Outcome 14 to 18 years after percutaneous transluminal coronary angioplasty

R have substantially enhanced the acute safety and effectiveness of percutaneous transluminal coronary angioplasty (PTCA), and the early outcomes of patients treated by PTCA have been well characterized. Because PTCA was introduced only 20 years ago and because procedural volumes during its early use were relatively small, little is known of the late outcome of patients treated with PTCA. The purpose of this study was to determine the clinical status of a consecutive patient cohort in whom $14 years had elapsed since their first PTCA was performed. • • • Between September 1978 and September 1982, 129 consecutive patients underwent a first PTCA at our institution. Follow-up data on hospital admissions, recurrent acute myocardial infarction, subsequent revascularizations, and vitals statistics were obtained from patients or relatives contacted by telephone, from a professional organization (Equifax, Atlanta, Georgia), or from the National Registry of Death, Washington, DC. Patients were questioned at follow-up as to the need for medications, presence of angina, level of activity and hospitalizations for chest pain, acute myocardial infarction (AMI), PTCA or coronary artery bypass grafts (CABG). Initial PTCA results and baseline characteristics from each patient were obtained from our computerized database. A successful PTCA was defined as a $20% decrease in luminal stenosis. Mortality was identified by hospital medical records notification from a patient’s relative or confirmation in the National Registry of Death. Recurrent AMI and repeat PTCA or CABG were determined by questioning the patient during the interview and confirming this result in most of the cases through medical records. Univariable analysis was performed to assess differences in death, recurrent AMI, PTCA, or CABG according to gender, anginal status, presence of diabetes mellitus, extent of coronary artery disease, age .60 years, and initial PTCA result. Chi-square analysis and t test were used to perform these comparisons. Life-table survival curves were used to examine time until death, AMI, CABG, and repeat PTCA throughout the follow-up period. Statistical significance was assessed at the 5% level of significance. The characteristics of the 129 consecutive patients in whom balloon angioplasty was attempted are shown in Table I. Mean age was 53 6 0.9 years (SD) (range 29 to 78). Women were an average 3.6 years older than men. This difference was statistically significant (p 5 0.03). In our cohort, 98 patients (76%) were men, 33 patients (26%) had a prior AMI, and 7 patients (6%) had a previous CABG. Hypertension and current tobacco use were the most prevalent cardiac risk factors. Angiographic data, PTCA results, and events before hospital discharge are shown in Table II. Single-vessel coronary disease was found in 104 of the patients (81%). Angioplasty was attempted in 131 lesions, 75 (58%) of which were performed in the left anterior descending artery. PTCA success was obtained in 80 patients (65%). Mean stenosis severity before PTCA was 80% with an average stenosis reduction of 51% after angioplasty. In-hospital mortality was 0.8%. None of the patients experienced a Q-wave myocardial infarction. In-hospital CABG was performed in 22 of the patients (17%). Follow-up data were obtained during a 12-month period in 123 of the 129 patients. Events at 14-year follow-up are shown in Table III. Kaplan-Meier estimates of freedom from events at 14 to 18 years are shown in Figure 1. Cumulative mortality at 14 years was 26%. There was no difference in mortality according to PTCA result, angina status, age $60 years, history of diabetes mellitus, or presence of multivessel coronary artery disease. Women had a 42% incidence of death compared with 22% in men (p 5 0.03). Insufficient information was available to determine the cause of death in our patients. During the follow-up period, 16% of the patients experienced a nonfatal AMI. Recurrent myocardial infarction was not influenced by the extent of coronary disease, age, or initial PTCA success. Surgical revascularization was performed in 41% of the patients. The incidence of CABG was greater in patients with an unsuccessful PTCA compared with those with a successful result (63% vs 29%, p 5 0.002). This difference was found early on because most of the patients with a failed angioplasty underwent bypass surgery. Repeat PTCA was performed in 34% of the patients. Information for the indication, site, and results of subsequent angioplasties were not available. Repeat PTCA was not influenced by the initial PTCA result, age, extent of coronary disease, or gender. Among the 123 patients, 24% were free of death, myocardial infarction, CABG surgery, and asymptomatic at 14 years. At follow-up, 89 patients were contacted by telephone. In this group 80% were free of angina, 53% were moderately to highly active and the average number of antianginal medications used was 1.1, including b blockers, calcium channel blockers, and nitrates. From Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island; and Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania. Dr. Jimenez’s address is: Cleveland Clinic Foundation, Mail Box 674, 9500 Euclid Ave, Cleveland, Ohio, 44195. E-mail: JimeneJ@ccf.org. Manuscript received August 31, 1999; revised manuscript received and accepted December 3, 1999.