sooner than 2 weeks.

8 However, we cannot be certain clinical results with direct myocardial injection of phVEGF165 as sole therapy
for myocardial ischemia. Circulation 1998;98:2800 –2804.
of this conclusion because plasma levels of VEGF-2 2. Symes JF, Losordo DW, Vale PR, Lathi KG, Esakof DD, Mayskiy M, Isner
during the present investigation are not available. JM. Gene therapy with vascular endothelial growth factor for inoperable coronary
One-year mortality and morbidity were low, with 1 artery disease. Ann Thorac Surg 1999;68:830 –836.
3. Witzenbichler B, Asahara T, Murohara T, Silver M, Spyridopoulos I, Magner
death (3%) and 2 myocardial infarctions (7%). Although M, Principe N, Kearney M, Hu JS, Isner JM. Vascular endothelial growth
this study was not designed to assess mortality, this rate factor-C (VEGF-C/VEGF-2) promotes angiogenesis in the setting of tissue isch-
compares favorably with published studies of similar emia. Am J Pathol 1998;153:381–394.
4. Joukov V, Pajusola K, Kaipainen A, Chilov D, Lahtinen I, Kukk E, Saksela O,
no-option patients treated with transmyocardial revascu- Kalkkinen N, Alitalo K. A novel vascular endothelial growth factor, VEGF-C, is
larization showing 1-year mortalities of 5%,9 15%,10 a ligand for the Flt4 (VEGFR-3) and KDR (VEGFR-2) receptor tyrosine kinases.
11%,11 12%,12 and 5%.13 Myocardial infarction rates at EMBO J 1996;15:290 –298.
5. Jeltsch M, Kaipainen A, Joukov V, Meng X, Lakso M, Rauvala H, Swartz M,
1 year in these transmyocardial laser revascularization Fukumura D, Jain RK, Alitalo K. Hyperplasia of lymphatic vessels in VEGF-C
studies ranged from 6% to 15%. In a more benign patient transgenic mice. Science 1997;276:1423–1425.
population of “operable” class II and III patients and 6. Zar JH. Biostatistical Analysis. Englewood Cliffs, NJ: Prentice-Hall, 1984.
7. Henry TD, Rocha-Singh K, Isner JM, Kereiakes DJ, Giordano FJ, Simons M,
using an intracoronary injection of an adenovirus vector Losordo DW, Hendel RC, Bonow RO, Eppler SM, et al. Intracoronary admin-
containing the FGF4 gene, the Angiogenic Gene Ther- istration of recombinant human vascular endothelial growth factor to patients
apy (AGENT) trial14 reported no deaths. with coronary artery disease. Am Heart J 2001;142:872–880.
8. Vale PR, Losordo DW, Milliken CE, Maysky M, Esakof DD, Symes JF, Isner
At 1-year follow up, there was minimal evidence JM. Left ventricular electromechanical mapping to assess efficacy of
of progressive disease elsewhere in the coronary cir- phVEGF(165) gene transfer for therapeutic angiogenesis in chronic myocardial
culation of these patients; only 1 patient required ischemia. Circulation 2000;102:965–974.
9. Burkhoff D, Schmidt S, Schulman SP, Myers J, Resar J, Becker LC, Weiss J,
angioplasty to a remote part of the heart. However, Jones JW. Transmyocardial laser revascularisation compared with continued
longer follow-up will be required to document the medical therapy for treatment of refractory angina pectoris: a prospective ran-
domised trial. ATLANTIC Investigators. Angina Treatments-Lasers and Normal
progression of disease and whether there is a relation Therapies in Comparison. Lancet 1999;354:885–890.
to treatment with VEGF-2 in this patient population 10. Frazier OH, March RJ, Horvath KA. Transmyocardial revascularization with
with aggressive atherosclerosis. a carbon dioxide laser in patients with end-stage coronary artery disease. New
Engl J Med 1999;341:1021–1028.
Acknowledgment: Scripps Clinic: John D. Rogers, 11. Schofield PM, Sharples LD, Caine N, Burns S, Tait S, Wistow T, Buxton M,
Wallwork J. Transmyocardial laser revascularisation in patients with refractory
MD, Paul S. Teirstein, MD, Susan Moody, CRC, angina: a randomised controlled trial. Lancet 1999;353:519 –524.
Mark Bully, RN, BSN, CCRC; St. Elizabeth’s Medi- 12. Aaberge L, Nordstrand K, Dragsund M, Saatvedt K, Endresen K, Golf S,
cal Center: Nancie Cummings, MS; Hennepin County Geiran O, Abdelnoor M, Forfang K. Transmyocardial revascularization with CO2
laser in patients with refractory angina pectoris. Clinical results from the Nor-
Medical Center: Charlene Boisjolie, RN, MA; Uni- wegian randomized trial. J Am Coll Cardiol 2000;35:1170 –1177.
versity of Iowa: Kathy Schneider, ADN; Rush-Pres- 13. Allen KB, Dowling RD, Fudge TL, Schoettle GP, Selinger SL, Gangahar
byterian-St. Luke’s Medical Center: Kim Oswald, RN, DM, Angell WW, Petracek MR, Shaar CJ, O’Neill WW. Comparison of
transmyocardial revascularization with medical therapy in patients with refrac-
BSN; Statistical analysis: David Cloutier, BS tory angina. New Engl J Med 1999;341:1029 –1036.
14. Grines CL, Watkins MW, Helmer G, Penny W, Brinker J, Marmur JD, West
A, Rade JJ, Marrott P, Hammond HK, Engler RL. Angiogenic Gene Therapy
1. Losordo DW, Vale PR, Symes JF, Dunnington CH, Esakof DD, Maysky M, (AGENT) trial in patients with stable angina pectoris. Circulation 2002;105:
Ashare AB, Lathi K, Isner JM. Gene therapy for myocardial angiogenesis: initial 1291–1297.

Analysis of Baseline Factors Associated With Reduction

in Chest Pain in Patients With Angina Pectoris Treated
by Enhanced External Counterpulsation
William E. Lawson, MD, Elizabeth D. Kennard, PhD, John C.K. Hui, PhD,
Richard Holubkov, PhD, and Sheryl F. Kelsey, PhD, for the IEPR Investigators

Data from the International Enhanced External Coun- whereas those with diabetes mellitus, prior bypass
terpulsation (EECP) Patient Registry were analyzed to surgery, and heart failure were less likely to
determine which patient characteristics influence im- benefit. 䊚2003 by Excerpta Medica, Inc.
provement in angina class with EECP treatment. Pa- (Am J Cardiol 2003;92:439 – 443)
tients with severely disabling angina at baseline,
men, and those without a history of smoking are
more likely to improve their angina class after EECP,
E nhanced external counterpulsation (EECP) is a
noninvasive medical device for treating patients
with coronary disease. Three pairs of pneumatic cuffs
are applied to the lower extremities and inflated and
From the State University of New York at Stony Brook, Stony Brook, deflated in synchrony with the cardiac cycle. The cuffs
New York; and the University of Pittsburgh, Pittsburgh, Pennsylvania.
Dr. Lawson’s address is: SUNY Stony Brook, HSC T-17-020, Stony
are sequentially inflated (applying 250 to 300 mm Hg
Brook, New York 11740. E-mail: wlawson@ts.uh.sunysb.edu. Manu- of external pressure) at the onset of ventricular dias-
script received January 15, 2003; revised manuscript received and tole, returning blood in the lower extremities to the
accepted May 6, 2003. central circulation, producing aortic diastolic augmen-

©2003 by Excerpta Medica, Inc. All rights reserved. 0002-9149/03/$–see front matter 439
The American Journal of Cardiology Vol. 92 August 15, 2003 doi:10.1016/S0002-9149(03)00662-3
 patients who will be followed for 3 years. Patients
TABLE 1 Patient Characteristics and Medical History Before
Enhanced External Counterpulsation (EECP) who underwent their first EECP were used for the
present analysis.
Variable (n ⫽ 4,592) EECP was typically prescribed for 35-hour ses-
Age (yrs) (range) 66.7 ⫾ 10.8 (30–101) sions, 1 hour/day, over a period of 7 weeks. During
Men 75.1% treatment sessions, patients were routinely monitored
White 93.5% by electrocardiography, pulse oximetry, finger pleth-
Duration of coronary artery disease 10.8 ⫾ 8.2
(yrs) ysmography; a nurse was in attendance, and a super-
Prior myocardial infarction 67.3% vising physician was immediately available. An initial
Congestive heart failure 31.6% history and subsequent interval history was obtained
Unstable angina pectoris 3.2% before each treatment, at the end of therapy, and at 6
Prior coronary angioplasty 65.0%
Prior coronary bypass 67.3%
months after treatment. Interval end points included
Prior revascularization 85.7% an evaluation of Canadian Cardiovascular Society
Multivessel coronary disease 75.2% (CCS) anginal functional class, angina frequency, ni-
Left ventricular ejection fraction (%)* 46.5 ⫾ 13.9 troglycerin use, changes in medications, quality of
Diabetes mellitus 41.4% life, and interim events (major adverse cardiovascular
Hypertension 70.0%
Hyperlipidemia 79.4% events such as death, myocardial infarction, and re-
Noncardiac vascular disease 30.3% vascularization). Success was defined as a decrease of
Past or present smoking 70.6% at least 1 CCS angina class after a course of treatment.
*Ejection fraction was ⬍35% for 18.7% of patients.
Univariate associations between patient baseline
characteristics and angina reduction were examined
using chi-square tests for categoric variables and Wil-
coxon tests for continuous variables. Significance was
tation, and increasing venous return and cardiac out- defined as p ⬍0.05. Logistic regression analysis was
put.1 The cuffs are deflated at the end of ventricular used to determine independent predictors decreases in
diastole, decreasing peripheral resistance to flow and angina class. All factors showing an association with
providing left ventricular unloading.2 EECP is typi- reduction in angina with a p value of ⬍0.2 were put
cally used to treat patients with angina refractory to into the model and a backward selection technique
conventional medical therapy and poor candidates for was used to determine significant independent predic-
revascularization with angioplasty or bypass surgery. tors. Additional analyses were done to determine in-
EECP has consistently been shown to be effective in dependent predictors of a decrease in angina class for
treating patients with angina using various measures, those with and without severe (CCS class III or IV)
including: improved functional class,3,4 reduced angi- angina.
nal symptoms,5,6 improved quality-of-life indexes,7–9 As of June 2002, there were 5,000 patients enrolled
improved stress radionuclide perfusion,10,11 increased from 106 EECP treatment sites (6 international and
exercise time,12,13 and increased time to ST-segment 100 in the United States).20 Only patients with no
depression.14 Treatment with EECP has also been previous EECP treatment on enrollment in the Regis-
demonstrated to increase nitric oxide levels and de- try were analyzed in this report (n ⫽ 4,592). Patients
crease malondialdehyde, a marker of lipid peroxida- completed a mean of 34 ⫾ 10 hours of treatment, with
tion, as well as to decrease endothelin-1 levels.15–17 83.1% completing the course as prescribed. Patients’
The benefit of EECP has been shown to be sustained characteristics, medical history, and cardiovascular
at 3 and 5 years after treatment by radionuclide stress risk factors at the start of EECP are listed in Table 1.
testing and quality-of-life measures.18,19 Cardiac medications included ␤ blockers (65.7%), cal-
The International EECP Patient Registry (IEPR) cium channel blockers (46.1%), angiotensin-convert-
was organized to evaluate—across a broad range of ing enzyme inhibitors (38.3%), angiotensin receptor
providers and patients—the patterns of use, safety, blockers (10.0%), long-acting nitrates (74.8%), lipid-
and efficacy of EECP by consecutively tracking the lowering medications (67.5%), and aspirin (70.9%).
results and side effects of EECP therapy at partic- Major adverse cardiovascular events occurring
ipating centers (currently 106). This report summa- over the course of therapy were low and included
rizes the results of the IEPR. We characterized the death in 0.3% of patients, myocardial infarction in
patients’ demographics, evaluated the safety and 0.9%, coronary bypass in 0.2%, and angioplasty in
effectiveness of EECP, and determined which pa- 0.8%. Exacerbation of heart failure was noted in 1.9%
tient characteristics predict a successful response to of patients and unstable angina in 2.8%. These latter
treatment with EECP. events were not attributed to EECP by the investiga-
••• tors. There were no reported incidences of pulmonary
The IEPR at the Epidemiology Data Center of the embolism. Minor adverse events included 1.4% of
University of Pittsburgh Graduate School of Public patients with skin breakdown and 1.0% with muscu-
Health was initiated in January 1998 to sequentially loskeletal problems attributable to EECP treatment.
track—across a broad spectrum of participating pro- No clinically important arrhythmias were reported,
viders—the demographics, entry characteristics, and suggesting that arrhythmias are not a major concern
outcomes of all patients with angina treated with during EECP.
EECP. The IEPR has completed enrollment of 5,000 It is well known that the amplitude or area under

440 THE AMERICAN JOURNAL OF CARDIOLOGY姞 VOL. 92 AUGUST 15, 2003

 treatment was 0.80 ⫾ 0.5 and the last
hour was 1.07 ⫾ 0.6, an improve-
ment of 33.8% (p ⬍0.01 using paired
t test).
Angina status by the CCS classi-
fication for before and after treat-
ment is shown in Figure 2. Patients
in the IEPR cohort responded to
EECP treatment; angina functional
class improved ⱖ1 class(es) in 73%
of treated patients, ⱖ2 classes in
38.2%, ⱖ3 classes in 17.3%, did not
change in 26.0%, and worsened in
1.1%. Mean angina episodes per
week at baseline were 10.1 ⫾ 12.9
and decreased to 2.5 ⫾ 5.8 episodes/
week after EECP treatment. Baseline
nitroglycerin use was 9.5 ⫾ 11.9
times/week before EECP and de-
creased to 2.7 ⫾ 6.5 times/week after
EECP.
As shown in Figure 2, most pa-
tients (82.3%) were in CCS classes
III or IV at baseline, and 75.5% of
these patients reduced their angina
by at least 1 class after EECP. Those
with less severe angina (class I or II)
still had a significant decrease in an-
FIGURE 1. Operation of EECP and hemodynamic effectiveness. ECG ⴝ electrocardio- gina after EECP (61.9% of patients).
gram.
Other factors that showed some as-
sociation with a decrease in angina
are listed at the top of Table 2. These
included men, having never smoked, and the absence
of heart failure, diabetes mellitus, and a prior coronary
bypass. However, it should be noted that even patients
with heart failure and diabetes mellitus, who were
likely to have more extensive vascular disease and
more severe ventricular dysfunction, achieved a suc-
cess rate (as measured by a decrease in CCS class) of
approximately 70%. Age and cardiac risk factors other
than diabetes mellitus and smoking were not signifi-
cant predictors. Using logistic regression modeling,
significant independent predictors of angina reduction
were higher angina class at baseline, men, and no
history of smoking. Diabetes mellitus, heart failure,
and prior coronary bypass were all associated with
less angina reduction. Table 3 lists odds ratios and
FIGURE 2. Changes in CCS angina class before and after EECP. confidence intervals for these attributes.
Stratifying the model by severe (class III or IV)
angina produced the results that are listed in Table 4.
the systolic blood pressure waveform represents myo- For patients with severe angina, the only significant
cardial workload and the amplitude or area under the independent predictor of angina reduction was the
diastolic waveform reflects coronary perfusion pres- absence of heart failure. For patients with less severe
sure and myocardial oxygen supply. Therefore, the (class I or II) angina, the only significant independent
ratio of peak diastolic amplitude to peak systolic am- predictor of improvement in angina was history of
plitude could potentially serve as an index of myocar- smoking. Both diabetes mellitus and prior bypass sur-
dial energy supply and demand, an indicator of the gery were associated with less angina reduction.
hemodynamic effectiveness of EECP treatment. A •••
diagram of the calculation of the EECP effectiveness A benefit from EECP was seen in all patient sub-
index is given in Figure 1. The average peak ampli- groups. Although patients with diabetes mellitus, heart
tude effectiveness index for the 4,592 patients ana- failure, and prior bypass surgery showed less benefit
lyzed in this study during the first hour of EECP with regard to the decrease of CCS angina class, the

BRIEF REPORTS 441

 this, over 77% of patients with heart
TABLE 2 Reduction of Angina by at Least One Class Using Predictive Factors
failure achieve a decrease in angina
Prevalence Success Rate With Success Rate class. In preliminary reports, EECP
Predictive Factor of Factor Factor Without Factor p Value has increased maximal oxygen up-
Class III or IV angina 82.3% 75.5% 61.9% ⬍0.001 take and exercise tolerance in pa-
Men 75.1% 73.8% 70.9% 0.056 tients with heart failure.21 This will
Never smoked 29.4% 75.3% 72.1% 0.025 be explored in the ongoing random-
Diabetes mellitus 41.4% 71.1% 74.5% 0.010
Heart failure 31.6% 70.0% 74.7% 0.001 ized multicenter trial of EECP in pa-
Prior bypass surgery 67.3% 72.6% 74.4% 0.200 tients with heart failure patients (Pro-
spective Evaluation of EECP in
Congestive Heart Failure [PEECH]).
For the patients presenting with
TABLE 3 Odds Ratios for Predictors of Success* in Patients (n
more mild or moderate angina, the presence of diabe-
⫽ 4,287) Who Underwent Enhanced External tes mellitus and prior coronary bypass assumes im-
Counterpulsation (EECP) portance in determining treatment effect. It is not
Attribute Odds Ratio 95% Confidence Interval
surprising that diabetes mellitus and prior coronary
bypass emerged as predictors of a lower likelihood of
CCS angina class II vs I 2.03 1.41–2.92 benefit because both are clearly correlated with more
CCS angina class III vs I 3.64 2.59–5.11
CCS angina class IV vs I 4.08 2.84–5.85
extensive vascular disease. In addition, diabetics dem-
Men 1.24 1.06–1.46 onstrate impaired angiogenesis and endothelial func-
Never smoked 1.26 1.08–1.47 tion, and a propensity to atherothrombosis. It is some-
Diabetes mellitus 0.75 0.65–0.87 what surprising that a history of non-smoking
Heart failure 0.84 0.73–0.96
Prior coronary bypass 0.83 0.71–0.96
predicted benefit. Most of the cardiovascular effects of
smoking are relatively transient (vasoconstriction, en-
*Success in EECP is defined as patients who have a decrease of ⱖ1 CCS dothelial damage, desaturation, hypercoagulability);
angina class.
the risk of ex-smokers eventually returns to the norm
of non-smokers. The collected data do not permit
further refinement of participants’ smoking habits.
Further study is needed to clarify the relation of smok-
TABLE 4 Odds Ratios for Independent Predictors of Success* ing to outcome.
by Initial Severity of Angina in Patients Who Underwent
Enhance External Counterpulsation (EECP)
Patient CCS
1. Suresh K, Simandl S, Lawson WE, Hui JCK, Lillis O, Burger L, Guo T, Cohn
Angina PF. Maximizing the hemodynamic benefit of enhanced external counterpulsation.
Classification Odds 95% Confidence Clin Cardiol 1998;21:649 –653.
Before EECP Attribute Ratio Interval 2. Taguchi I, Ogawa K, Oida A, Abe S, Kaneko N, Sakio H. Comparison of
hemodynamic effects of enhanced external counterpulsation and intra-aortic
Class III or IV Congestive heart failure 0.73 0.62–0.85 balloon pumping in patients with acute myocardial infarction. Am J Cardiol
Diabetes mellitus 0.69 0.51–0.94 2000;86:1139 –1141.
Class I or II Prior coronary bypass 0.67 0.50–0.90 3. Lawson WE, Hui JCK, Lang G. Treatment benefit in the Enhanced External
Never smoked 1.40 1.00–1.81 Counterpulsation Consortium. Cardiology 2000;94:31–35.
4. Lawson WE, Hui JCK. Enhanced external counterpulsation for chronic myo-
*Success in EECP is defined as patients who have a decrease of ⱖ1 CCS cardial ischemia. J Crit Illness 2000;15:629 –636.
class. 5. Soran OZ, Crawford LE, Schneider VM, Feldman AM. Enhanced external
counterpulsation in the management of patients with cardiovascular disease. Clin
Cardiol 1999;22:173–178.
6. Lawson WE, Cohn PF, Hui JCK, Soroff HS. Enhanced external counterpul-
sation: review of U.S. clinical research to date. Cardiovasc Rev Rep 1997;18:
overall success rate in these subgroups was approxi- 25–29.
mately 70%. In practice, this translates into broad 7. Fricchione GL, Jaghab K, Lawson WE, Hui JCK, Jandorf L, Zheng ZS, Cohn
PF, Soroff HS. Psychosocial effects of enhanced external counterpulsation in the
clinical utility across the usual patient subgroups. angina patient. Psychosomatics 1995;36:494 –497.
Overall, EECP was effective in improving angina by 8. Cohn PF, Arora RR, Chou TM, Jain P, Nesto R, Fleishman B, Crawford L,
at least 1 CCS anginal class in 73% of patients. The McKiernan I, Lawson W. Comparison of prognostic surveys used in the Multi-
center Study of Enhanced External Counterpulsation (MUST-EECP) (abstr). Eur
importance of heart failure in these patients is empha- Heart J 1999;20:479.
sized by the finding that for the patients with the most 9. Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, McKiernan T, Nesto
R, Ferrans CE, Keller S. Effects of enhanced external counterpulsation on
severe angina, heart failure is the only independent health-related quality of life continue 12 months after treatment: a substudy of the
factor associated with a decrease in angina class. Multicenter Study of Enhanced External Counterpulsation. J Investig Med 2002;
Heart failure is often a reflection of extensive, estab- 50:25–32.
10. Lawson WE, Hui JCK, Soroff HS, Zheng ZS, Kayden DS, Sasvary D, Atkins
lished vascular disease and irreversible myocardial H, Cohn PF. Efficacy of enhanced external counterpulsation in the treatment of
injury. Improvement in this setting may be limited or angina pectoris. Am J Cardiol 1992;70:859 –862.
may require different dosing (additional hours of treat- 11. Masuda D, Nohara R, Hirai T, Kataoka K, Chen LG, Hosokawa R, Inubushi
M, Tadamura E, Fujita M, Sasayama S. Enhanced external counterpulsation
ment). Previous IEPR reports showed only 77.9% of improved myocardial perfusion and coronary flow reserve in patients with
patients with heart failure completed therapy versus chronic stable angina: evaluation by 13N-ammonia positron emission tomogra-
86.2% of patients without heart failure.20 Whether this phy. Eur Heart J 2001;22:1451–1458.
12. Lawson WE, Hui JCK, Zheng ZS, Burger L, Jiang L, Lillis O, Oster Z, Soroff
reflects less treatment, less benefit, or dropout because H, Cohn PF. Improved exercise tolerance following enhanced external counter-
of a lack of benefit remains to be determined. Despite pulsation: Cardiac or peripheral effect? Cardiology 1996;87:271–275.

442 THE AMERICAN JOURNAL OF CARDIOLOGY姞 VOL. 92 AUGUST 15, 2003

13. Lawson WE, Hui JCK, Guo T, Berger L, Cohn PF. Prior revascularization 18. Lawson WE, Hui JCK, Zheng ZS, Oster Z, Katz J, Diggs P, Burger L,
increases the effectiveness of enhanced external counterpulsation. Clin Cardiol Cohn CD, Soroff HS, Cohn PF. Three-year sustained benefit from enhanced
1998;21:841–844. external counterpulsation in chronic angina pectoris. Am J Cardiol 1995;75:
14. Arora RR, Chou TM, Jain D, Fleischmann B, Crawford L, McKiernan T, 840 –841.
Nesto RW. The Multicenter Study of Enhanced External Counterpulsation 19. Lawson WE, Hui JC, Cohn PF. Long-term prognosis of patients with angina
(MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and treated with enhanced external counterpulsation: five-year follow-up study. Clin
anginal episodes. JACC 1999;33:1833–1840. Cardiol 2000;23:254 –258.
15. Qian X-X, Wu W-K, Zheng Z-S, Zhan C-Y, Yu B-Y, Lawson WE, Hui JCK.
20. Lawson WE, Kennard ED, Holubkov R, Kelsey SF, Strobeck JE, Soran O,
Effect of enhanced external counterpulsation on lipid peroxidation in coronary
Feldman AM, for the IEPR Investigators. Benefit and safety of enhanced external
disease (abstr). J Heart Dis 1999;1:116.
16. Gui-Fu W, Qiang-Sun Z, Zhen-Sheng Z, Miao-Qing Z, Lawson WE, Hui counterpulsation in treating coronary artery disease patients with a history of
JCK. A neurohormonal mechanism for the effectiveness of enhanced external congestive heart failure. Cardiology 2001;96:78 –84.
counterpulsation (abstr). Circulation 1999;100:I–832. 21. Soran O, Fleishman B, Demarco T, Grossman W, Schneider VM, Manzo
17. Qian X-X, Wu W-K, Zheng Z-S, Zhan C-Y, Yu B-Y, Lawson WE, Hui JCK. K, de Lame P-A, Feldman AM. Enhanced external counterpulsation in pa-
Effect of enhanced external counterpulsation on nitric oxide production in cor- tients with heart failure: a multicenter feasibility study. Congest Heart Fail
onary disease (abstr). J Heart Dis 1999;1:193. 2002;8:204 –208.

Comparison of In-Hospital and One-Year Outcomes

After Multiple Coronary Arterial Stenting in Patients
>80 Years Old Versus Those <80 Years Old
Yoshio Kobayashi, MD, Roxana Mehran, MD, Gary S. Mintz, MD,
George Dangas, MD, PhD, Issam Moussa, MD, Alexandra J. Lansky, MD,
Gregg W. Stone, MD, Jeffrey W. Moses, MD, and Martin B. Leon, MD

The present study evaluated in-hospital and 1-year

TABLE 1 Baseline Clinical Characteristics
outcomes after multivessel stenting in patients aged
>80 (75 patients, 241 lesions) and <80 years (894 ⬍80 Yrs ⱖ80 Yrs
(n ⫽ 894) (n ⫽ 75) p Value
patients, 2,678 lesions). Despite a high technical suc-
cess rate of multivessel stenting, octogenarians had Age (yrs) 63 ⫾ 10 84 ⫾ 4 ⬍0.001
Men 74% 47% ⬍0.001
higher in-hospital cardiac and noncardiac complica- Unstable angina pectoris 76% 84% 0.15
tion rates and a higher mortality rate at 1-year clin- Diabetes mellitus 32% 35% 0.6
ical follow-up compared with their younger Systemic hypertension 63% 64% 1.0
Hypercholesterolemia* 73% 53% ⬍0.001
counterparts. 䊚2003 by Excerpta Medica, Inc. Smoker 57% 30% ⬍0.001
(Am J Cardiol 2003;92:443– 446) Prior myocardial infarction 50% 64% 0.03
Prior coronary angioplasty 39% 30% 0.13

T he elderly comprise a rapidly growing segment of

1
the population. Because coronary artery disease is
2
common in elderly patients, percutaneous coronary
Prior bypass surgery
Congestive heart failure
Peripheral vascular disease
48%
16%
20%
38%
26%
28%
0.10
0.04
0.07
Renal insufficiency† 9% 19% 0.003
intervention, which in the current era implies stent LV ejection fraction 46 ⫾ 14 41 ⫾ 13 0.01
implantation, has been used widely to treat lesions in
*Medication dependent or cholesterol ⬎240 mg/dl. †Admission creatinine
elderly patients.3– 8 Recently, several studies9 –11 have
of ⬎2.0 mg/dl or previous treatment for renal insufficiency.
shown good acute success and acceptable long-term LV ⫽ left ventricular.
outcomes after multivessel stenting. Because of a high
frequency of multivessel disease4,12 and high periop-
erative morbidity and mortality of bypass surgery in utive patients who underwent multivessel stenting.
octogenarians,13 multivessel stenting may be the pre- Multivessel stenting was defined as stenting in ⱖ2
ferred treatment in this population. However, there is major native coronary artery territories (diagonal
little information about acute and long-term outcomes branches and left anterior descending arteries were
after multivessel stenting in octogenarians. The considered part of the same major territory) or saphe-
present study evaluated in-hospital and 1-year out- nous vein grafts. Patients with acute myocardial in-
comes after multivessel stenting in octogenarians. farction ⬍48 hours before the study were excluded.
••• There were 969 consecutive patients who underwent
The prospective database of the Cardiovascular multivessel stenting of 2,919 lesions. Patients were
Research Foundation was queried to identify consec- divided into 2 groups: those who were ⬍80 years old
(894 patients, 2,678 lesions) and those who were ⱖ80
From the Cardiovascular Research Foundation, Lenox Hill Heart and years old (75 patients, 241 lesions).
Vascular Institute, New York, New York. Dr. Mehran’s address is:
Cardiovascular Research Foundation, 55 East 59th Street, 6th Floor,
All procedures were performed after written in-
New York, New York 10022. E-mail: rmehran@crf.org. Manuscript formed consent was obtained. All patients received
received March 20, 2003; revised manuscript received and ac- aspirin 325 mg/day ⱖ24 hours before the procedure,
cepted May 7, 2003. which was continued indefinitely. Patients were

©2003 by Excerpta Medica, Inc. All rights reserved. 0002-9149/03/$–see front matter 443
The American Journal of Cardiology Vol. 92 August 15, 2003 doi:10.1016/S0002-9149(03)00663-5