title: Incidence and distribution of occluded culprit arteries and impact of coronary collaterals on outcome in patients with non-ST-segment elevation myocardial infarction and early invasive treatment strategy.
abstract: BACKGROUND
  It is assumed that patients with non-ST-elevation myocardial infarctions (NSTEMI) showing an infero- or posterolateral occluded culprit artery (OCA) during diagnostic angiography frequently elude standard 12-lead electrocardiogram diagnosis. In addition, coronary collaterals may have beneficial effects in patients with OCA.
  
  
  METHODS
  We examined 448 consecutive NSTEMI patients within 72 h of symptom onset. All patients underwent early invasive angiography plus optimal medical therapy. We compared clinical characteristics and 30-days/6-month major adverse cardiovascular events (MACE) between patients with OCA and non-OCA. The secondary objective was to investigate the effect of angiographically visible coronary collaterals on 6-month MACE in patients with OCA.
  
  
  RESULTS
  The angiograms revealed OCA in 130 (29%) of 448 patients. Patients with OCA showed more often infero- or posterolateral lesions (75 vs. 53%, p < 0.001) and more collaterals (57 vs. 8%, p < 0.001) compared with those with non-OCA. Patients with OCA had larger infarcts (peak CK-MB 2.1 ± 2.3 vs. 1.2 ± 1.1 μmol/L/s, p < 0.001), lower left ventricular ejection fraction (42 ± 21 vs. 48 ± 20%, p = 0.01), were more often revascularized (89 vs. 78%, p = 0.005), and had higher risk-adjusted 6-month MACE largely driven by its association with non-fatal reinfarctions (HR 2.16, 95% CI 1.04-4.50, p = 0.04). Patients with OCA and angiographically absent collaterals had significantly higher risk-adjusted 6-month MACE than those with OCA and angiographically visible collaterals (HR 1.96, 95% CI 1.02-3.76, p = 0.04).
  
  
  CONCLUSIONS
  Approximately one-fourth of patients with NSTEMI revealed OCA that was more frequently found in coronary arteries supplying the infero- or posterolateral myocardium. Patients with OCA had larger infarcts and more non-fatal reinfarctions than patients with non-OCA. Well-developed collaterals may limit the myocardial damage in these patients.
authors.affiliation: Department of Internal Medicine/Cardiology, University of Leipzig, Heart Center, 04289, Leipzig, Germany. bahrmann@gmx.de
authors.forename: Philipp
authors.initials: P
authors.lastname: Bahrmann
authors.forename: Justus
authors.initials: J
authors.lastname: Rach
authors.forename: Steffen
authors.initials: S
authors.lastname: Desch
authors.forename: Gerhard C
authors.initials: GC
authors.lastname: Schuler
authors.forename: Holger
authors.initials: H
authors.lastname: Thiele
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000789:Angina, Unstable / Q000209:etiology / Q000401:mortality; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D015415:Biomarkers / Q000097:blood; D002317:Cardiovascular Agents / Q000009:adverse effects / Q000627:therapeutic use*; D016009:Chi-Square Distribution; D003097:Collateral Circulation; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D003326:Coronary Circulation; D054059:Coronary Occlusion / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D052279:Creatine Kinase, MB Form / Q000097:blood; D005260:Female; D005858:Germany; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D009206:Myocardium / Q000201:enzymology / Q000473:pathology; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012008:Recurrence; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left
chemical_list: D015415:Biomarkers; D002317:Cardiovascular Agents; D052279:Creatine Kinase, MB Form