Residual high-grade angina after enhanced external counterpulsation therapy

McCullough, Peter A.; Henry, Timothy D.; Kennard, Elizabeth D.; Kelsey, Sheryl F.; Michaels, Andrew D.; for the IEPR Investigators,

doi:10.1016/j.carrev.2006.12.003

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Volume 8, Issue 3 , Pages 161-165, July 2007

Residual high-grade angina after enhanced external counterpulsation therapy☆

Peter A. McCullough
- Department of Medicine, Divisions of Cardiology, Nutrition and Preventive Medicine, William Beaumont Hospital, Royal Oak, MI 48073, USA
- Corresponding author. Divisions of Cardiology, Nutrition, and Preventive Medicine, William Beaumont Hospital, 4949, Colidge Highway, Royla Oak, MI 48073, USA. Tel.: +1 248 655 5948; fax: +1 248 655 5901.
Timothy D. Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA
Elizabeth D. Kennard
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
Sheryl F. Kelsey
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
Andrew D. Michaels
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, UT, USA
for the IEPR Investigators

Received 6 December 2006; accepted 12 December 2006.

Abstract

Objective

We evaluated the degree of residual angina on the outcomes of enhanced external counterpulsation (EECP) therapy for chronic stable angina.

Background

Angina refractory to medical therapy is common in the pool of patients who are not completely revascularized by angioplasty or bypass surgery.

Methods

We examined 902 patients enrolled from 1998 to 2001 in the Second International Enhanced External Counterpulsation Patient Registry. Baseline and outcome variables were stratified by the last recorded Canadian Cardiovascular Society class.

Results

Residual Class 3 (12.1%) or 4 (2.3%) angina was uncommon among patients with severe coronary artery disease after treatment with EECP. Prevalence of diabetes, hypertension, dyslipidemia, and heart failure was similar among the anginal post-EECP anginal classes. Multivessel coronary disease was more common in those with higher-grade angina at completion. More frequent and severe angina at entry was more common in those with the higher anginal classes at EECP (P<.001). There were no differences in the rates of chronic medications utilized or prior revascularization. At 3-year follow-up, rates of death, myocardial infarction, percutaneous coronary intervention, and coronary artery bypass surgery tended to be higher across increasing residual angina classes. The composite cardiac event rates were 34%, 33%, and 44% for those with Class 0, Class 1/2, and Class 3/4 angina at EECP completion (P=.01), respectively. Multivariate analysis for the composite endpoint found residual Class 3/4 angina (OR=1.59, 95% CI=1.19–2.17, P=.002), diabetes (OR=1.57, 95% CI=1.23–2.01, P=.0003), age (per decile OR=1.17, 95% CI=1.04–1.31, P=.007), and greater EECP augmentation (OR=0.79, 95% CI=0.65–0.96, P=.02) as significant predictors.

Conclusions

Residual high-grade angina after EECP occurs in those with more severe angina and multivessel disease at baseline and is associated with cardiac events over the next 3 years. These data suggest that close clinical observation and intensive management of those with high-grade angina post-EECP are warranted.

Keywords: Coronary artery disease, Angina, Enhanced external counterpulsation, Cardiac events, Mortality