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Acute Coronary Occlusions in NSTEMI Undergoing Percutaneous Coronary Intervention: Insights From the CathPCI Registry
Riyad Yazan Kherallah1, Syed Zaid2, Yazan Assaf1
1Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA.
Background:
Patients may present with acute coronary occlusions (ACOs) without manifesting electrocardiographic criteria for ST-segment elevation myocardial infarction (STEMI).
Objectives:
The aim of this study was to examine the incidence, clinical characteristics, and in-hospital outcomes of non-ST-segment elevation myocardial infarction (NSTEMI) with ACO.
Methods:
The study included patients with STEMI and NSTEMI in the CathPCI Registry who underwent percutaneous coronary intervention between April 1, 2018, and June 30, 2023. ACO was defined as 100% stenosis deemed acute. The cohort was stratified into STEMI (including STEMI equivalents), NSTEMI-ACO, and NSTEMI-no-ACO. The primary outcome was a composite of in-hospital stroke, myocardial infarction, or cardiovascular mortality. A sensitivity analysis with ACO defined as 100% acute occlusion or TIMI flow grade 0 or 1 in the culprit artery was performed.
Results:
Of 1,198,544 patients, 26.1% had STEMI, 11.0% had NSTEMI-ACO (15% of whom had NSTEMI), and 62.9% had NSTEMI-no-ACO. Compared with those with NSTEMI-no-ACO, NSTEMI-ACO patients had more cardiogenic shock (9.0% STEMI vs 3.8% NSTEMI-ACO vs 1.9% NSTEMI-no-ACO; P < 0.001), ventricular arrhythmias (4.9% vs 2.0% vs 1.3%; P < 0.001), and in-hospital cardiac arrest (6.1% vs 2.7% vs 1.6%; P < 0.001). Patients with NSTEMI-ACO had a higher risk for the primary composite compared with those with NSTEMI-no-ACO (adjusted OR: 2.26; 95% CI: 2.18-2.34; P < 0.001) but a lower risk compared with those with STEMI (adjusted OR: 0.54; 95% CI: 0.52-0.56; P < 0.001). Using a definition of ACO including TIMI flow grade 0 or 1, NSTEMI-ACO accounted for 216,054 presentations (24.4% of NSTEMI). In-hospital outcomes were similarly worse compared with NSTEMI-no-ACO and better compared with STEMI.
Conclusions:
ACO occurs in a substantial proportion of patients with NSTEMI and is associated with worse in-hospital outcomes relative to those with NSTEMI-no-ACO. Further studies of early identification and reperfusion practices for NSTEMI-ACO are warranted.