Acute Occlusion of the Infarct-Related Artery as a Predictor of Very Long-Term Mortality in Patients with Acute Myocardial Infarction

Aim. The survey’s aim was to examine the significance of infarct-related artery (IRA) occlusion (verified angiographically) on very long-term outcomes of patients with acute myocardial infarction, within the STEMI and NSTEMI diagnosis. Methods. A single-center, nonrandomized, registry-based study on patients treated for acute coronary syndrome with percutaneous coronary intervention between June 2011 and December 2016 was conducted. Patients with angiographically proven IRA occlusion (100% stenosis with TIMI flow 0 distal to occlusion) were categorized as occlusive myocardial infarction (OMI) and patients with patent IRA (50–99% stenosis with TIMI 1–3 flow) were categorized as nonocclusive myocardial infarction (NOMI) and very long-term outcomes were analyzed. Data were collected prospectively from the hospital’s PCI registry and the database of the Croatian Institute of Public Health. Results. A total of 2450 patients were included in the study. 796 (32.5%) patients had NOMI and 1654 patients (67.5%) had OMI. According to ECG changes, 1534 patients presented with STEMI (62,6%) and 916 with NSTEMI (37,8%). 88% of STEMI patients presented with OMI and 12% with NOMI, while patients with NSTEMI in 33,8% presented with OMI and in 66,81% with NOMI. A median follow-up was 4.7 years. There was no significant difference in cardiovascular mortality between the groups (14.8% vs 13.1%; OMI vs NOMI, respectively; p = 0.374 ) neither in all-cause mortality (19% vs 21.5%; OMI vs NOMI, respectively; p = 0.374 ). Patients with NSTEMI had a significantly higher very long-term mortality (21.6% vs 18.1%; NSTEMI vs STEMI, respectively; p = 0.029 ). Conclusion. The main findings of the study are as follows: (1) total IRA occlusion was not associated with higher long-term mortality; (2) NSTEMI was associated with a higher mortality rate compared with STEMI, independent of angiographic presentation (OMI/NOMI); (3) IRA occlusion was not associated with significantly higher mortality rates in patients with STEMI and NSTEMI, respectively.

Total Occlusion of the Infarct-Related Artery in Non-ST-Elevation Myocardial Infarction (NSTEMI)—How Can We Identify These Patients?

Background and Objectives: Regardless of the improvement in key recommendations in non-ST-elevation myocardial infarction (NSTEMI), the prevalence of total occlusion (TO) of infarct-related artery (IRA), and the impact of TO of IRA on outcomes in patients with NSTEMI, remain unclear. Aim: The study aimed to assess the incidence and predictors of TO of IRA in patients with NSTEMI, and its clinical significance. Material and Methods: The study was a single-center retrospective cohort analysis of 399 consecutive patients with NSTEMI (293 male, mean age: 71 ± 10.1 years) undergoing percutaneous coronary intervention. The study population was categorized into patients with TO and non-TO of IRA on coronary angiography. In-hospital and one-year mortality were analyzed. Results: TO of IRA in the NSTEMI population occurred in 138 (34.6%) patients. Multivariate analysis identified the following independent predictors of TO of IRA: left ventricular ejection fraction (odds ratio (OR) 0.949, p < 0.001); family history of coronary artery disease (CAD) (OR 2.652, p < 0.001); and high-density lipoprotein (HDL) level (OR 0.972, p = 0.002). In-hospital and one-year mortality were significantly higher in the TO group than the non-TO group (2.8% vs. 1.1%, p = 0.007 and 18.1% vs. 6.5%, p < 0.001, respectively). The independent predictors of in-hospital mortality were: left ventricular ejection fraction (LVEF) at admission (OR 0.768, p = 0.004); and TO of IRA (OR 1.863, p = 0.005). Conclusions: In the population of patients with NSTEMI, TO of IRA represents a considerably frequent phenomenon, and corresponds with impaired outcomes. Therefore, the utmost caution should be paid to prevent delay of coronary angiography in NSTEMI patients with impaired left ventricular systolic function, metabolic disturbances, and a family history of CAD, who are at increased risk of TO of IRA.

The impact of bifurcation lesion in infarct-related artery of NSTE-ACS patients

Introduction Angioplasty of bifurcation lesions remains challenging. In most studies, long-term outcomes were less favourable compared to non-bifurcation lesions. Patients with bifurcation lesions were excluded from most of the randomised studies of AMI. Purpose The aim of this study was to determine the prognostic impact of bifurcation lesion on three-year outcome in a prospective cohort of NSTE-ACS patients. Bifurcation lesions (BFLs) remain a challenging lesion subset, often associated with lower success rates than less complex lesions. There are few data regarding the impact of BFLs in the setting of NSTE-ACS. Methods Patients admitted for NSTE-ACS and indication for coronary angiography were prospectively evaluated. Patients were divided into 2 groups according to whether infarct-related-artery lesions were vs. were not a bifurcation lesion. Major outcomes were assessed at 3 years. Results A total of 296 patients were evaluated: mean age was 62±12 years and 58% were male. The three-year mortality was 12.2% (36 patients) and the three-year MACCE was 26.4% (78 patients). The bifurcation lesion group included 62 patients (20.9%).The three-year mortality and MACCE in the patients of the bifurcation lesion group was significantly higher (19.4% vs. 10.3%; p=0.046) and (45.2% vs. 21.4%; p≤10–3) respectively. Conclusion In NSTE-ACS, bifurcation lesions portend worse prognosis. This may guide prognostication and decision making in treatment. FUNDunding Acknowledgement Type of funding sources: None. MACCE occurrence: Bifurcation impact

Sex Differences in the Non-infarct-Related Artery-Based Quantitative Flow Ratio in Patients With ST-Elevation Myocardial Infarction: A Retrospective Study

Introduction: It has been reported that sex has well-established relationships with the prevalence of coronary artery disease (CAD) and the major adverse cardiovascular events. Compared with men, the difference of coronary artery and myocardial characteristics in women has effects on anatomical and functional evaluations. Quantitative flow ratio (QFR) has been shown to be effective in assessing the hemodynamic relevance of lesions in stable coronary disease. However, its suitability in acute myocardial infarction patients is unknown. This study aimed to evaluate the sex differences in the non-infarct-related artery (NIRA)-based QFR in patients with ST-elevation myocardial infarction (STEMI).Methods: In this study, 353 patients with STEMI who underwent angiographic cQFR assessment and interventional therapy were included. According to contrast-flow QFR (cQFR) standard operating procedures: reliable software was used to modeling the hyperemic flow velocity derived from coronary angiography in the absence of pharmacologically induced hyperemia. 353 patients were divided into two groups according to sex. A cQFR ≤0.80 was considered hemodynamically significant, whereas invasive coronary angiography (ICA) luminal stenosis ≥50% was considered obstructive. Demographics, clinical data, NIRA-related anatomy, and functional cQFR values were recorded. Clinical outcomes included the NIRA reclassification rate between men and women, according to the ICA and cQFR assessments.Results: Women were older and had a higher body mass index (BMI) than men. The levels of diastolic blood pressure, troponin I, peak creatine kinase-MB, low-density lipoprotein cholesterol, N terminal pro B-type natriuretic peptide, stent diameter, and current smoking rate were found to be significantly lower in the female group than in the male group. Women had a lower likelihood of a positive cQFR ≤0.80 for the same degree of stenosis and a lower rate of NIRA revascularization. Independent predictors of positive cQFR included male sex and diameter stenosis (DS) &gt;70%.Conclusions: cQFR values differ between the sexes, as women have a higher cQFR value for the same degree of stenosis. The findings suggest that QFR variations by sex require specific interpretation, as these differences may affect therapeutic decision-making and clinical outcomes.

Echocardiographic Assessment of Right Ventricular Function in Post Thrombolysed Acute Inferior Wall Infarction Patients with Angiographic Correlation

BACKGROUND A significant number of patients with acute Inferior wall infarction will have RV dysfunction and most of them have occlusion of either right or left circumflex coronary artery. But RV assessment is not done routinely in echocardiographic examination. Patients present with inferior wall myocardial infarction (IWMI) subsequently develop right ventricular myocardial infarction (RVMI) and have poor prognosis. In this study we wanted to evaluate the incidence of RVMI and the role of echocardiography in assessing RV function and its impact in predicting infarct related artery by angiographic analysis in acute IWMI after thrombolysis. METHODS 86 patients with acute IWMI after thrombolysis were randomly selected. Echocardiographic examination of RV function was performed within 72 hours after thrombolysis. We applied RV echo parameters like FAC (Fractional Area Change %), TAPSE (Tricuspid Annular Plane Systolic Excursion), RV S’ (RV Systolic Excursion Velocity) and MPI (Myocardial Performance Index) to assess RV function. 48 patients underwent coronary angiogram which included 10 patients with normal RV function, rest with RV dysfunction. RESULTS Among 86 patients, we compared 64 patients of RV dysfunction with 22 patients having normal function. Echo indices were significantly lower in RV dysfunction group. FAC ( 27 ± 5.95 vs 45 ± 5.4 ) TAPSE (8.5 ± 2.0 19.59 ± 2.8 ), RV S’ ( 5.78 ± 1.26 vs 17.2 ± 3.5 ) and RVMPI (0.22 ± 0.03 vs 0.57± 0.03). Angiographic analysis of 28 of 38 patients with RV dysfunction showed significant proximal lesion in RCA as compared to only 2 among 10 patients with normal RV function. CONCLUSIONS Conventional echo examination will underestimate RV dysfunction hence we applied echo parameters like FAC, TAPSE, RV S’ and RVMPI and a significant proportion of thrombolysed acute IWMI patients were found to have RV dysfunction and it was also helpful in the prediction of infarct related artery which would be predominantly a critical proximal RCA occlusion. KEY WORDS RVMI (Right Ventricular Myocardial Infarction), FAC (Fractional Area Change %), TAPSE (Tricuspid Annular Plane Systolic Excursion), RV S’ (RV Systolic Excursion Velocity) ,MPI (Myocardial Performance Index), IRA ( Infarct Related Artery)

Isolated ST-Elevation Myocardial Infarction Involving Leads I and aVL: Angiographic and Electrocardiographic Correlations from a Tertiary Care Center

Background. Determining the infarct-related artery in STEMI during a coronary angiogram can be challenging due to the affliction of multiple vessels. Isolated STEMI involving only EKG leads I and aVL is infrequent. Localization of infarct-related artery based on EKG findings has not been previously done in this subset. Methods. All consecutive de novo acute coronary syndrome (ACS) patients admitted to coronary care unit with ST elevations involving only leads I and aVL were screened for enrollment. Patients with ST elevation in any additional lead and those who refused a coronary angiogram were excluded. Subsequently, a coronary angiogram was done as part of primary PCI or a pharmacoinvasive approach to identify the infract-related artery (IRA). IRA was defined by characteristics of lesion, flow of blood through stenosis, and presence of intracoronary thrombus. Coronary angiogram was interpreted by two independent observers blinded to the EKG findings. ST changes in inferior and precordial leads were analyzed to find ECG predictors of the culprit artery. Results. A total of 54 eligible patients of ACS were included in the study. The first major diagonal (D1) was the most frequent IRA in 35.2% followed by left circumflex-obtuse marginal (LCX-OM11) in 29.6%, left anterior descending (LAD) in 20.4%, and ramus intermedius (RI) in 14.8%. Out of total patients with ST depression in lead V2, the LCX-OM11 group was IRA in 50% cases while the RI, D1, and LAD groups accounted for 31.8%, 13.6%, and 4.5%, respectively ( p < 0.001 ). Similarly, LCX-OM1 was the most frequent IRA subjects with ST depressions in leads V1 and V3 (44.4%; p = 0.010 and 46.2%; p = 0.003 , resp.). On the contrary, in patients with ST depression in lead III, LAD and D1 were the most frequent IRA as compared to LCX-OM1 and RI though statistical significance was not attained ( p = 0.857 for lead III). ST-segment depression in lead V2 had a positive predictive value of 60% and a negative predictive value of 100% for LCX-OM1 as IRA. Similarly, ST-segment depression in lead V2 had a positive predictive value of 20% and a negative predictive value of 100% for the RI group. Conclusions. In patients presenting with isolated ST elevation in leads I and aVL, the most frequent IRA on angiogram was first diagonal. ST depressions in EKG leads V1–V3 were the most common predictor of LCX–OM1 while those in inferior leads indicated LAD-D1 as the IRA.

Relationship Between C-Reactive Protein to Albumin Ratio and Infarct-Related Artery Patency in Patients With ST-Segment Elevation Myocardial Infarction

The C-reactive protein to albumin ratio (CAR) is a predictive marker of systemic inflammatory state in atherosclerotic coronary disease when compared with the predictive value of these 2 markers separately. We investigated the relationship between CAR and infarct-related artery (IRA) patency in patients with ST-segment elevation myocardial infarction (STEMI). The study population (n = 1047) was divided into 2 groups according to IRA patency which was assessed by the Thrombolysis in Myocardial Infarction (TIMI) flow grade. Nonpatent flow was defined as TIMI grade 0 (no-reflow), 1, and 2 flows, and normal flow was defined as TIMI 3 flow. There was a significant positive correlation between CAR and SYNTAX score ( r = 0.312, P < .001) and a negative correlation between CAR and TIMI grade flow ( r = −0.210, P < .001). At a cutoff level of 0.693, the CAR predicted TIMI no-reflow with a sensitivity of 65.4% and a specificity of 65.5% (area under the curve: 0.670, 95% CI: 0.62-0.71, P < .001). Multivariate logistic regression analyses showed that CAR was an independent predictor of IRA patency (0.003 [0.001-0.029]; P < .001). A higher CAR is a significant and independent predictor of IRA patency in patients with STEMI.

Multivessel Intervention in Myocardial Infarction with Cardiogenic Shock: CULPRIT-SHOCK Trial Outcomes in the PL-ACS Registry

Background: The aim of the study was a comparison of culprit-lesion-only (CL-PCI) with the multivessel percutaneous coronary intervention (MV-PCI) in terms of 30-day and 12-month mortality in a national registry. Methods: Patients from the PL-ACS registry with MI and CS were analyzed. Patients meeting the criteria of the CULPRIT-SHOCK trial were divided into two groups: CL-PCI and MV-PCI groups. Results: Of the 3265 patients in the PL-ACS registry with MI complicated by CS, the criteria of the CULPRIT-SHOCK trial were met by 2084 patients (63.8%). The CL-PCI was performed in 883 patients, and MV-PCI was performed in 1045 patients. After the propensity score matching analysis, 617 well-matched pairs were obtained. In a 30-day follow-up, death from any cause occurred in 49.3% in the CL-PCI group and 57.0% in the MV-PCI group (RR 0.86, 95% CI 0.58–0.92, p = 0.0081). After 12 months, the rate of mortality was 62.5% in the CL-PCI group and 68.0% in the MV-PCI group (RR 0.92, 95% CI 0.84–1.01, p = 0.066). Conclusions: The results confirm the validity of CULPRIT-SHOCK findings in a national registry and current guideline-recommended strategy of revascularization limited to the infarct-related artery.