Angina Treatments—Lasers And Normal Therapies in Comparison - ATLANTIC (Angina)
To compare transmyocardial revascularization (TMR) with standard medical therapy in patients with medically refractory angina pectoris.
Patients Screened: Not given
Patients Enrolled: 182
Canadian Cardiovascular Society Angina Class III or IV despite maximum tolerated dosages of at least two anti-anginal drugs. Reversible perfusion defects.
Ejection fraction <30%, recent unstable angina or change in anginal pattern.
Change in exercise duration on a standard protocol
Quality of life, angina, dipyramidole thallium stress test
Patients were randomized to TMR with continued medical therapy (n=92) or medical therapy alone (n=90). TMR was applied under general anesthesia through a limited muscle sparing left thoracotomy with a holmium:YAG laser.
5% of the TMR patients and 10% of the medical therapy patients died during the study. Unstable angina requiring hospitalization occurred in 37 patients of the TMR group vs 69 patients in the medical therapy group. Heart failure or left ventricular dysfunction occurred in 25 patients of the TMR group vs 10 patients in the medical therapy group, and myocardial infarction was noted in 14 and 8 patients of the TMR and medical therapy group, respectively. Exercise duration increased in the TMR group at all time points, with median improvement of >60 seconds. Over 50% of the medical therapy group had a decrease in their exercise time. At 12 months, total exercise time increased by a median of 65 seconds in the TMR group and decreased by 46 seconds in the medical therapy group (p<0.0001). Only 26% of the TMR patients had angina during the final exercise test, compared with 58% of the medical therapy group. After 12 months, CCSA score had decreased by greater than or equal to 2 scores in 61% of the TMR group vs only 11% in the medical therapy group. Patients with more severe angina at baseline were more likely to have greater improvement with TMR. At 12 months 48% of the TMR group vs only 14% of the medical therapy group were in CCSA Class less than or equal to 2 (p<0.001). The quality of life index score increased significantly more in the TMR group than in the medical treatment group. However, the change in the percentage of myocardium with fixed and reversible perfusion defects at 3, 6 and 12 months was comparable between the TMR and medical therapy group. LVEF did not change in the medical therapy group from baseline to 3 months, whereas it decreased by 3% in the TMR group (p<0.0001).
TMR was more effective than medical therapy alone in alleviating symptoms of angina and increasing exercise performance. However, it was not associated with improvement in myocardial perfusion, as assessed by dipyridamole thallium scan. TMR may provide benefits in patients with no other therapeutic options.
Clinical Topics: Anticoagulation Management, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Statins, Acute Heart Failure
Keywords: Follow-Up Studies, Morphine, Holmium, Purinergic P2Y Receptor Antagonists, Thoracotomy, Thrombosis, Catheterization, Exercise Test, Myocardial Infarction, Drug-Eluting Stents, Heparin, Percutaneous Coronary Intervention, Body Mass Index, Quality of Life, Thrombectomy, Heart Failure, Thallium, Organoplatinum Compounds, Coronary Artery Bypass, Ventricular Dysfunction, Left, Dipyridamole, Lasers, Solid-State, Diabetes Mellitus
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