Multiple culprit arteries in patients with ST segment elevation myocardial infarction referred for primary
Peter M Pollak1, Shailja V Parikh, Muhammed Kizilgul
1Department of Internal Medicine, Division of Cardiology, University of Virginia, Charlottesville, Virginia, USA.
Insights
Patients with ST-segment elevation myocardial infarctions and multiple culprit arteries are unique. This population experiences high rates of cardiogenic shock without a clear cause.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- ST-segment elevation myocardial infarction (STEMI) typically involves a single occluded coronary artery.
- Multiple culprit arteries in STEMI are rare but present a distinct clinical challenge.
Purpose of the Study:
- To describe the characteristics and outcomes of patients with STEMI and multiple culprit arteries.
- To analyze baseline features, electrocardiographic and angiographic findings, and clinical course.
Main Methods:
- Case series analysis of 18 patients with STEMI and angiographically confirmed multiple culprit arteries.
- Inclusion of a literature review of 29 additional patients for a total cohort of 47.
- Summary of demographic, clinical, laboratory, and outcome data.
Main Results:
- The cohort was predominantly male (85%) with a history of tobacco use (49%).
- Nearly one-third presented with inferior STEMI, yet 50% had simultaneous occlusions in the right and left anterior descending coronary arteries.
- Over one-third of patients experienced hemodynamic instability and cardiogenic shock upon presentation.
Conclusions:
- Patients with STEMI and multiple culprit arteries represent a unique, high-risk population.
- High rates of cardiogenic shock are observed in this group.
- No clear predisposing factors were identified in most cases.
Abstract:
In most cases of acute ST-segment elevation myocardial infarction, only 1 epicardial artery contains an occluding thrombus, commonly referred to as the "culprit" artery. Rarely, however, patients present with >1 acutely thrombosed coronary artery (i.e., "multiple culprits"). The investigators present their experience with 18 patients presenting with ST-segment elevation myocardial infarctions and angiographically documented multiple culprit arteries, provide a detailed review of an additional 29 patients previously reported, and summarize baseline characteristics, pertinent electrocardiographic and angiographic findings, laboratory values, and clinical outcomes for all 47 patients. In this case series, most patients were men (85%) with histories of tobacco use (49%). Although nearly 1/3 of the patients had isolated inferior ST-segment elevation on initial 12-lead electrocardiography, 50% of them had simultaneous thrombotic occlusions of the right coronary and the left anterior descending coronary arteries documented on coronary angiography. These patients were hemodynamically unstable on presentation, with >1/3 in cardiogenic shock. In most cases, no other potential predisposing factors were identified. In conclusion, patients with multiple culprit arteries in the setting of ST-segment elevation myocardial infarctions represent a unique population with high rates of cardiogenic shock and no clear cause.
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