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1. All of the following statements about the impact of age on coronary revascularization are true except:

a. Compared to older patients, patients < 40 years of age typically have fewer cardiac risk factors and less extensive disease
b. PTCA success rates among elderly patients (65-75 years) exceed 90%; however, there is increased risk of death after acute closure and a 2-3 fold increase in peripheral vascular complications and blood transfusion
c. CABG and PTCA achieve similar long-term survival rates for patients between the ages of 65-75 years
d. Compared to younger patients, octogenarians have more acute complications and late cardiac death after PTCA

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Answer: Although coronary artery disease typically occurs with advancing age, 3-6% of patients are less than 40 years old. Compared to older patients, young patients typically have more cardiac risk factors and less extensive disease. Compared to younger patients, elderly patients (age 65-75 years) undergoing coronary revascularization are more often female, and they are more likely to have diffuse disease, calcified lesions, unstable angina, prior MI, comorbid conditions, and low ejection fractions. Nevertheless, elective use of CABG, PTCA, and stents can be performed with success rates > 90% and major complication rates of 3-13%. However, the elderly are at increased risk of death after acute closure, and they have a 2-3 fold increased risk of peripheral vascular complications (pseudoaneurysm, AV fistula, large hematoma) and blood transfusions. Patients between the ages of 65-75 with symptomatic coronary artery disease should be offered percutaneous or surgical revascularization; CABG and PTCA/stent achieve similar long-term survival rates. However, PTCA/stent is associated with less in-hospital morbidity and mortality, but more repeat procedures are needed to treat recurrent angina. Procedural success can be achieved in 85% of patients > 80 years old. Compared to younger patients, octogenarians have more acute complications and late cardiac death.  (Answer: a)

2. After accounting for differences in the prevalence of diabetes mellitus, hypertension, unstable angina, and prior MI, gender still has a significant independent effect on PTCA outcome:

a. True
b. False

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Answer: Several studies suggest that females have a higher in-hospital mortality than males. However, females are older and have a higher prevalence of diabetes mellitus, hypertension, unstable angina, and prior MI. After accounting for these differences, gender has little or no independent effect on outcome; a report from BARI suggested improved outcome for females. (Answer: b)

3. Most studies indicate that PTCA outcome is independent of race:

a. True
b. False

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Answer:  Despite greater comorbidity and coronary risk factors among African-Americans, results from the 1985-1986 NHLBI PTCA Registry indicate that PTCA outcome is independent of race. In a report using non-balloon devices, procedure-related death was higher among blacks, which may have been due to a higher prevalence of comorbid conditions. (Answer: a)

4. All of the following statements about diabetics are true except:

a. Compared to non-diabetics, patients with diabetes have a 2-3 fold higher rate of coronary disease, and they are at increased risk of myocardial infarction, congestive heart failure, and death
b. Compared to non-diabetics undergoing bypass surgery, diabetics have more in-hospital stroke, late MI, and repeat revascularization
c. Acute procedural successful rates for PTCA are similar between diabetics and non-diabetics
d. In the Bypass Angioplasty Revascularization Investigation (BARI), 5-year mortality rates for diabetics with multivessel disease were independent of the mode of initial revascularization
e. In RAVEL, PCI using a sirolimus-eluting stent resulted in less restenosis than use of a standard (bare) stent

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Answer:  Compared to nondiabetics, patients with diabetes mellitus have a 2-3 fold higher rate of coronary disease, and they are at increased risk of myocardial infarction, congestive heart failure, and cardiac mortality. Compared to nondiabetics, patients with diabetes have more in-hospital deaths and strokes, reduced long-term survival, and more late MI, CABG, and PTCA. Approximately 20-25% of diabetics die within 5 years of CABG. Even after correction for differences in baseline characteristics (unstable angina, lower EF, multivessel disease, other comorbidity), diabetes mellitus is still an independent predictor of adverse outcome. Approximately 10-20% patients submitted for percutaneous intervention have diabetes mellitus. Most PTCA series indicate similar acute success rates (- 90%) among diabetics and nondiabetics, despite more unstable angina, prior MI, prior CABG, peripheral vascular disease, coronary calcification, and lower ejection fractions in diabetics. In the Bypass Angioplasty Revascularization Investigation (BARI) trial, PTCA patients with diabetes had higher 5-year mortality compared to CABG patients with diabetes (35% vs. 19%, p = 0.0024). In CAVEAT-I, compared to non-diabetics undergoing directional atherectomy, diabetics had more angiographic restenosis (60% vs 47%) and more frequent bypass surgery (12.8% vs 8.5%). Results from STRESS I-II trials suggest that stenting maybe preferred to PTCA in diabetics, but restenosis rates after stenting remain higher in diabetics vs. non-diabetics. Recent results from RAVEL reported less restenosis among 19 diabetics treated with a sirolimus-coated stent compared to  25 diabetics treated with a standard stent (0% vs. 47%) (Answer: d, e)

5. PTCA patients on chronic dialysis have more ischemic and vascular complications, late cardiac events, and restenosis than PTCA patients not on dialysis:

a. True
b. False

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Answer: PTCA of chronic dialysis patients is associated with high rates of ischemic and vascular complications, and frequent clinical recurrence. In the largest report to date, patients on hemodialysis undergoing PTCA or CABG had 2-3 fold higher mortality at 1 and 12 months compared to the general PTCA population.  (Answer: a)

6. All of the following statements about cardiac transplantation patients are true except:

a. Coronary artery disease is the leading cause of death among patients who survive more than 1-year after cardiac transplantation
b. Angina pectoris is a common manifestation of coronary disease
c. Diltiazem and lipid lowering agents may reduce the progression of allograft vasculopathy
d. PTCA can be performed with acceptable success and complication rates

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Answer:  Coronary artery disease is the leading cause of death among patients who survive more than one year after cardiac transplantation, and affects 20-40% of allografts 1-5 years after transplantation. Angiographic abnormalities range from focal stenoses to diffuse involvement of the entire epicardial coronary circulation. Because allograft hearts are denervated, angina pectoris is distinctly uncommon — clinical presentations typically include silent myocardial infarction, heart failure, or sudden death. Unfortunately, medical therapy and surgical revascularization are relatively ineffective: Medical therapy is empiric and consists of risk factor modification, immunosuppressive and antiplatelet agents, diet, and exercise. Diltiazem (30-90 mg orally 3 times/day) and lipid lowering agents may retard the progression of coronary disease and are uniformly recommended. PTCA, atherectomy, and stents have been applied to small numbers of patients. Combined data show success rates of 91% and in-hospital mortality in 5%.  (Answer: b)

7. Elective PTCA for patients with silent ischemia is safe, relieves objective evidence of ischemia, and improves 1-year survival:

a. True
b. False

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Answer: The presence of silent ischemia increases the risk of adverse cardiac events. Findings from the Asymptomatic Cardiac Ischemia Pilot (ACIP) trial suggest that compared to medical therapy alone, revascularization may improve the extent and frequency of exercise-induced ischemia, anginal status, and 1-year survival. Elective PTCA on patients with silent ischemia is safe and effective. The ACIP and other ongoing randomized trials will determine whether suppression of silent ischemia by PTCA or bypass surgery improves long-term outcome.  (Answer: a)