Culprit Lesion Detection in Patients Presenting With Non-ST Elevation Acute Coronary Syndrome and Multivessel Disease
Matthew Mercieca Balbi1, Paola Scarparo1, Maria Natalia Tovar1
1Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands.
Insights
Identifying the culprit lesion in non-ST elevation acute coronary syndrome (NSTE-ACS) with multivessel disease (MVD) is challenging. Coronary angiography identified the culprit lesion in 86% of patients, with intravascular imaging improving accuracy when needed.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Non-ST elevation acute coronary syndrome (NSTE-ACS) management relies on identifying the culprit lesion for revascularization.
- Multivessel coronary disease (MVD) presents challenges in pinpointing the specific culprit lesion.
Purpose of the Study:
- To investigate the rate of culprit lesion identification in patients with NSTE-ACS and MVD using coronary angiography.
- To evaluate the utility of complementary imaging techniques and clinical outcomes associated with culprit lesion identification.
Main Methods:
- Analysis of consecutive NSTE-ACS patients with MVD (January 2012-December 2016).
- Evaluation of coronary angiograms, intravascular imaging, and ECGs for culprit lesion detection.
- Long-term follow-up for major adverse cardiac events (MACE) and mortality.
Main Results:
- The culprit lesion was identified in 86% of 1107 patients by angiography; 14% had unclear culprits.
- Higher lesion complexity correlated with difficulty in identification.
- Intravascular imaging identified the culprit lesion in 96.4% of cases where applied.
- No significant differences in mortality or MACE between groups with and without angiographic culprit identification.
Conclusions:
- Coronary angiography fails to identify the culprit lesion in over 10% of NSTE-ACS patients with MVD.
- Intravascular imaging significantly improves diagnostic accuracy for culprit lesion detection in complex cases.
Background/Purpose:
Identification of the culprit lesion in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) allows appropriate coronary revascularization but may be unclear in patients with multivessel coronary disease (MVD). Therefore, we investigated the rate of culprit lesion identification during coronary angiography in NSTE-ACS and multivessel disease.
Methods/Materials:
Consecutive patients presenting with NSTE-ACS and MVD, between January 2012 and December 2016 were evaluated. Coronary angiograms, intravascular imaging, and ECGs were analyzed for culprit lesion identification. Long-term clinical outcomes in terms of major adverse cardiac events (MACE) and mortality were reported in patients with or without culprit identification.
Results:
A total of 1107 patients with NSTE-ACS and MVD were included in the analysis, 310 (28.0%) with unstable angina and 797 (72.0%) with non-ST elevation myocardial infarction. The culprit lesion was angiographically identified in 952 (86.0%) patients, while no clear culprit lesion was found in 155 (14.0%) patients. ECG analysis allowed to predict the location of the culprit vessel with low sensitivity (range 28.4%-36.7%) and high specificity (range 90.6%-96.5%). Higher lesion complexity was associated with inability to identify the culprit. Intravascular imaging was applied in 55 patients and helped to identify the culprit lesion in 53 patients (96.4%). There was no difference in all-cause mortality (21.4% vs. 25.8%, p = 0.24) and MACE (39.2% vs. 47.6%, p = 0.07) between the cohorts with or without culprit lesion identification by angiography.
Conclusions:
The culprit lesion appeared unclear by coronary angiography in >10% of patients with NSTE-ACS and MVD. Complementary invasive imaging substantially enhanced the diagnostic accuracy of culprit lesion detection.
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