Occlusion of the infarct-related coronary artery presenting as acute coronary syndrome with and without ST-elevation: impact of inflammation and outcomes in a real-world prospective cohort.
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Publisher DOI
PubMed ID
37197909
Description
BACKGROUND
Patients with ST-segment elevation typically feature total coronary occlusion (TCO) of the infarct-related artery (IRA) on angiography, which may result in worse outcomes. Yet, relying solely on ECG findings may be misleading and those presenting with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) may have TCO as well. Herein, we aimed to delineate clinical characteristics and outcomes of patients with ACS stratified by IRA location.
METHODS
A total of 4'787 ACS patients were prospectively recruited between 2009 and 2017 in SPUM-ACS (ClinicalTrials.gov Identifier: NCT01000701). The primary endpoint was major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction and non-fatal stroke at one year. Multivariable-adjusted survival models were fit using backward selection.
RESULTS
4'412 ACS patients were included in this analysis, 56.0% (n = 2469) STEMI and 44.0% (n = 1943) NSTE-ACS. The IRA was the right coronary artery (RCA) in 33.9% (n = 1494), the left-anterior descending coronary artery (LAD) in 45.6% (n = 2013) and the left circumflex (LCx) in 20.5% (n = 905) patients. In ST-elevation myocardial infarction (STEMI) patients, TCO (defined as TIMI 0 flow at angiography) was observed in 55% of cases with LAD, in 63% with RCA and in 55% with LCx. In those presenting with NSTE-ACS, TCO was more frequent in those with LCx and RCA as compared to the LAD (27% and 24%, respectively, vs. 9%, p<0.001). Among patients with NSTE-ACS, occlusion of the LCx was associated with an increased risk of MACE during 1 year after the index ACS (fully adjusted HR 1.68, 95% CI 1.10-2.59, p = 0.02; reference: RCA and LAD). Features of patients with NSTE-ACS associated with TCO of the IRA included elevated lymphocyte and neutrophil counts, higher levels of hs-CRP and hs-TnT, lower eGFR, and notably a negative history of MI.
CONCLUSION
In NSTE-ACS, both LCx and RCA involvement was associated with TCO at angiography despite the absence of ST-segment elevation. Involvement of the LCx, but not the LAD or RCA, as the IRA represented an independent predictor of MACE during 1-year follow-up. Hs-CRP, lymphocyte and neutrophil counts were independent predictors of total IRA occlusion suggesting a possible role of systemic inflammation in the detection of TCO irrespective of ECG presentation.
Patients with ST-segment elevation typically feature total coronary occlusion (TCO) of the infarct-related artery (IRA) on angiography, which may result in worse outcomes. Yet, relying solely on ECG findings may be misleading and those presenting with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) may have TCO as well. Herein, we aimed to delineate clinical characteristics and outcomes of patients with ACS stratified by IRA location.
METHODS
A total of 4'787 ACS patients were prospectively recruited between 2009 and 2017 in SPUM-ACS (ClinicalTrials.gov Identifier: NCT01000701). The primary endpoint was major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction and non-fatal stroke at one year. Multivariable-adjusted survival models were fit using backward selection.
RESULTS
4'412 ACS patients were included in this analysis, 56.0% (n = 2469) STEMI and 44.0% (n = 1943) NSTE-ACS. The IRA was the right coronary artery (RCA) in 33.9% (n = 1494), the left-anterior descending coronary artery (LAD) in 45.6% (n = 2013) and the left circumflex (LCx) in 20.5% (n = 905) patients. In ST-elevation myocardial infarction (STEMI) patients, TCO (defined as TIMI 0 flow at angiography) was observed in 55% of cases with LAD, in 63% with RCA and in 55% with LCx. In those presenting with NSTE-ACS, TCO was more frequent in those with LCx and RCA as compared to the LAD (27% and 24%, respectively, vs. 9%, p<0.001). Among patients with NSTE-ACS, occlusion of the LCx was associated with an increased risk of MACE during 1 year after the index ACS (fully adjusted HR 1.68, 95% CI 1.10-2.59, p = 0.02; reference: RCA and LAD). Features of patients with NSTE-ACS associated with TCO of the IRA included elevated lymphocyte and neutrophil counts, higher levels of hs-CRP and hs-TnT, lower eGFR, and notably a negative history of MI.
CONCLUSION
In NSTE-ACS, both LCx and RCA involvement was associated with TCO at angiography despite the absence of ST-segment elevation. Involvement of the LCx, but not the LAD or RCA, as the IRA represented an independent predictor of MACE during 1-year follow-up. Hs-CRP, lymphocyte and neutrophil counts were independent predictors of total IRA occlusion suggesting a possible role of systemic inflammation in the detection of TCO irrespective of ECG presentation.
Date of Publication
2023-09-12
Publication Type
Article
Subject(s)
Keyword(s)
Infarct Size Infarct-related artery - Non-ST-segment elevation myocardial infarction Inflammation - Left Circumflex coronary artery
Language(s)
en
Contributor(s)
Bruno, Francesco | |
Adjibodou, Boris | |
Obeid, Slayman | |
Kraler, Simon | |
Wenzl, Florian A | |
Akhtar, M Majid | |
Denegri, Andrea | |
Roffi, Marco | |
Muller, Olivier | |
von Eckardstein, Arnold | |
Templin, Christian | |
Lüscher, Thomas F |
Additional Credits
Series
European heart journal. Quality of care & clinical outcomes
Publisher
Oxford University Press
ISSN
2058-1742
Access(Rights)
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