Percutaneous transluminal coronary angioplasty for rest angina pectoris requiring intravenous nitroglycerin and intraaortic balloon counterpulsation.

In selected patients with medically refractory rest angina, percutaneous transluminal coronary angioplasty (PTCA) might be a reasonable alternative to coronary artery bypass graft surgery. Between January 1987 and November 1989, 1 operator at a Veterans Administration center performed PTCA on 73 vessels in 56 patients with rest angina of sufficient severity to require intravenous nitroglycerin in all 56 and intraaortic balloon counter-pulsation (IABP) in 18. Of the 56 patients, 17 (30%) had 1-vessel disease, 14 (25%) had 2-vessel disease and 25 (45%) had 3-vessel disease; 14 (25%) had greater than or equal to 1 prior bypass surgery, 35 (62.5%) were within 30 days of an acute infarction, 12 (21%) had left ventricular ejection fraction less than 0.50 and 7 (12.5%) were greater than 70 years of age. PTCA was successful in 61 (84%) vessels and 47 (84%) patients (greater than or equal to 1 vessel plus relief of angina). During index hospitalization, there were 2 deaths (3.6%), 4 myocardial infarctions (7.2%), 4 emergent bypass surgeries (7.2%) and 1 semiemergent bypass (1.8%) for technically unsuccessful PTCA. In follow-up from 3 to 36 months, there has been 1 additional myocardial infarction (1.8%), 1 late death (1.8%), 2 repeat PTCAs (3.6%), 6 crossovers to bypass (10.7%) and 38 patients (68%) have remained cardiac-event free. Although this angioplasty cohort is small and selected, these data raise the possibility that a prospective randomized comparison of PTCA versus bypass surgery might be feasible and appropriate in a subset of unstable angina patients who require intravenous nitroglycerin or IABP.