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Exercise testing after chronic total coronary occlusion revascularization in patients with STEMI and a concurrent
Anna van Veelen1, Ivo M van Dongen1,2, Joëlle Elias1
1Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, The Netherlands.
Insights
Chronic total occlusion percutaneous coronary intervention (CTO PCI) reduced exercise chest pain in STEMI patients. Successful CTO PCI was linked to more ventricular ectopy (VE) during exercise, warranting further study.
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- Hypoxic myocardium in chronic total occlusion (CTO) territories can trigger ventricular ectopy (VE) and angina during exercise.
- Percutaneous coronary intervention (PCI) aims to restore blood flow to ischemic regions.
Purpose of the Study:
- To evaluate the impact of CTO PCI on exercise-induced ventricular ectopy (VE) and symptoms.
- To assess the role of CTO PCI in managing ST-segment elevation myocardial infarction (STEMI) patients.
Main Methods:
- Analysis of exercise electrocardiograms (X-ECGs) from the EXPLORE-trial sub-study.
- Randomized comparison of CTO PCI versus no-CTO PCI in 302 STEMI patients at 4-month follow-up.
Main Results:
- CTO PCI group showed a significant reduction in exercise-induced chest pain (0% vs. 8.5%).
- No significant difference in exercise duration, endurance, ST-deviation, or heart rate between groups.
- Successful CTO PCI correlated with increased VE frequency (26% vs. 8%), without affecting sustained arrhythmias or mortality.
Conclusions:
- CTO PCI in STEMI patients may reduce exercise-related chest pain and increase maximum systolic blood pressure.
- Successful CTO PCI is associated with higher VE during exercise, a finding requiring further investigation.
Objectives:
To assess the effect of chronic total occlusion percutaneous coronary intervention (CTO PCI) on ventricular ectopy (VE) and symptomatology during exercise testing.
Background:
During exercise, the hypoxic myocardium in the CTO-territory can act as a substrate for VE and could lead to anginal complaints.
Methods:
In the EXPLORE-trial, 302 ST-segment elevation myocardial infarction (STEMI)-patients were randomized to CTO PCI or no-CTO PCI. For this sub-study, we analyzed all available exercise electrocardiograms (X-ECGs) at 4 months follow-up on symptoms and electrocardiographic parameters.
Results:
A total of 155 X-ECGs were available, 80 in the CTO PCI group (51.6%) and 75 in the no-CTO PCI group (48.4%). There were no differences regarding exercised time, achieved endurance, ST-deviation nor maximum heart-rate. The percentage of patients experiencing chest-pain during exercise was lower in the CTO PCI group (0% vs. 8.5%, p = .03). Also, there was a trend towards a higher maximum systolic blood pressure (SBP, 185 mmHg vs. 175, p = .09). No difference in VE was found between randomization groups, but patients with successful CTO PCI had a higher frequency of VE, compared to failed and no-CTO PCI (26% vs. 8%, p = .02). This did not result in higher frequencies of sustained ventricular arrhythmias or mortality.
Conclusion:
In conclusion, in STEMI-patients, CTO PCI is associated with a small reduction of chest-pain during exercise and tended to be associated with an increase of maximum SBP. The observation that successful CTO PCI was associated with more VE during exercise, compared with failed/no-CTO PCI needs further exploration.
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