DOI: 10.1097/01.mca.0000129883.86374.6c
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PMID: 15179121
Issn Print: 0954-6928
Publication Date: 2004/05/01
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Excerpt
Percutaneous coronary revascularization (PCR) with balloon angioplasty with or without stenting and coronary artery bypass graft (CABG) surgery are very effective in reducing the frequency of angina and exercise-induced myocardial ischemia and in increasing angina-free exercise duration [23–28]. However, compared with treatment with antianginal drugs [14,15,24,25,28–30] or exercise training [31], these procedures do not reduce mortality or lower the incidence of MI in patients with stable angina pectoris. On the contrary, the procedures are associated with an immediate increase in morbidity and mortality [14,15]. Despite these facts, PCR is being performed with increasing frequency before an adequate trial of medical therapy. This trend is likely to worsen with the recent introduction of drug coated stents [32–35], which have reduced the incidence of restenosis to around 10% from 20–48% reported with bare metal stents [36]. However, long term experience with drug coated stents is lacking; sub-acute thrombosis (0.6–1.6%) following placement of drug coated stents remains a concern, and comparative studies with bare coated stents have failed to show a decrease in the frequency of MI and death [37]. There is also a paucity of long-term results in patients with diabetes mellitus and in those with obstructions in the small coronary vessels.
There is an ever increasing number of patients who are reporting recurrence of angina after PCR and CABG surgery. It is estimated that more than 50% of patients experience recurrence of angina following PCR and invariably all patients experience recurrence of symptoms 10–15 years following CABG surgery. Many of these patients are not suitable for a repeat revascularization procedure due to unsuitable anatomy and often do not adequately respond to or are refractory to conventional antianginal drugs [14,15,38,39].
Recurrence of angina within 6–9 months following a PCR is often due to restenosis of the dilated lesion or instent stenosis. However, many patients continue to experience angina despite the presence of patent stents and in these patients angina may be due to endothelial dysfunction. Other patients experience recurrence of symptoms over time due to progression of the disease in non-dilated segments of the coronary arteries. The management of patients with recurrence of angina after PCR often requires use of one or more antianginal drugs and a repeat PCR or even CABG surgery provided the coronary anatomy is suitable.
Recurrence of angina within the first few months of CABG surgery is invariably due to technical problems during harvesting or insertion of venous or arterial grafts at the time of surgery or due to incomplete revascularization. Recurrence of symptoms, several years after bypass surgery, is invariably due to progression of disease in the native coronary arteries and also to extensive graft atherosclerosis. Treatment options are often limited in this group of patients due to high rates of MI and death after a repeat CABG surgery or following PCR procedures such as brachytherapy or placement of stents inside a previous stent.
Thus, there is a need for newer therapies to manage this growing population of patients.
