title: Impact of nonculprit vessel myocardial perfusion on outcomes of patients undergoing percutaneous coronary intervention for acute coronary syndromes: analysis from the ACUITY trial (Acute Catheterization and Urgent Intervention Triage Strategy).
abstract: OBJECTIVE
  This study evaluated the impact of nonculprit vessel myocardial perfusion on outcomes of non-ST-segment elevation acute coronary syndromes (NSTE-ACS) patients.
  
  
  BACKGROUND
  ST-segment elevation myocardial infarction patients have decreased perfusion in areas remote from the infarct-related vessel. The impact of myocardial hypoperfusion of regions supplied by nonculprit vessels in NSTE-ACS patients treated with percutaneous coronary intervention (PCI) is unknown.
  
  
  METHODS
  The angiographic substudy of the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial included 6,921 NSTE-ACS patients. Complete 3-vessel assessments of baseline coronary TIMI (Thrombolysis In Myocardial Infarction) flow grade and myocardial blush grade (MBG) were performed. We examined the outcomes of PCI-treated patients according to the worst nonculprit vessel MBG identified per patient.
  
  
  RESULTS
  Among the 3,826 patients treated with PCI, the worst nonculprit MBG was determined in 3,426 (89.5%) patients, including 375 (10.9%) MBG 0/1 patients, 475 (13.9%) MBG 2 patients, and 2,576 (75.2%) MBG 3 patients. Nonculprit MBG 0/1 was associated with worse baseline clinical characteristics. Patients with nonculprit MBG 0/1 versus MBG 3 had increased rates of 30-day (3.0% vs. 0.7%, p < 0.0001) and 1-year (4.4% vs. 1.0%, p < 0.0001) death. Similar results were found among patients with pre-procedural TIMI flow grade 3 in the culprit vessel, where nonculprit vessel MBG 0/1 (hazard ratio: 2.81 [95% confidence interval: 1.63 to 4.84], p = 0.0002) was the strongest predictor of 1-year mortality.
  
  
  CONCLUSIONS
  Reduced myocardial perfusion in an area supplied by a nonculprit vessel is associated with increased short- and long-term mortality rates in NSTE-ACS patients undergoing PCI. Furthermore, worst nonculprit MBG is able to risk-stratify patients with normal baseline flow of the culprit vessel.
authors.affiliation: Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut. Electronic address: alexandra.lansky@yale.edu.
authors.forename: Alexandra J
authors.initials: AJ
authors.lastname: Lansky
authors.affiliation: Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Vivian G
authors.initials: VG
authors.lastname: Ng
authors.affiliation: Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Meller
authors.affiliation: Division of Cardiology, Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York.
authors.forename: Ke
authors.initials: K
authors.lastname: Xu
authors.affiliation: Division of Cardiology, Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York.
authors.forename: Martin
authors.initials: M
authors.lastname: Fahy
authors.affiliation: Division of Cardiology, New York University School of Medicine, New York, New York.
authors.forename: Frederick
authors.initials: F
authors.lastname: Feit
authors.affiliation: Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.affiliation: Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand.
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.affiliation: Division of Cardiology, Mount Sinai Medical Center, New York, New York.
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.affiliation: Department of Cardiology, Hôpital Cardiologique, Lille, France.
authors.forename: Michel E
authors.initials: ME
authors.lastname: Bertrand
authors.affiliation: Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium.
authors.forename: Walter
authors.initials: W
authors.lastname: Desmet
authors.affiliation: Department of Cardiology, University Hospital, Normandy, France.
authors.forename: Martial
authors.initials: M
authors.lastname: Hamon
authors.affiliation: Division of Cardiology, Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York.
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery; D000368:Aged; D006328:Cardiac Catheterization / Q000592:standards*; D017023:Coronary Angiography; D003326:Coronary Circulation / Q000502:physiology*; D004311:Double-Blind Method; D004562:Electrocardiography; D004630:Emergencies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D010496:Pericardium / Q000503:physiopathology*; D017410:Practice Guidelines as Topic; D011379:Prognosis; D011446:Prospective Studies; D015996:Survival Rate / Q000639:trends; D014218:Triage / Q000592:standards*; D014481:United States / Q000453:epidemiology
keywords: acute coronary syndrome; epicardial flow; mortality; myocardial perfusion; non-culprit vessel; percutaneous coronary intervention