title: Incidence and impact of totally occluded culprit coronary arteries in patients presenting with non-ST-segment elevation myocardial infarction.
abstract: The accuracy of the 12-lead electrocardiogram in detecting coronary artery occlusion is limited. We sought to determine the incidence, distribution, and outcomes of patients who have total occlusion of the culprit artery but present with non-ST-segment elevation myocardial infarction (NSTEMI). The randomized Acute Catheterization and Urgent Intervention Triage Strategy trial enrolled 13,819 patients presenting with non-ST-segment elevation acute coronary syndromes who underwent an early invasive strategy. The present study includes 1,319 patients with baseline biomarker elevation (NSTEMI) and no history of coronary artery bypass graft who underwent percutaneous coronary intervention of a single culprit vessel. We compared the baseline characteristics and outcomes according to whether the culprit vessel was occluded (baseline Thrombolysis In Myocardial Infarction [TIMI] 0 to 1) or patent (TIMI 2 to 3 flow) by angiographic core laboratory assessment. TIMI 0 to 1 flow in the culprit artery was present in 262 of 1,319 (19.9%) patients. The incidence of coronary occlusion was 28.4%, 19.3%, and 12.6% in patients with NSTEMI because of right coronary, left circumflex, and left anterior descending artery disease, respectively. Patients with an occluded culprit artery were more commonly men and had ST-segment deviation ≥1 mm. One-year outcomes, including death (3.5% vs 3.0%, p = 0.68) and myocardial infarction (8.4% vs 9.6%, p = 0.47), did not differ significantly between patients with versus without occluded culprit arteries, respectively. In conclusion, the present study demonstrates that the culprit artery is totally occluded in approximately 1 in 5 patients presenting with NSTEMI and single-vessel disease; however, the presence of total occlusion in NSTEMI was not associated with an incremental hazard of death or reinfarction at 1 year.
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Josephine
authors.initials: J
authors.lastname: Warren
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, New York; Cardiovascular Research Foundation, New York, New York. Electronic address: roxana.mehran@mountsinai.org.
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Yu
authors.affiliation: Cardiovascular Research Foundation, New York, New York.
authors.forename: Ke
authors.initials: K
authors.lastname: Xu
authors.affiliation: Hôpital Cardiologique, Lille, France.
authors.forename: Michel E
authors.initials: ME
authors.lastname: Bertrand
authors.affiliation: Lehigh Valley Health Network, Allentown, Pennsylvania.
authors.forename: David A
authors.initials: DA
authors.lastname: Cox
authors.affiliation: Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.
authors.forename: A Michael
authors.initials: AM
authors.lastname: Lincoff
authors.affiliation: Sarah Cannon Research Institute, Nashville, Tennessee.
authors.forename: Steven V
authors.initials: SV
authors.lastname: Manoukian
authors.affiliation: Duke University Medical Center, Durham, North Carolina.
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.affiliation: London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Pocock
authors.affiliation: Department of Medicine, University of Auckland, Auckland, New Zealand; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand.
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.affiliation: Cardiovascular Research Foundation, New York, New York; NewYork-Presbyterian/Columbia University Medical Center, New York, New York.
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D000368:Aged; D006328:Cardiac Catheterization; D017023:Coronary Angiography; D054059:Coronary Occlusion / Q000150:complications / Q000175:diagnosis / Q000453:epidemiology*; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D009204:Myocardial Revascularization / Q000379:methods*; D011446:Prospective Studies; D012307:Risk Factors; D014481:United States / Q000453:epidemiology