intermediate
risk group than did the standard ACC/AHA scheme. The stenosis
characteristics of chronic total occlusion, high grade (80-99% diameter)
stenosis, stenosis bend of more than 60 degrees, and excessive tortuosity
were particularly predictive of adverse procedural outcome. This improved
scheme may improve clinical decision making and provide a framework on
which to base meaningful subgroup analysis in randomized trials assessing
the efficacy of percutaneous coronary angioplasty.
ARTICLES
Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease. Implications for patient selection. Multivessel Angioplasty Prognosis Study Group
Division of Cardiology, University of Michigan Medical Center, Ann Arbor 48109-0022.
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