The role of coronary collateral circulation in patients presenting with acute left main coronary artery occlusion

Introduction Acute occlusion of the unprotected left main coronary artery (LMCA) is an uncommon occurrence associated with a dismal prognosis. Whereas the role of early recruited coronary collateral circulation (CC) in prognosis of ST-segment elevation acute myocardial infarction (STEMI) patients is still controversial, it seems to be important in patients with acute LMCA occlusion. This study aimed to evaluate the coronary CC in patients with acute LMCA occlusion and its impact in short and long-term outcomes. Methods In a retrospective two-center study, we identified 7630 patients with STEMI or high-risk non-ST segment elevation myocardial infarction who underwent emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analyzed 83 patients who presented with unprotected LMCA acute occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and classified them in 2 groups based on the degree of CC through the right coronary artery as seen in the emergent angiography: patients with no filling of collateral vessels or filling of collateral vessels without any epicardial filling of the occluded vessel [Rentrop class 0–1 (71 patients)]; and patients with partial or complete epicardial filling by collateral vessels [CC Rentrop class 2–3 (12 patients)]. Results Compared to patients with CC Rentrop 0–1, patients with CC Rentrop 2–3 presented significantly later to medical attention (symptom to coronary angiography time 8.7 vs 4.3 hours, p=0.02). Despite that, patients with CC Rentrop 2–3 had a significantly lower prevalence of cardiogenic shock at admission (16.7 vs 57.7%, p=0.01). During hospitalization, Killip class III-IV presentation (33.3 vs 88.7%, p<0.001) and inotropic/vasopressor therapy use (25.0 vs 69.0%, p=0.01) were less frequent in CC Rentrop 2–3 patients. The CC Rentrop 2–3 group had a significantly lower in-hospital (16.7 vs 53.5%, p=0.02) and 30-day mortality (9.1 vs 52.2%, p=0.01). In patients surviving hospitalization there was no significant difference in 1-year (30.0 vs 19.4%, p=0.48) and 5-year mortality (70.0 vs 77.4%, p=0.68). Conclusion A well-developed coronary CC was associated to lower short-term mortality in patients presenting with acute occlusion of the unprotected LMCA. Nevertheless, in patients surviving index-event, there was no difference in the long-term outcomes. Further studies are needed to clarify if clinical approach (eg. early short-term mechanical circulatory support) of patients with CC Rentrop 0–1 should be different from those with CC Rentrop 2–3 in order to improve the outcomes of the former patients. FUNDunding Acknowledgement Type of funding sources: None.

Association Between Surrogate Index of Insulin Resistance and Coronary Collateral Circulation in Patients with Coronary Chronic Total Occlusion Lesions

Background: Recent studies have substantiated the role of triglyceride glucose index (TyG index) in the prognosis of coronary artery disease (CAD) patients while no relevant studies revealed the association between TyG index and coronary collateral circulation (CCC) in the event of coronary chronic total occlusion (CTO). Our study intends to explore whether or to what extent TyG index is associated with less developed CCC in CAD patients with CTO lesions.Methods: The study enrolled 1093 ACS patients undergoing percutaneous coronary intervention (PCI) for at least one CTO lesion. Relevant data was collected from Beijing Anzhen Hospital record system. The degree of collaterals was determined according to Rentrop classification system. The correlation between TyG index and coronary collateralization was assessed.Results: Overall, 318 patients were divided into poor CCC group. TyG index was significantly higher in patients with poor CCC (9.3±0.65 vs. 8.8±0.53, P＜0.001). After adjusting for various confounding factors, TyG index remained to be correlated with the occurrence of poor CCC, with an ORs (95% CIs) of 1.59 (1.07-2.36) in T2 group and 5.72 (3.83-8.54) in T3 group compared with the first tertile. Besides, subgroup analysis showed that higher TyG index values remained to be strongly associated with increased risks of poor CCC. Lastly, to compare the risk assessment efficacy for the formation of CCC between TyG index and glycosylated hemoglobin A1c (HbA1c) and another insulin resistance (IR) surrogate marker triglyceride-to-high-density lipoprotein cholesterol ratio, area under the receiver-operating characteristic (ROC) curve (AUC) was obtained, a significant improvement on the risk assessment performance for the poor CCC emerged when adding TyG index into a baseline model [AUC, 0.629 for baseline model vs. 0.724 for baseline model + TyG index vs. 0.638 for baseline model +HbA1c vs. 0.721 for baseline model +TG/HDL-C, P<0.001; net reclassification improvement (NRI) for TyG index, 0.238, P＜0.001; integrated discrimination improvement (IDI) for TyG index, 0.103, P＜0.001].Conclusions: The TyG index is strongly associated with the occurrence of poor CCC in CAD patients with CTO lesions and its risk assessment performance is better than HbA1c and TG-to-HDL-C ratio.

Non-high-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio serve as a predictor for coronary collateral circulation in chronic total occlusive patients

Objective The present study investigated the potential correlation between non-high-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio (non-HDL-C/HDL) and the formation of coronary collateral circulation (CCC) in coronary artery disease cases with chronic total occlusive (CTO) lesions. Methods Two experienced cardiologists identified and selected patients with CTO lesions for retrospective analysis. The 353 patients were divided into a CCC poor formation group (Rentrop 0–1 grade, n = 209) and a CCC good formation group (Rentrop 2–3 grade, n = 144) based on the Cohen-Rentrop standard. A comparison of non-HDL-C/HDL ratios between the two groups was performed. The Spearman test was used to obtain the correlation between the cholesterol ratio and Rentrop grade. Independent predictors of CCC were analyzed using logistic regression. Receiver operating characteristic (ROC) curve analysis was also performed to quantify the predictive value of research indicator. Results The non-HDL-C/HDL ratio in the CCC poor formation group was elevated markedly compared to the CCC good formation group [( 3.86 ± 1.40) vs ( 3.31 ± 1.22), P = 0.000]. The Spearman test results indicated that non-HDL-C/HDL negatively correlated with Rentrop grade (r = − 0.115, P = 0.030). Multivariate logistic regression analysis showed that non-HDL-C/HDL ratio was an independent predictor of CCC formation (OR = 1.195, 95%CI = 1.020–1.400, P = 0.027). The area under the curve of ROC for detecting CCC poor formation was 0.611 (95% CI: 0.551–0.671, P = 0.000) with an optimal cut-off value of 2.77. Conclusion Non-HDL-C/HDL negatively correlated with the formation of CCC and served as an independent predictor of CCC formation, which may be used as a biomarker for the evaluation of CCC.

Systemic immune inflammation index: a novel predictor for coronary collateral circulation

Aim: Recently, a new inflammatory and prognostic marker has emerged called as Systemic Immune Inflammation Index (SII). In the current study, we searched the relation between SII and Coronary Collateral Circulation (CCC) formation in stable Coronary Artery Disease (CAD). Materials & methods: 449 patients with stable CAD who underwent coronary angiography and documented coronary stenosis of 95% or more in at least one major coronary vessel were included in the study. The study patients were divided into two groups according to the Rentrop score as well CCC (Rentrop 2–3) and bad CCC (Rentrop 0–1). Blood samples for SII and other laboratory parameters were gathered from all the patients on admission. The SII score was formulized as platelet × neutrophil/lymphocyte counts. Results: Patients, who had developed bad CCC had a higher C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), platelets/lymphocyte ratio (PLR) and SII levels compared to those who had developed well CCC (p < 0.001, for all). Multivariate logistic regression analysis showed that high levels of SII was an independent predictor of bad CCC (OR: 1.005, 95% confidence interval (CI): 1.003–1.006, p < 0.001) together with dyslipidemia, high levels of CRP and NLR. In Receiver Operator Characteristic curve (ROC) analysis, the optimal cutoff value of SII to predict poor CCC was found to be 729.8, with 78.4% sensitivity and 74.6% specificity (area under ROC curve = 0.833 (95% CI: 0.777–0.889, p < 0.001). Conclusion: We have demonstrated that SII, a novel cardiovascular risk marker, might be used as one of the independent predictors of CCC development.

Relationship Between C-Reactive Protein to Albumin Ratio and Coronary Collateral Circulation in Patients With Stable Coronary Artery Disease

We investigated the relationship between the C-reactive protein (CRP) to albumin ratio (CAR) and coronary collateral circulation (CCC) in stable coronary artery disease (CAD). Patients with stable CAD (n = 354) who underwent coronary angiography for suspected CAD and had a total occlusion ≥1 major coronary artery were included in the study. The participants were divided into 2 groups according to the Rentrop score as satisfactory CCC (Rentrop 2-3) and poor CCC (Rentrop 0-1). Patients who had poor CCC had a higher CRP, neutrophil/lymphocyte ratio (NLR), and CAR levels compared with those who had satisfactory CCC ( P < .001, P = .046, P < .001, respectively). The CAR (odds ratio: 3.522, 95% CI: 2.515-4.932, P < .001), CRP, NLR, and diabetes mellitus were independent predictors of poor CCC. In receiver operator characteristic curve (ROC) analysis, the optimal cutoff value of CAR to predict poor CCC was 1.27 (area under ROC curve = 0.735 [95% CI: 0.667-0.803], P < .001). A raised CAR may be an independent predictor of poor CCC.