Cardiovascular clinics最新文献

Percutaneous transluminal angioplasty is an established method of revascularization in a variety of arterial stenotic conditions. When applied to specific morphologic and clinical indications, it can be very effective. It appears to be the procedure of choice for focal stenotic lesions of the iliac and femoropopliteal system. Its role in infrapopliteal atherosclerotic disease is less certain, but more optimistic, with recent reports. New methods for preventing restenosis and abrupt closure are currently being developed, and they appear to be promising as adjunctive therapy with mechanical catheter-directed intervention. The future of these adjunctive agents will likely improve the outcome and reduce the immediate failure rates of angioplasty. Other modalities, including thermal laser angioplasty and atherectomy, also appear to have a promising future. These methods, coupled with better endoluminal guidance, such as ultrasound, will help guide the interventional procedure more precisely and hopefully broaden the application and improve the outcome.

The central aim of this review was to examine the application of intervention therapy for CAD in the elderly population. The data reviewed indicates that it is no longer appropriate to use age 70 or 75 as the upper limit of eligibility for thrombolytic intervention in patients with acute myocardial infarction. Elderly who are physiologically active without contraindications to thrombolytic therapy should be considered eligible. Additional controlled trials specifically targeted at the elderly population are needed to better define the precise dosing regimen and the magnitude and extent of bleeding complications in this group. Nevertheless, it appears appropriate to recommend thrombolytic intervention for most eligible elderly patients presenting with acute myocardial infarction. This recommendation is based on the fact that the higher mortality in the elderly results in more lives saved per patient treated than for younger patients. It is important to reemphasize that this recommendation is for treating elderly patients with acute infarction as suggested by ST-segment elevation and/or Q waves, without contraindications to thrombolytic therapy. Those with non-Q-wave infarctions, hypertension, recent stroke, history of bleeding, or other contraindications are not candidates. Regarding intervention therapy in other elderly patients with acute and chronic manifestations of coronary disease, results also appear very encouraging. Elderly patients appearing to tolerate PTCA include those with all forms of angina from chronic stable angina to unstable angina. Although only observational data are on hand at present, our review suggests these elderly patients tolerate PTCA well and indeed may benefit. The elderly patients who have co-morbid factors that adversely influence the application of CABG for revascularization may be the best candidates for PTCA. At present, the challenge for the physician is to carefully assess each elderly patient on an individual basis for intervention therapy. This evaluation should be aimed at identifying factors that may permit application of intervention treatment to the elderly patients who are most likely to receive the greatest benefit.

The decision to proceed with cardiac valve surgery in patients older than 70 years must be made with careful deliberation. Clearly, the risks of surgery are increased, but the potential benefits in rehabilitating the individual back to a productive and full life are real. An aggressive surgical approach should be taken in patients with aortic stenosis. More caution should be used in advocating mitral valve or double-valve replacement in the elderly, especially when other factors place these individuals in a high-risk category. Both patients and their families should be fully aware of the potential risks and benefits in weighing their decision to proceed with surgical therapy.