Impact of Chronic Total Occlusion in a Noninfarct-related Artery on Clinical Outcomes in Patients With Acute ST-elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Abstract

In the setting of primary percutaneous coronary intervention (PCI), encountering with chronic total occlusion (CTO) in a noninfarct-related artery (IRA) is not a rare situation. Limited information on the impact of CTO on clinical outcomes in acute ST-elevation myocardial infarction (STEMI) patients undergoing primary PCI has raised more concerns. The aim of the present study was to evaluate the effect of concurrent CTO in a non-IRA on the clinical outcomes in patients with STEMI undergoing primary PCI.In the present prospective study, 555 consecutive patients with STEMI who underwent early primary PCI from January 2010 to December 2013 were included. The patients were divided into 2 groups: no CTO and CTO. Data on 12 months follow-up was obtained from 449 patients. The primary endpoint was the composite of hospitalization from angina, reinfarction, heart failure, or re-revascularization, and cardiac death at 12 months follow-up.Of the 555 patients, 75 (13.5%) had CTO in a non-IRA. Compared with patients in no CTO group, more patients in CTO group had hypertension (62.7% vs 46.5%, P = 0.009), diabetes (49.3% vs 35.0%, P = 0.024), and 3-vessel disease (52.0% vs 32.3%, P = 0.001). Patients with CTO had a lower left ventricular ejection fraction (LVEF) (40.1% ± 16.8% vs 54.3% ± 12.1%, P = 0.038), more presented with cardiogenic shock on admission (13.3% vs 4.8%, P = 0.008), compared with patients without CTO. Complete revascularization (CR) was less achieved in CTO group than in no CTO group (33.3% vs 49.1%, P = 0.013). The 12-month cardiac mortality rate was 14.5% versus 6.2% (P = 0.039), the incidence of 12-month primary endpoint was 38.7% versus 21.2% (P = 0.003) for CTO and no CTO group, respectively. Multivariate analysis revealed that after correction for baseline differences, CTO in a non-IRA (hazard ratio 4.183, 95% confidence interval 1.940–6.019, P = 0.001), cardiogenic shock on admission (hazard ratio 3.286, 95% confidence interval 1.097–9.845, P = 0.034), and 3-vessel disease (hazard ratio 2.678, 95% confidence interval 1.221–5.874, P = 0.014) remained an independent predictor of 1-year cardiac mortality in patients with STEMI undergoing primary PCI.CTO in a non-IRA in patients with STEMI undergoing primary PCI is associated with a poor prognosis. The presence of CTO in a non-IRA, cardiogenic shock on admission and 3-vessel disease might be an independent risk factor for greater 1-year cardiac mortality in patients with acute STEMI undergoing primary PCI.

Staged Percutaneous Intervention for Concurrent Chronic Total Occlusions in Patients With ST‐Segment–Elevation Myocardial Infarction: A Systematic Review and Meta‐Analysis

“…Our study further extends these conclusions to patients with STEMI who underwent PCI in nIRA CTO as shown in another meta‐analysis of contemporary RCTs in patients with STEMI with multivessel CAD 7. The idea that patients with acute STEMI and concurrent nIRA CTO would demonstrate clinical benefit from CTO PCI was generated from the apparent 2‐fold increased mortality and morbidity rates among patients with STEMI and multivessel CAD and CTO 4, 5, 21. Even among patients without STEMI, increased mortality has been attributed to the presence of CTOs in nIRAs 3, 6.…”

“…7 The idea that patients with acute STEMI and concurrent nIRA CTO would demonstrate clinical benefit from CTO PCI was generated from the apparent 2-fold increased mortality and morbidity rates among patients with STEMI and multivessel CAD and CTO. 4,5,21 Even among patients without STEMI, increased mortality has been attributed to the presence of CTOs in nIRAs. 3,6 One of the possible mechanisms of increased mortality in patients with CTO could be a larger infarct size caused by the acute occlusion of a donor artery to CTO.…”

Successful revascularization of noninfarct related artery with chronic total occlusion among acute myocardial infarction patients

“…[ 4 , 12 – 17 ] Finally, 5 studies containing a total of 1083 patients were included in the analysis, of which there was 1 randomized controlled trial, [ 11 ] and 4 observational studies. [ 18 – 21 ] Details and baseline characteristics of the included studies are listed in Tables 1 – 5 . The quality of the enrolled studies was assessed using the Newcastle-Ottowa scale in Table 2 .…”

“…Long-term cardiac mortality was reported in the above 5 studies. [ 11 , 18 – 21 ] Successful revascularization of CTO was closely linked with decreased long-term cardiac mortality (the absolute risk was 6.02% vs 12.55%; OR: 0.36, 95% CI: 0.19–0.68; P = .002).…”

Non-infarct related chronically occluded coronary arteries and its association with diabetes and prediabetes

“…In the setting of primary percutaneous coronary intervention, encountering with non-IRA CTOs is not a rare situation. 20 Among STEMI patients, about 50% have single vessel disease, while about 40% have multivessel disease (MVD) and near 10% have MVD with non-IRA CTO. 21 The occurrence of non-IRA CTO is present in approximately one-third of patients with non-ST elevation myocardial infarction (NSTEMI) and MVD.…”