Coronary collaterals in patients with ST-elevation myocardial infarction presenting late after symptom onset
Anne Freund1,2,3, Thomas Stiermaier4,5, Suzanne de Waha-Thiele4,5
1Heart Center Leipzig, Department of Internal Medicine/Cardiology, University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany. anne.freund@medizin.uni-leipzig.de.
Insights
Well-developed coronary collaterals in ST-elevation myocardial infarction (STEMI) patients presenting late after symptom onset significantly reduce infarct size and long-term mortality. This highlights the prognostic importance of collateral circulation in STEMI outcomes.
Area of Science:
- Cardiology
- Cardiovascular Research
- Interventional Cardiology
Background:
- The prognostic role of coronary collaterals in ST-elevation myocardial infarction (STEMI) is debated, particularly in patients with delayed presentation.
- Existing research often focuses on early STEMI presentation, leaving the impact of collaterals in late-presenting patients less understood.
Purpose of the Study:
- To investigate the prognostic significance of coronary collateralization in STEMI patients presenting with prolonged ischemia, 12-48 hours after symptom onset.
- To assess the impact of collateralization on microvascular obstruction, infarct size, and long-term mortality in this patient group.
Main Methods:
- Subanalysis of a randomized trial involving STEMI patients presenting 12-48 hours post-symptom onset.
- Assessment of coronary collateralization using the Rentrop classification in 95 patients with TIMI flow grade 0 or 1 prior to PCI.
- Magnetic resonance imaging (MRI) to quantify microvascular obstruction and infarct size.
- Four-year follow-up to determine long-term mortality.
Main Results:
- 65% of patients had poor collateralization (Rentrop grade 0 or 1), while 35% had well-developed collaterals (Rentrop grade 2 or 3).
- Patients with well-developed collaterals showed significantly smaller areas of microvascular obstruction (2.1% vs. 4.5% LV, p=0.03) and infarct size (27.9% vs. 34.8% LV, p=0.047).
- Four-year mortality was substantially lower in patients with good collateralization (6% vs. 25%, p=0.02).
- Poor collateralization independently predicted long-term mortality, alongside cardiogenic shock and unsuccessful PCI.
Conclusions:
- Sufficient coronary collateralization positively influences microvascular obstruction and infarct size in late-presenting STEMI patients.
- Good collateralization is associated with reduced long-term mortality in STEMI patients presenting 12-48 hours after symptom onset.
- Coronary collateral status is a crucial independent predictor of long-term outcomes in STEMI.
Background:
The role of coronary collaterals in ST-elevation myocardial infarction (STEMI) remains controversial. So far, studies examining the effect of collaterals on outcome mainly focused on patients presenting early after symptom onset. We sought to investigate the prognostic influence of coronary collateralization in patients presenting with prolonged ischemia late after symptom onset.
Methods And Results:
The study is a subanalysis of a randomized trial addressing thrombus aspiration in STEMI patients presenting between 12 and 48 h after symptom onset with a follow-up period of a minimum of 4 years. A total of 95 patients with a Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 or 1 prior to percutaneous coronary intervention (PCI) were included in the analysis. Of these, 62 patients (65%) had none or poor coronary collateralization according to the Rentrop classification (Rentrop grade 0 or 1) compared to 33 (35%) with well-developed collateralization (Rentrop grade 2 or 3). In comparison, patients with well-developed collateralization had a smaller area of microvascular obstruction (2.1 ± 3.8 vs. 4.5 ± 4.9% of left ventriclular mass (%LV), p = 0.03) and infarct size (27.9 ± 11.7 vs. 34.8 ± 17.2% LV, p = 0.047) on magnetic resonance imaging. Further, mortality at 4-years follow-up was lower (6% Rentrop grade 2 or 3 vs. 25% Rentrop grade 0 or 1, p = 0.02). Poor collateralization was an independent predictor of long-term mortality on multivariate Cox regression analyses in addition to cardiogenic shock and unsuccessful PCI during the index procedure.
Conclusion:
Sufficient coronary collateralization has a positive impact on microvascular obstruction, infarct size and long-term mortality in STEMI patients presenting between 12 and 48 h after symptom onset.
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