Acute coronary occlusion with vs. without ST elevation: impact on procedural outcomes and long-term all-cause
Mohammed Abusharekh1, Jürgen Kampf1, Iryna Dykun1
1Department of Cardiology and Vascular Medicine, The West German Heart and Vascular Center Essen, University Hospital Essen, Hufeland Street 55, 45147 Essen, Germany.
Insights
Patients with non-ST-elevation myocardial infarction (NSTEMI) experiencing acute total occlusion (ATO) face similar risks and mortality rates as those with ST-elevation myocardial infarction (STEMI). This suggests classifying myocardial infarction by occlusion status is more informative.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Myocardial Infarction Research
Background:
- Acute total occlusion (ATO) is frequently observed in non-ST-elevation myocardial infarction (NSTEMI) patients.
- The prognostic implications of ATO in NSTEMI compared to ST-elevation myocardial infarction (STEMI) require further investigation.
Purpose of the Study:
- To compare procedural outcomes and long-term mortality in patients with STEMI and NSTEMI, stratified by the presence or absence of ATO.
- To evaluate the clinical significance of classifying acute myocardial infarction (AMI) based on arterial occlusion status.
Main Methods:
- Retrospective analysis of 2269 AMI patients undergoing coronary angiography (2004-2019).
- ATO defined by TIMI 0-1 flow or TIMI 2-3 with peak troponin >100x upper limit of normal.
- Multivariable Cox regression used to assess the association between presentation and long-term mortality.
Main Results:
- 471 (29.3%) of 1605 NSTEMI patients had ATO.
- ATO-positive NSTEMI patients showed higher rates of cardiogenic shock and no-reflow compared to ATO-negative NSTEMI and STEMI patients.
- ATO-positive NSTEMI and STEMI were associated with significantly increased long-term mortality (1.60 and 1.55 hazard ratios, respectively) compared to ATO-negative NSTEMI.
Conclusions:
- NSTEMI patients with ATO exhibit unfavorable procedural outcomes and increased long-term mortality, mirroring outcomes seen in STEMI.
- The presence of arterial occlusion is a critical factor in determining prognosis for AMI patients.
- Classifying AMI by occlusion status, rather than solely by STEMI vs. NSTEMI, may offer a more accurate prognostic framework.
Background:
Acute total occlusion (ATO) is diagnosed in a substantial proportion of patients with non-ST-elevation myocardial infarction (NSTEMI). We compared procedural outcomes and long-term mortality in patients with STEMI with NSTEMI with vs. without ATO.
Methods And Results:
We included patients with acute myocardial infarction (AMI) undergoing invasive coronary angiography between 2004 and 2019 at our centre. Acute total occlusion was defined as thrombolysis in myocardial infarction (TIMI) 0-1 flow in the infarct-related artery or TIMI 2-3 flow with highly elevated peak troponin (>100-folds the upper reference limit). Association between presentation and long-term mortality was evaluated using multivariable adjusted Cox regression analysis. From 2269 AMI patients (mean age 66 ± 13.2 years, 74% male), 664 patients with STEMI and 1605 patients with NSTEMI (471 [29.3%] with ATO) were included. ATO(+)NSTEMI patients had a higher frequency of cardiogenic shock and no reflow than ATO(-)NSTEMI with similar rates compared with STEMI patients (cardiogenic shock: 2.76 vs. 0.27 vs. 2.86%, P < 0.0001, P = 1; no reflow: 4.03 vs. 0.18 vs. 3.17%, P < 0.0001, P = 0.54). ATO(+)NSTEMI and STEMI were associated with 60 and 55% increased incident mortality, respectively, as compared with ATO(-)NSTEMI (ATO(+)NSTEMI: 1.60 [1.27-2.02], P < 0.0001, STEMI: 1.55 [1.24-1.94], P < 0.0001). Likewise, left ventricular ejection fraction (48.5 ± 12.7 vs. 49.1±11 vs. 50.6 ± 11.8%, P = 0.5, P = 0.018) and global longitudinal strain (-15.2 ± -5.74 vs. -15.5 ± -4.84 vs. -16.3 ± -5.30%, P = 0.48, P = 0.016) in ATO(+)NSTEMI were comparable to STEMI but significantly worse than in ATO(-)NSTEMI.
Conclusion:
Non-ST-elevation myocardial infarction patients with ATO have unfavourable procedural outcomes, resulting in increased long-term mortality, resembling STEMI. Our findings suggest that the occlusion perspective provides a more appropriate classification of AMI than differentiation into STEMI vs. NSTEMI.
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