Data on the long-term prognosis of percutaneous coronary intervention (PCI) in young patients are limited. The aim of the present study was to report the immediate and long-term clinical outcomes in a consecutive series of young patients with premature coronary artery disease who underwent PCI with stent implantation. During the study period (2005 to 2010), 214 consecutive patients aged ≤40 years who had undergone PCI with a bare metal stent or drug-eluting stent implantation were retrospectively selected and analyzed. Primary end point of this study was the incidence of major adverse cardiac and cerebrovascular events at short- and long-term follow-up. Mean age was 36.3 ± 3.5 years and 88.3% of patients were men. Three-quarters were active smokers and all patients had ≥1 conventional cardiovascular risk factor. The total number of implanted stents was 272 (154 bare metal stent and 118 drug-eluting stent). During the hospital stay, no patient died, and the incidence of major adverse cardiac and cerebrovascular events was 2.3%. No additional events had occurred at 30 days of follow-up. At a median follow-up of 757 days (interquartile range 365 to 1,818), the overall death rate was 0.9%, and a new revascularization procedure was needed in 12.6% of patients. The major adverse cardiac and cerebrovascular event-free survival rate at the median follow-up point and 1,818 days was 89.6% and 84.2%, respectively. Active smoking and left ventricular ejection fraction <50% were independent predictors of major adverse cardiac and cerebrovascular events. In conclusion, PCI in young patients lead to excellent results in short- and long-term follow-up and should be considered as the treatment of choice. Traditional risk factors are important prognostic determinants of adverse events and might help identify higher risk patients within this cohort.
Previous studies have reported the prognosis of percutaneous coronary intervention (PCI) to be good in young patients ; however, most of the evidence has been from retrospective analyses performed in the prestent or pre–drug-eluting stent (DES) era on heterogeneous populations in which the upper age limit ranged widely. Data on immediate and long-term clinical outcomes of “modern” PCI in young patients are still lacking. Thus, the aim of the present study was to report the immediate and long-term clinical outcomes in a consecutive series of young patients with premature coronary artery disease (CAD) who underwent PCI with stent implantation.
Methods
All consecutive patients aged ≤40 years treated with PCI and stent implantation (bare metal stent or DES) from 2005 to 2010 at 5 tertiary care centers were retrospectively selected and analyzed. No patient was excluded from the analysis. All data related to hospital admissions, procedures, and outcomes were collected in each center using the hospital recording network. Information regarding the clinical status at the latest clinical follow-up available was collected by clinical visits and telephone interviews and from the referring physician. After the procedure, if not contraindicated, all patients were advised to continue lifelong aspirin and either 250-mg ticlopidine twice daily or 75-mg clopidogrel for 1 to 12 months or more, if appropriate.
All patients provided written informed consent, and the ethical committee approved the database.
In the present report, the following events were analyzed cumulatively at the latest clinical follow-up point available: cardiac and overall death, myocardial infarction (MI), cerebrovascular accident, target lesion revascularization, and target vessel revascularization. The occurrence of stent thrombosis was defined on the basis of the Academic Research Consortium definitions. Stent thrombosis was defined as acute, subacute, late, and very late if the event occurred within 24 hours, 30 days, <1 year, or >1 year after the procedure, respectively. Deaths were classified as cardiac or noncardiac. Cardiac death was defined as any death from a cardiac cause (e.g., MI, low-output failure, fatal arrhythmia), procedure-related deaths, and death from an unknown cause. Target lesion revascularization was defined as any repeat intervention of the target lesion or other complication of the target lesion. The target lesion was defined as the treated segment 5 mm proximally to the stent and 5 mm distally to the stent. Target vessel revascularization was defined as any repeat intervention of any segment of the target vessel, defined as the entire major coronary vessel proximal and distal to the target lesion, including upstream and downstream branches and the target lesion itself. Cerebrovascular accidents were defined as stroke, transient ischemic attacks, and reversible ischemic neurologic deficits adjudicated by a neurologist and confirmed by computed tomography scanning. Non–Q-wave MI was defined as elevation of the serum creatinine kinase isoenzyme MB 3 times the upper limit of normal. Q-wave MI was defined as the development of new pathologic Q waves in ≥2 contiguous leads with or without creatinine kinase or creatinine-MB levels elevated above normal.
The primary end point of our study was the incidence of major adverse cardiac and cerebrovascular events (MACCE), including death (distinguished as noncardiac death and cardiac death), MI, cerebrovascular accidents, and any revascularization (repeat PCI or coronary artery bypass grafting) at short- and long-term follow-up.
Because the central limit theorem ensures that, after a sample size >30 has been reached, the mean of a continuous variable has an approximately normal distribution, all continuous variables are reported as the mean ± standard deviation and categorical variables are expressed as frequencies. Cumulative event rates were evaluated using Kaplan-Meier estimates and compared using the log-rank test. Univariate and multivariate analyses were performed to identify independent predictors of adverse events. Specifically, all variables significantly associated with the clinical event of interest on univariate analysis (p <0.10) were entered into subsequent models. After appropriate checks for underlying assumptions, multivariate Cox proportional hazard analyses were performed, with the enter method for all pertinent covariates. The results of the multivariate Cox analyses are reported as hazard ratios, with the 95% confidence intervals and p values.
A 2-tailed p value <0.05 was considered statistically significant. All analyses were performed with SPSS for Windows, version 13.0.1 (SPSS, Chicago, Illinois).
Results
The baseline characteristics are summarized in Tables 1 and 2 . During 2005 to 2010, 214 patients aged ≤40 years underwent PCI with stent implantation. Of the 214 patients, 88% were men, 77% were active smokers, and approximately 6 of 10 had hypertension, hypercholesterolemia, or a family history of CAD. Diabetes was present in only 7% of the population. The most common clinical presentation was ST-segment elevation MI (57%), followed by acute coronary syndrome/non–ST-segment elevation MI (32.7%). Finally, 4 patients (1.9%) had a previous diagnosis of autoimmune/rheumatic disease and 4 patients (1.9%) were habitual cocaine users. Single-vessel disease was present in 3/4 of patients, often involving the left anterior descending artery (53.7%). The mean lesion length was 20.2 ± 10.9 mm. A total of 154 bare metal stents and 118 DESs were implanted. Compared to bare metal stents, the DESs were smaller (3 ± 0.41 mm vs 3.7 ± 0.9 mm) and longer (29 ± 15.6 mm vs 19.3 ± 6.8 mm). Evidence of spontaneous dissection was rare (0.9%). The mean left ventricular ejection fraction was 53.6% ± 8.7%. At discharge, almost all patients were prescribed statins (92.6%) and ≥1 antihypertensive agent (β blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers were prescribed in 79%, 71.5%, and 14% of patients, respectively).
| Characteristic | Value |
|---|---|
| Age (years) | 36.3 ± 3.5 |
| Men | 189 (88.3%) |
| Hypertension (>140/90 mm Hg) | 132 (61.7%) |
| Hypercholesterolemia (>200 mg/dl) | 114 (53.3%) |
| Diabetes mellitus | 15 (7.0%) |
| Active smokers | 165 (77.1%) |
| Renal failure | 2 (0.9%) |
| Chronic heart failure | 0 (0.0%) |
| Cocaine use | 4 (1.9%) |
| Use of contraceptive pill | 12 (5.6%) |
| Autoimmune disease | 3 (1.4%) |
| Previous acute myocardial infarction | 8 (3.7%) |
| Previous coronary artery bypass grafting | 3 (1.4%) |
| Previous percutaneous coronary intervention | 4 (1.9%) |
| Clinical presentation | |
| Silent ischemia | 10 (4.7%) |
| Stable angina | 12 (5.6%) |
| Acute coronary syndrome/non–ST-segment elevation myocardial infarction | 70 (32.7%) |
| ST-segment elevation myocardial infarction | 122 (57.0%) |
| Left ventricular ejection fraction (%) | 53.6 ± 8.7 |
| Home medications | |
| Statins | 11 (5.1%) |
| β Blockers | 10 (4.7%) |
| Angiotensin-converting enzyme inhibitors | 10 (4.7%) |
| Angiotensin receptor blockers | 3 (1.4%) |
| Acetylsalicylic acid | 3 (1.4%) |
| Clopidogrel | 2 (0.9%) |
| Oral hypoglycemic agents | 3 (1.4%) |
| Insulin | 9 (4.2%) |
| Characteristic | Value |
|---|---|
| Multivessel coronary disease | 57 (26.6%) |
| Diseased coronary artery | |
| Left main | 4 (1.9%) |
| Left anterior descending | 115 (53.7%) |
| Left circumflex | 72 (33.6%) |
| Right | 85 (39.7%) |
| Evidence of spontaneous dissection | 2 (0.9%) |
| Reference vessel diameter (mm) | 3.2 ± 0.42 |
| Vessels treated per patient | 1.22 ± 0.5 |
| Lesions treated per patient | 1.3 ± 0.6 |
| Lesion length | 20.2 ± 10.9 |
| Bifurcations | 49 (22.9%) |
| Stents per patient | 1.2 ± 0.51 |
| Bare metal stents | 154 |
| Bare metal stents per patient | 1.17 ± 0.43 |
| Bare metal stent total length (mm) | 19.3 ± 6.8 |
| Bare metal stent diameter (mm) | 3.7 ± 0.9 |
| Drug-eluting stents | 118 |
| Drug-eluting stents per patient | 1.33 ± 0.56 |
| Drug-eluting stent total length (mm) | 29 ± 15.6 |
| Drug-eluting stent diameter (mm) | 3 ± 0.41 |
| Predilation | 125 (58.4%) |
| Postdilation | 133 (62.1%) |
| Medications at discharge | |
| Statins | 198 (92.6%) |
| β Blockers | 169 (79.0%) |
| Angiotensin-converting enzyme inhibitors | 153 (71.5%) |
| Angiotensin receptor blockers | 30 (14.0%) |
| Acetylsalicylic acid | 210 (98.1%) |
| Clopidogrel | 206 (96.3%) |
| Ticlopidine/prasugrel | 8 (3.7%) |
| Proton pump inhibitors | 141 (65.9%) |
| Oral hypoglycemic agents | 5 (2.3%) |
| Insulin | 13 (6.1%) |
| Mean duration of dual antiplatelet therapy (days) | 170.6 ± 142.4 |
The incidence of in-hospital, short-term (30-day) and long-term adverse events are reported in Table 3 . During the hospital stay, no patient died, and no cerebrovascular accident was recorded. MI occurred in 5 patients. One patient underwent repeat PCI because of an MI due to acute stent thrombosis (in-stent thrombosis with a bare metal stent). The incidence of in-hospital MACCE (hierarchically reported) was 2.3%. At 30 days of follow-up, no additional adverse event occurred. At a median follow-up of 757 days (interquartile range 365 to 1,818), the overall mortality was 0.9% (2 patients died from cardiac causes), and the incidence of MI was 3.7%. A new revascularization procedure was needed in 12.6% of patients (target vessel revascularization 6.5%, other vessel PCI 4.7%, and coronary artery bypass grafting 1.4%). Definite or probable stent thrombosis occurred in 3 patients (1.4%). On multivariate analysis, active smoking and left ventricular ejection fraction <50% were independent predictors of MACCE (p = 0.01, 95% confidence interval 1.3 to 8.24; and p = 0.03, 95% confidence interval 1.1 to 8.34, respectively; Table 4 ).
| Variable | n (%) |
|---|---|
| In-hospital events | |
| Death | 0 (0.0%) |
| Myocardial infarction | 5 (2.3%) |
| Q-wave myocardial infarction | 1 (0.5%) |
| Cerebrovascular accident | 0 (0.0%) |
| Repeat percutaneous coronary intervention | 1 (0.5%) |
| Coronary artery bypass grafting | 0 (0.0%) |
| Major adverse cardiac and cerebrovascular events | 5 (2.3%) |
| Stent thrombosis | 1 (0.5%) |
| Events at 30 days of follow-up | |
| Death | 0 (0.0%) |
| Myocardial infarction | 0 (0.0%) |
| Q-wave myocardial infarction | 0 (0.0%) |
| Cerebrovascular accident | 0 (0.0%) |
| Repeat percutaneous coronary intervention | 0 (0.0%) |
| Coronary artery bypass grafting | 0 (0.0%) |
| Major adverse cardiac and cerebrovascular events | 0 (0.0%) |
| Stent thrombosis | 0 (0.0%) |
| Events at long-term follow-up (median 757 days; interquartile range 365–1,818) | |
| Cardiac death | 2 (0.9%) |
| Noncardiac death | 0 (0.0%) |
| Myocardial infarction | 8 (3.7%) |
| Target lesion revascularization | 12 (5.6%) |
| Target vessel revascularization | 14 (6.5%) |
| Other vessel percutaneous coronary intervention | 10 (4.7%) |
| Cerebrovascular accident | 0 (0.0%) |
| Coronary artery bypass grafting | 3 (1.4%) |
| Major adverse cardiac and cerebrovascular events | 31 (14.5%) |
| Definite/probable stent thrombosis | 3 (1.4%) |
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