sooner than 2 weeks.
8 However, we cannot be certain clinical results with direct myocardial injection of phVEGF165 as sole therapy
of this conclusion because plasma levels of VEGF-2
during the present investigation are not available.
One-year mortality and morbidity were low, with 1
death (3%) and 2 myocardial infarctions (7%). Although
this study was not designed to assess mortality, this rate
compares favorably with published studies of similar
no-option patients treated with transmyocardial revascu-
larization showing 1-year mortalities of 5%,9 15%,10
11%,11 12%,12 and 5%.13 Myocardial infarction rates at
1 year in these transmyocardial laser revascularization
studies ranged from 6% to 15%. In a more benign patient
population of “operable” class II and III patients and
using an intracoronary injection of an adenovirus vector
containing the FGF4 gene, the Angiogenic Gene Ther-
apy (AGENT) trial14 reported no deaths.
At 1-year follow up, there was minimal evidence
of progressive disease elsewhere in the coronary cir-
culation of these patients; only 1 patient required
angioplasty to a remote part of the heart. However,
longer follow-up will be required to document the
progression of disease and whether there is a relation
to treatment with VEGF-2 in this patient population
with aggressive atherosclerosis.
Acknowledgment: Scripps Clinic: John D. Rogers,
MD, Paul S. Teirstein, MD, Susan Moody, CRC,
Mark Bully, RN, BSN, CCRC; St. Elizabeth’s Medi-
cal Center: Nancie Cummings, MS; Hennepin County
Medical Center: Charlene Boisjolie, RN, MA; Uni-
versity of Iowa: Kathy Schneider, ADN; Rush-Pres-
byterian-St. Luke’s Medical Center: Kim Oswald, RN,
BSN; Statistical analysis: David Cloutier, BS
1. Losordo DW, Vale PR, Symes JF, Dunnington CH, Esakof DD, Maysky M,
Ashare AB, Lathi K, Isner JM. Gene therapy for myocardial angiogenesis: initial
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-
terpulsation (EECP) Patient Registry were analyzed to
determine which patient characteristics influence im-
provement in angina class with EECP treatment. Pa-
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,
From the State University of New York at Stony Brook, Stony Brook,
New York; and the University of Pittsburgh, Pittsburgh, Pennsylvania.
Dr. Lawson’s address is: SUNY Stony Brook, HSC T-17-020, Stony
Brook, New York 11740. E-mail: wlawson@ts.uh.sunysb.edu. Manu-
script received January 15, 2003; revised manuscript received and
accepted May 6, 2003.
©2003 by Excerpta Medica, Inc. All rights reserved.
The American Journal of Cardiology Vol. 92 August 15, 2003
for myocardial ischemia. Circulation 1998;98:2800 –2804.
2. Symes JF, Losordo DW, Vale PR, Lathi KG, Esakof DD, Mayskiy M, Isner
JM. Gene therapy with vascular endothelial growth factor for inoperable coronary
artery disease. Ann Thorac Surg 1999;68:830 –836.
3. Witzenbichler B, Asahara T, Murohara T, Silver M, Spyridopoulos I, Magner
M, Principe N, Kearney M, Hu JS, Isner JM. Vascular endothelial growth
factor-C (VEGF-C/VEGF-2) promotes angiogenesis in the setting of tissue isch-
emia. Am J Pathol 1998;153:381–394.
4. Joukov V, Pajusola K, Kaipainen A, Chilov D, Lahtinen I, Kukk E, Saksela O,
Kalkkinen N, Alitalo K. A novel vascular endothelial growth factor, VEGF-C, is
a ligand for the Flt4 (VEGFR-3) and KDR (VEGFR-2) receptor tyrosine kinases.
EMBO J 1996;15:290 –298.
5. Jeltsch M, Kaipainen A, Joukov V, Meng X, Lakso M, Rauvala H, Swartz M,
Fukumura D, Jain RK, Alitalo K. Hyperplasia of lymphatic vessels in VEGF-C
transgenic mice. Science 1997;276:1423–1425.
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,
Losordo DW, Hendel RC, Bonow RO, Eppler SM, et al. Intracoronary admin-
istration of recombinant human vascular endothelial growth factor to patients
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
JM. Left ventricular electromechanical mapping to assess efficacy of
phVEGF(165) gene transfer for therapeutic angiogenesis in chronic myocardial
ischemia. Circulation 2000;102:965–974.
9. Burkhoff D, Schmidt S, Schulman SP, Myers J, Resar J, Becker LC, Weiss J,
Jones JW. Transmyocardial laser revascularisation compared with continued
medical therapy for treatment of refractory angina pectoris: a prospective ran-
domised trial. ATLANTIC Investigators. Angina Treatments-Lasers and Normal
Therapies in Comparison. Lancet 1999;354:885–890.
10. Frazier OH, March RJ, Horvath KA. Transmyocardial revascularization with
a carbon dioxide laser in patients with end-stage coronary artery disease. New
Engl J Med 1999;341:1021–1028.
11. Schofield PM, Sharples LD, Caine N, Burns S, Tait S, Wistow T, Buxton M,
Wallwork J. Transmyocardial laser revascularisation in patients with refractory
angina: a randomised controlled trial. Lancet 1999;353:519 –524.
12. Aaberge L, Nordstrand K, Dragsund M, Saatvedt K, Endresen K, Golf S,
Geiran O, Abdelnoor M, Forfang K. Transmyocardial revascularization with CO2
laser in patients with refractory angina pectoris. Clinical results from the Nor-
wegian randomized trial. J Am Coll Cardiol 2000;35:1170 –1177.
13. Allen KB, Dowling RD, Fudge TL, Schoettle GP, Selinger SL, Gangahar
DM, Angell WW, Petracek MR, Shaar CJ, O’Neill WW. Comparison of
transmyocardial revascularization with medical therapy in patients with refrac-
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
(AGENT) trial in patients with stable angina pectoris. Circulation 2002;105:
1291–1297.
whereas those with diabetes mellitus, prior bypass
surgery, and heart failure were less likely to
benefit. 䊚2003 by Excerpta Medica, Inc.
(Am J Cardiol 2003;92:439 – 443)
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
deflated in synchrony with the cardiac cycle. The cuffs
are sequentially inflated (applying 250 to 300 mm Hg
of external pressure) at the onset of ventricular dias-
tole, returning blood in the lower extremities to the
central circulation, producing aortic diastolic augmen-
0002-9149/03/$–see front matter 439
doi:10.1016/S0002-9149(03)00662-3

TABLE 1 Patient Characteristics and Medical History Before
Enhanced External Counterpulsation (EECP)
Variable (n ⫽ 4,592)
Age (yrs) (range) 66.7 ⫾ 10.8 (30–101)
Men 75.1%
White 93.5%
Duration of coronary artery disease 10.8 ⫾ 8.2
(yrs)
Prior myocardial infarction 67.3%
Congestive heart failure 31.6%
Unstable angina pectoris 3.2%
Prior coronary angioplasty 65.0%
Prior coronary bypass 67.3%
Prior revascularization 85.7%
Multivessel coronary disease 75.2%
Left ventricular ejection fraction (%)* 46.5 ⫾ 13.9
Diabetes mellitus 41.4%
Hypertension 70.0%
Hyperlipidemia 79.4%
Noncardiac vascular disease 30.3%
Past or present smoking 70.6%
*Ejection fraction was ⬍35% for 18.7% of patients.
tation, and increasing venous return and cardiac out-
put.1 The cuffs are deflated at the end of ventricular
diastole, decreasing peripheral resistance to flow and
providing left ventricular unloading.2 EECP is typi-
cally used to treat patients with angina refractory to
conventional medical therapy and poor candidates for
revascularization with angioplasty or bypass surgery.
EECP has consistently been shown to be effective in
treating patients with angina using various measures,
including: improved functional class,3,4 reduced angi-
nal symptoms,5,6 improved quality-of-life indexes,7–9
improved stress radionuclide perfusion,10,11 increased
exercise time,12,13 and increased time to ST-segment
depression.14 Treatment with EECP has also been
demonstrated to increase nitric oxide levels and de-
crease malondialdehyde, a marker of lipid peroxida-
tion, as well as to decrease endothelin-1 levels.15–17
The benefit of EECP has been shown to be sustained
at 3 and 5 years after treatment by radionuclide stress
testing and quality-of-life measures.18,19
The International EECP Patient Registry (IEPR)
was organized to evaluate—across a broad range of
providers and patients—the patterns of use, safety,
and efficacy of EECP by consecutively tracking the
results and side effects of EECP therapy at partic-
ipating centers (currently 106). This report summa-
rizes the results of the IEPR. We characterized the
patients’ demographics, evaluated the safety and
effectiveness of EECP, and determined which pa-
tient characteristics predict a successful response to
treatment with EECP.
•••
The IEPR at the Epidemiology Data Center of the
University of Pittsburgh Graduate School of Public
Health was initiated in January 1998 to sequentially
track—across a broad spectrum of participating pro-
viders—the demographics, entry characteristics, and
outcomes of all patients with angina treated with
EECP. The IEPR has completed enrollment of 5,000
440 THE AMERICAN JOURNAL OF CARDIOLOGY姞
patients who will be followed for 3 years. Patients
who underwent their first EECP were used for the
present analysis.
EECP was typically prescribed for 35-hour ses-
sions, 1 hour/day, over a period of 7 weeks. During
treatment sessions, patients were routinely monitored
by electrocardiography, pulse oximetry, finger pleth-
ysmography; a nurse was in attendance, and a super-
vising physician was immediately available. An initial
history and subsequent interval history was obtained
before each treatment, at the end of therapy, and at 6
months after treatment. Interval end points included
an evaluation of Canadian Cardiovascular Society
(CCS) anginal functional class, angina frequency, ni-
troglycerin use, changes in medications, quality of
life, and interim events (major adverse cardiovascular
events such as death, myocardial infarction, and re-
vascularization). Success was defined as a decrease of
at least 1 CCS angina class after a course of treatment.
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
defined as p ⬍0.05. Logistic regression analysis was
used to determine independent predictors decreases in
angina class. All factors showing an association with
reduction in angina with a p value of ⬍0.2 were put
into the model and a backward selection technique
was used to determine significant independent predic-
tors. Additional analyses were done to determine in-
dependent predictors of a decrease in angina class for
those with and without severe (CCS class III or IV)
angina.
As of June 2002, there were 5,000 patients enrolled
from 106 EECP treatment sites (6 international and
100 in the United States).20 Only patients with no
previous EECP treatment on enrollment in the Regis-
try were analyzed in this report (n ⫽ 4,592). Patients
completed a mean of 34 ⫾ 10 hours of treatment, with
83.1% completing the course as prescribed. Patients’
characteristics, medical history, and cardiovascular
risk factors at the start of EECP are listed in Table 1.
Cardiac medications included ␤ blockers (65.7%), cal-
cium channel blockers (46.1%), angiotensin-convert-
ing enzyme inhibitors (38.3%), angiotensin receptor
blockers (10.0%), long-acting nitrates (74.8%), lipid-
lowering medications (67.5%), and aspirin (70.9%).
Major adverse cardiovascular events occurring
over the course of therapy were low and included
death in 0.3% of patients, myocardial infarction in
0.9%, coronary bypass in 0.2%, and angioplasty in
0.8%. Exacerbation of heart failure was noted in 1.9%
of patients and unstable angina in 2.8%. These latter
events were not attributed to EECP by the investiga-
tors. There were no reported incidences of pulmonary
embolism. Minor adverse events included 1.4% of
patients with skin breakdown and 1.0% with muscu-
loskeletal problems attributable to EECP treatment.
No clinically important arrhythmias were reported,
suggesting that arrhythmias are not a major concern
during EECP.
It is well known that the amplitude or area under
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
increases the effectiveness of enhanced external counterpulsation. Clin Cardiol
1998;21:841–844.
14. Arora RR, Chou TM, Jain D, Fleischmann B, Crawford L, McKiernan T,
Nesto RW. The Multicenter Study of Enhanced External Counterpulsation
(MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and
anginal episodes. JACC 1999;33:1833–1840.
15. Qian X-X, Wu W-K, Zheng Z-S, Zhan C-Y, Yu B-Y, Lawson WE, Hui JCK.
Effect of enhanced external counterpulsation on lipid peroxidation in coronary
disease (abstr). J Heart Dis 1999;1:116.
16. Gui-Fu W, Qiang-Sun Z, Zhen-Sheng Z, Miao-Qing Z, Lawson WE, Hui
JCK. A neurohormonal mechanism for the effectiveness of enhanced external
counterpulsation (abstr). Circulation 1999;100:I–832.
17. Qian X-X, Wu W-K, Zheng Z-S, Zhan C-Y, Yu B-Y, Lawson WE, Hui JCK.
Effect of enhanced external counterpulsation on nitric oxide production in cor-
onary disease (abstr). J Heart Dis 1999;1:193.
18. Lawson WE, Hui JCK, Zheng ZS, Oster Z, Katz J, Diggs P, Burger L,
Cohn CD, Soroff HS, Cohn PF. Three-year sustained benefit from enhanced
external counterpulsation in chronic angina pectoris. Am J Cardiol 1995;75:
840 –841.
19. Lawson WE, Hui JC, Cohn PF. Long-term prognosis of patients with angina
treated with enhanced external counterpulsation: five-year follow-up study. Clin
Cardiol 2000;23:254 –258.
20. Lawson WE, Kennard ED, Holubkov R, Kelsey SF, Strobeck JE, Soran O,
Feldman AM, for the IEPR Investigators. Benefit and safety of enhanced external
counterpulsation in treating coronary artery disease patients with a history of
congestive heart failure. Cardiology 2001;96:78 –84.
21. Soran O, Fleishman B, Demarco T, Grossman W, Schneider VM, Manzo
K, de Lame P-A, Feldman AM. Enhanced external counterpulsation in pa-
tients with heart failure: a multicenter feasibility study. Congest Heart Fail
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