A contemporary re-evaluation of culprit lesion severity in patients presenting with STEMI
Liam M McCormick1, Stephen P Hoole, Adam J Brown
1Department of Interventional Cardiology, Papworth Hospital, Cambridge, UK.
Insights
ST-segment elevation myocardial infarction (STEMI) culprit lesions are angiographically significant, similar to stable lesions. This study re-evaluated stenosis severity in STEMI patients, finding anatomical severity comparable to stable coronary artery disease.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Biology
Background:
- Historical data link plaque rupture to myocardial infarction, but recent studies highlight hemodynamically significant stenoses (FFR ≤ 0.8) and high plaque burden (MLA < 4 mm² by IVUS) as prognostically important.
- The prognostic significance of culprit stenosis severity in ST-segment elevation myocardial infarction (STEMI) requires re-evaluation.
Purpose of the Study:
- To re-evaluate the severity of culprit stenosis in patients presenting with STEMI.
- To compare the anatomical and functional significance of culprit lesions in STEMI with stable coronary artery disease.
Main Methods:
- Quantitative coronary angiography (QCA) was performed after thrombus aspiration in 336 STEMI patients undergoing primary percutaneous coronary intervention (PPCI).
- Measurements included reference area (RA), minimum luminal area (MLA), and percentage area stenosis (AS).
- QCA and fractional flow reserve (FFR) were measured in 50 stable angina patients with intermediate lesions for validation.
Main Results:
- STEMI culprit lesions showed similar anatomical severity (AS: 91.6 ± 9.5%) compared to stable lesions (AS: 90.1 ± 8.1%).
- Angiographically severe lesions were more likely to be functionally significant by FFR (P = 0.02).
- Functionally significant lesions were more likely to be anatomically severe (P = 0.002).
Conclusions:
- Contemporary data indicate that STEMI culprit lesions, assessed by luminal stenosis post-thrombus aspiration, are angiographically significant.
- The severity of these STEMI lesions is comparable to stable, ischemia-inducing lesions.
Background:
Historical data report fatal myocardial infarction occurring when mildly-stenotic coronary plaques rupture; however, recent data suggest haemodynamically-significant coronary stenoses with fractional flow reserve (FFR) ≤ 0.8 and vessels with high plaque burden and minimum luminal area (MLA) < 4 mm(2) by intravascular ultrasound (IVUS) may be prognostically important. Therefore, we sought to re-evaluate culprit stenosis severity in patients presenting with ST-segment elevation myocardial infarction (STEMI).
Methods:
Patients undergoing primary percutaneous coronary intervention (PPCI) for STEMI with adjunctive thrombectomy between October 2008 and February 2010 (n = 336/572; 59%) underwent quantitative coronary angiography (QCA) after thrombus aspiration to determine vessel reference area (RA), MLA and percentage area stenosis (AS). To validate findings, QCA and FFR were measured in 50 patients with stable angina and an angiographically-intermediate lesion.
Results:
STEMI patients had anatomically-severe underlying culprit disease similar to that of the stable cohort (AS: 91.6 ± 9.5% versus 90.1 ± 8.1%; P = 0.11). Additionally, anatomically-severe lesions defined by QCA were more likely to be functionally-significant by FFR and vice-versa (P = 0.02 and 0.002 respectively).
Conclusion:
These contemporary data suggest that STEMI culprit lesions, defined by luminal stenosis after thrombus aspiration, are angiographically significant, with similar stenosis severity to stable, ischaemia-inducing lesions.
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