Diagnostic delays and cardiovascular mortality in left circumflex culprit ST-segment elevation myocardial infarction:
Dorian Garin1, Nolan Grin1, Diego Arroyo1
1Department of Cardiology, University and Hospital Fribourg, 1708, Fribourg, Switzerland.
Insights
Left circumflex artery (LCx) occlusions in ST-segment elevation myocardial infarction (STEMI) cause diagnostic delays and larger infarcts but have favorable long-term outcomes for survivors. Early mortality is higher, but prognosis improves significantly after 30 days.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Left circumflex artery (LCx) occlusions in ST-segment elevation myocardial infarction (STEMI) present unique clinical characteristics.
- Understanding the management and outcomes associated with LCx culprit lesions is crucial for optimizing patient care.
Purpose of the Study:
- To compare short-term management patterns and short- and long-term outcomes of STEMI patients with LCx culprit lesions versus non-LCx culprits.
- To investigate the impact of LCx occlusions on diagnostic times, infarct size, left ventricular ejection fraction (LVEF), and cardiovascular mortality.
Main Methods:
- Prospective registry of STEMI patients undergoing primary percutaneous coronary intervention.
- Comparison of process times, peak enzyme levels (CK-MB), LVEF, and cardiovascular mortality between LCx and non-LCx culprit groups.
- Multivariable generalized linear and Cox models were used for analysis.
Main Results:
- LCx culprit lesions were identified in 13.8% of STEMI patients.
- LCx occlusions were associated with diagnostic delays (6.7 min longer), higher peak CK-MB levels, and preserved LVEF compared to non-LCx culprits.
- Increased 30-day cardiovascular mortality was observed in the LCx group (adjusted HR 4.13).
Conclusions:
- LCx culprit lesions in STEMI are linked to diagnostic delays, larger enzymatic infarcts, and increased early cardiovascular mortality, despite preserved LVEF.
- Survivors of LCx-related STEMI beyond 30 days demonstrated favorable long-term prognoses, with no increased mortality at 1 year and a trend towards better 5-year survival.
- These findings suggest a distinct clinical trajectory for LCx culprit lesions in STEMI, necessitating tailored management strategies.
Objective:
ST-segment elevation myocardial infarction (STEMI) due to left circumflex artery (LCx) occlusion presents with a different phenotype from other culprit lesions. We assessed whether LCx culprits had different short-term management patterns and short- and long-term outcomes.
Methods:
The prospective Evaluation of a Fast-Track Protocol for ST-Elevation Myocardial Infarction registry included all consecutive patients with STEMI treated with primary percutaneous coronary intervention from June 2008 to November 2024. Process times, peak enzymes, left ventricular ejection fraction (LVEF), and cardiovascular (CV) mortality were compared in LCx and non-LCx culprits using multivariable generalized linear and Cox models.
Results:
Among 1205 patients, 166 (13.8%) had LCx culprit. LCx prolonged first medical contact to diagnosis by 6.7 min (p < 0.001); peak CK-MB was higher (+48 U L-1, p = 0.004), yet LVEF was 5.8 percentage points higher (p < 0.0001) than non-LCx. LCx showed increased 30-day CV mortality (adjusted HR 4.13; p = 0.001). Among survivors after 30 days, LCx showed no increased 1-year mortality (HR 0.62; p = 0.66) and trend toward better 5-year survival (HR 0.21; p = 0.12).
Conclusion:
LCx culprit lesions in our fast-track STEMI network showed diagnostic delays, larger enzymatic infarcts despite preserved LVEF, and increased early CV mortality. This contrasts with favorable long-term outcomes among survivors at 30 days, who indicated better prognosis than did survivors of left anterior descending and right coronary artery lesions.
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