Clinical outcome of patients with ST‐elevation myocardial infarction and angiographic evidence of coronary artery ectasia

Abstract

Objectives: The aim of this study was to describe the prevalence of coronary artery ectasia (CAE) in patients with ST-elevation myocardial infarction (STEMI) and to compare the long-term outcome of subjects with and without CAE undergoing emergent coronary angiography. Background:The prognostic impact of CAE in STEMI patients has been poorly investigated.Methods: This retrospective, single-center, study included consecutive patients with STEMI undergoing emergent coronary angiography from January 2012 to December 2017.The primary endpoint was the assessment of recurrent myocardial infarction (MI) in patients with versus those without CAE at the longest available follow-up. The propensity score weighting technique was employed to account for potential selection bias between groups.Results: From 1,674 patients with STEMI, 154 (9.2%) had an angiographic evidence of CAE; 380 patients were included in the no CAE group. CAE patients were more often males and smokers, and showed a lower prevalence of diabetes than no CAE patients. After percutaneous coronary intervention, the corrected thrombolysis in MI frame count (p < .001) and the myocardial blush grade (p < .001) were significantly lower in CAE than in no CAE patients.The mean follow-up was 1,218.3 ± 574.8 days. The adjusted risk for the primary outcome resulted significantly higher in patients with CAE compared to those without (adjusted HR: 1.84; p = .017). No differences in terms of all-cause and cardiac death were found between groups.Conclusions: In this study, STEMI patients with CAE had a distinct clinical and angiographic profile, and showed a significantly higher risk of recurrent MI than those without CAE.

Treatment and Outcome of Patients With Coronary Artery Ectasia: Current Evidence and Novel Opportunities for an Old Dilemma

“…However, there are growing evidence that patients with ACS and angiographic evidence of CAE have a high risk of future adverse events at follow up, irrespective of the presence of an EIRA. In a single-center observational study conducted by our group on 534 patients with STEMI, we found that 154 CAE patients developed a higher risk of recurrent MI at longterm follow up compared to a propensity-weighted group of 380 non-CAE STEMI (7). However, no significant differences in allcause death and cardiac death were reported between groups: probably a longer follow up and a larger number of patients might have yielded more conclusive results in terms of long-term mortality.…”

“…The wide variability in the reported prevalence has several reasons, including the lack of homogeneity in the adopted definition of CAE, a certain interoperator variability in the angiographic evaluation, geographical discrepancies, and the different clinical presentations of the patients included in the studies. Indeed, an even higher prevalence of CAE was reported in specific clinical settings, reaching up to 9% in some cohorts of patients with STsegment elevation MI (STEMI) (7). Nevertheless, since studies include only patients undergoing coronary angiography and/or presenting with ACS, it is reasonable to think that the real prevalence in the general population may be overestimated.…”

“…In the setting of an ACS with an EIRA, high thrombus burden with distal embolization and microvascular damage substantially increases the technical complexity of PCI, with a high risk of procedural failure and adverse events at long term (70). Given the high thrombus load, several reports showed a wider use of glycoprotein IIb/IIIa inhibitors and thrombus aspiration in patients treated with primary PCI of an EIRA (7,72,83). Despite these efforts, distal embolization with impairment of epicardial flow and/or microcirculatory reperfusion is frequently reported in these patients (73,82).…”

“…However, literature provide only limited and conflictual evidence on this topic, especially in asymptomatic patients with incidentally found CAE. The need for a tailored pharmacological approach with aggressive antithrombotic regimens is justified by the growing evidence of a high risk of cardiovascular events in patients with CAE, especially in the setting of an ACS (7,8,74,109). Doi et al found that among 51 CAE patients with MI, those who received OAC and reached a time-in-target therapeutic range ≥60% did not experience major cardiovascular events at 49 months follow-up (8).…”

“…CAE shows a wide spectrum of clinical manifestations, ranging from incidental findings in asymptomatic patients, to effort angina, exerciseinduced ischemia, and acute coronary syndrome (ACS) (5,6). Although the prognosis of CAE still represents a matter of debate, several studies reported a high risk of adverse events at longterm follow up in patients with myocardial infarction (MI) and angiographic evidence of CAE (7)(8)(9). The treatment of patients with CAE constitutes an unsolved problem both for clinical and interventional cardiologists since each therapeutic option offers its own advantages and drawbacks in this setting.…”