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.

Bruno, Francesco; Adjibodou, Boris; Obeid, Slayman; Kraler, Simon; Wenzl, Florian A; Akhtar, M Majid; Denegri, Andrea; Roffi, Marco; Muller, Olivier; von Eckardstein, Arnold; Räber, Lorenz; Templin, Christian; Lüscher, Thomas F (2023). 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. European heart journal. Quality of care & clinical outcomes, 9(6), pp. 564-574. Oxford University Press 10.1093/ehjqcco/qcad027

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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.

Item Type:	Journal Article (Original Article)
Division/Institute:	04 Faculty of Medicine > Department of Cardiovascular Disorders (DHGE) > Clinic of Cardiology
UniBE Contributor:	Räber, Lorenz
Subjects:	600 Technology > 610 Medicine & health
ISSN:	2058-1742
Publisher:	Oxford University Press
Language:	English
Submitter:	Pubmed Import
Date Deposited:	19 May 2023 11:29
Last Modified:	13 Sep 2023 00:13
Publisher DOI:	10.1093/ehjqcco/qcad027
PubMed ID:	37197909
Uncontrolled Keywords:	Infarct Size Infarct-related artery - Non-ST-segment elevation myocardial infarction Inflammation - Left Circumflex coronary artery
URI:	https://boris.unibe.ch/id/eprint/182669