© Borgis - Postępy Nauk Medycznych 7/2016, s. 518-522
*Leszek Majecki, Szymon Głodała, Marek Dąbrowski
The value of chronic total occlusion in a non-infarct-related artery in patients with multi-vessel coronary artery disease undergoing acute coronary syndromes
Znaczenie obecności przewlekle niedrożnej tętnicy wieńcowej, innej niż tętnica dozawałowa, u chorych z wielonaczyniową chorobą wieńcową i ostrym zespołem wieńcowym
Cardiology Clinic of Physiotherapy Division, 2nd Faculty of Medicine, Medical University of Warsaw, Father Jerzy Popiełuszko “Bielański” Hospital, Independent Public Health Care Institution in Warsaw
Head of Clinic: Professor Marek Dąbrowski, MD, PhD
Streszczenie
Wstęp. Współistnienie wielonaczyniowej choroby wieńcowej oraz przewlekle niedrożnej tętnicy wieńcowej pogarsza rokowanie odległe pacjentów.
Cel pracy. Porównanie pacjentów z ostrym zespołem wieńcowym pod względem obecności przewlekle niedrożnej tętnicy (CTO), innej niż dozawałowa (non-IRA), w odniesieniu do charakterystyki klinicznej, wpływu na uszkodzenie lewej komory serca i przeżycie odległe.
Materiał i metody. Badana populacja składała się z 402 kolejnych pacjentów z wielonaczyniową chorobą wieńcową (MVD) poddanych pilnej koronarografii z powodu ostrego zespołu wieńcowego (ACS).
Wyniki. Blisko u jednej trzeciej pacjentów stwierdzono przynajmniej jedną przewlekle niedrożną tętnicę (inną niż dozawałowa). Pacjentów z przewlekle niedrożną tętnicą wieńcową znacznie częściej hospitalizowano z powodu ostrego zespołu wieńcowego bez uniesienia odcinka ST (non-STE ACS, p = 0,005), byli oni też w starszym wieku oraz mieli wyższe ryzyko całkowite z uwagi na choroby współistniejące. Co najmniej umiarkowane uszkodzenie lewej komory serca stwierdzono u 25,6% pacjentów bez przewlekle niedrożnej tętnicy wieńcowej, natomiast u pacjentów z CTO odsetek ten sięgał 48,5% (p = 0,02).
Średnia, 490-dniowa, śmiertelność u wszystkich pacjentów z wielonaczyniową chorobą wieńcową wyniosła 13,18%. Śmiertelność całkowita oraz z przyczyn sercowo-naczyniowych u pacjentów z przewlekle niedrożną tętnicą wieńcową kształtowała się następująco: 17 i 12,5%, podczas gdy u pacjentów bez CTO wyniosła odpowiednio 11 i 9% (p = 0,2, p = 0,4).
Wnioski. U pacjentów z wielonaczyniową chorobą wieńcową poddanych pilnej koronarografii z powodu ostrego zespołu wieńcowego obecność przewlekle niedrożnej tętnicy wieńcowej, innej niż dozawałowa, ma istotny wpływ na uszkodzenie lewej komory serca oraz rokowanie odległe.
Summary
Introduction. The coexistence of multi-vessel disease (MVD) and chronic total occlusion (CTO) in patients undergoing coronarography due to acute coronary syndrome (ACS) is suggested to worsen the overall prognosis.
Aim. The comparison of patients with ACS without and with a chronic total occlusion (CTO) in a non-infarct-related artery (non-IRA) regarding the clinical characteristics, the impact on left ventricular (LV) damage and long-term survival.
Material and methods. The study population consisted of 402 consecutive patients with MVD undergoing coronarography because of ACS.
Results. Up to one third of patients revealed at least one non-IRA CTO. Patients with CTO more often suffered from non-STE ACS (p = 0.005) and had higher risk because of age and comorbidities. In 25.56% of patients without CTO at least moderate LV failure was diagnosed only whereas in CTO patients it amounted to 48.5% (p = 0.02).
The average 490-day mortality in all MVD-patients was up to 13.18%. All-cause and cardiovascular mortality in CTO patients was 17 and 12.5% while in patients without CTO 11 and 9%, respectively (p = 0.2 and p = 0.4).
Conclusions. In patients with MVD undergoing coronarography because of ACS the presence of CTO in non-IRA as compared with patients without CTO has a significant impact on LV impairment and overall prognosis.
List of abbreviations:
ACS – Acute Coronary Syndrome
STEMI – ST Segment Elevation Myocardial Infarction
NSTEMI – Non ST Segment Elevation Myocardial Infarction
UA – Unstable Angina
MVD – Multi-vessel Coronary Disease
CTO – Chronic Total Occlusion
Non-IRA – Non-Infarct-Related Artery
MI – Myocardial Infarction
PCI – Percutaneous Coronary Intervention
LV – Left Ventricle
EF – Ejection Fraction
TIMI – Thrombolysis In Myocardial Infarction
CABG – Coronary Artery Bypass Graft
Introduction
Unstable angina (UA), myocardial infarction with ST segment elevation (STEMI) and myocardial infarction without ST segment elevation (NSTEMI) constitute the core of acute coronary syndromes (ACS). According to the number of haemodynamically relevant narrowed vessels in angiography one may distinguish a single or multi-vessel coronary artery disease (MVD). The second one is found in approximately 45-80% of patients with ACS (1, 2). The presence of multi-vessel disease is believed to be an independent risk factor with worse outcome and prognosis in patients with ACS (3, 4). Chronic total occlusion of coronary artery (CTO) occurs in about 15-30% of patients with coronary artery disease (CAD) (5). The coexistence of MVD and CTO in other than infarct related coronary artery (non-IRA) in patients with ACS in some studies is suggested to worsen the overall prognosis (6). Therefore, in our study we tried to assess these variables in patients undergoing all types of ACS.
Aim
The comparison of patients with ACS without and with a chronic total occlusion (CTO) in a non-infarct-related artery (non-IRA) regarding the clinical characteristics, the impact on left ventricular (LV) damage and long-term survival.
Material and methods
The study is retrospective and all data and records were summoned up based on material obtained within standard medical procedures.
The study population consisted of 402 consecutive MVD patients who were hospitalized in 2009-2011 in our Cardiology Department after coronary angiography because of ACS. The presence of more than 50% lesion diameter stenosis in at least two of the epicardial coronary arteries was regarded as multi-vessel coronary disease. CTO in a non-IRA was defined as a total vessel occlusion lasting more than 3 months with the TIMI 0-1 blood flow grade in the artery not responsible for ACS. The CTO vessel diameter over 2 mm was taken into account only. The coronarographic assessment was performed by two invasive cardiologists independently. Ejection fraction (EF) was managed to evaluate echocardiographycally during index hospitalization in 92% of patients. An average 490-day (median 322) follow-up data were derived from both hospital documentation and telephone interviews.
Statistical analysis
Continuous variables were presented as mean value ± standard deviation, median and the Student’s t-test analyses were performed. Categorical variables were expressed as numbers and/or percentages. The chi-square test with Yates correction for discontinuity or Fisher’s exact test were used for comparative statistics. Graphic Kaplan-Meier method was used to describe survival in follow-up. P-value equal to or less than 0.05 was considered as statistically significant.
Results
Ultimately 402 consecutive patients with MVD undergoing ACS were enrolled in this study. In as much as 33.8% of all patients a non-IRA CTO was present.
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Piśmiennictwo
Pres D, Gąsior M, Poloński L: Treatment of patients with coronary artery disease and diabetes mellitus. Choroby Serca i Naczyń 2010; 7: 112-117.
Sukiennik A, Król A, Jachalska V et al.: Percutaneous coronary angioplasty in elderly patients: Assessment of in-hospital outcomes. Cardiology Journal 2007; 14: 143-154.
Sorajja P, Gersh BJ, Cox DA et al.: Impact of multi-vessel disease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Eur Heart J 2007; 28: 1709-1716.
Corpus RA, House JA, Marso SP et al.: Multi-vessel percutaneous coronary intervention in patients with multi-vessel disease and acute myocardial infarction. Am Heart J 2004; 148: 493-500.
Bryniarski L, Zabojszcz M, Bryniarski K, Terlecki M: Knowledge about chronic total coronary artery occlusions among Polish physicians. Post Kardiol Interw 2010; 6: 66-70.
Claessen BE, van der Schaaf RJ, Verouden NJ et al.: Evaluation of the effect of a concurrent chronic total occlusion on long-term mortality and left ventricular function in patients after primary percutaneous coronary intervention. JACC Cardiovasc Interv 2009; 2: 1128-1134.
Lexis CP, van der Horst IC, Rahel BM et al.: Impact of chronic total occlusions on markers of reperfusion, infarct size, and long-term mortality: a substudy from the TAPAS-trial. Catheter Cardiovasc Interv 2011; 77: 484-491.
Claessen BE, Dangas GD, Godino C et al.; Multinational CTO Registry: Impact of target vessel on long-term survival after percutaneous coronary intervention for chronic total occlusions. Catheterization and Cardiovascular Interventions 2013 Jul 1; 82(1): 76-82.
Hasegawa T, Godino C, Basavarajaiah S et al.: Differences in the clinical and angiographic characteristics of chronic total occlusion lesions in the three major coronary arteries. Journal of Interventional Cardiology 2014 Feb; 27(1): 44-49.
Claessen BE, Hoebers LP, van der Schaaf RJ et al.: Prevalence and impact of a chronic total occlusion in a non-infarct-related artery on long-term mortality in diabetic patients with ST elevation myocardial infarction. Heart 2010; 96: 1968-1972.
Claessen BE, Dangas GD, Weisz G et al.: Prognostic impact of a chronic total occlusion in a non-infarct-related artery in patients with ST-segment elevation myocardial infarction: 3-year results from the HORIZONS-AMI trial. Eur Heart J 2012; 33: 768-775.
Tajstra M, Gąsior M, Gierlotka M et al.: Comparison of Five-Year Outcomes of Patients With and Without Chronic Total Occlusion of Noninfarct Coronary Artery After Primary Coronary Intervention for ST-Segment Elevation Acute Myocardial Infarction. Am J Cardiol 2012; 109: 208-213.
Hoebers LP, Vis MM, Claessen BE et al.: The impact of multvessel disease with and without a co-existnig chtonic total occlusion on short- and long-term mortality in ST-elevation myocardial infarction patients with and without cardiogenic shock. Eur Heart J 2013; 15: 425-432.
Zhang HP, Zhao Y, Li H et al.: Impact of chronic total occlusion in a nonifarct-related artery on clinical outcomes in patients with acute ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Medicine 2016; 95(2); e2441.
Gierlotka M, Tajstra M, Gąsior M et al.: Impact of chronic total occlusion artery on 12-month mortality in patients with non-ST-segment elevation myocardial infarction treated by percutaneous coronary intervention (From the PL-ACS Registry). Int J Cardiol 2013 Sep 20; 168(1): 250-254.
Gąsior P, Hawranek M, Tajstra M et al.: Impact of chronic total occlusion localization on 12-month mortality in patients with non-ST segment elevation myocardial infarction treated with percutaneous coronary intervention. J Am Coll Cardiol 2014; 64(11_S). DOI: 10.1016/j.jacc.2014.07.261.
Rogers WJ, Frederick PD, Stoehr E et al.: Trends in presenting characteristics and hospital mortality among patients with ST elevation and non-ST elevation myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J 2008 Dec; 156(6): 1026-1034.
Montalescot G, Dallongeville J, Van Belle E et al.; OPERA Investigators: STEMI and NSTEMI: are they so different? 1 year outcomes in acute myocardial infarction as defined by the ESC/ACC definition (the OPERA registry). Eur Heart J 2007 Jun; 28(12): 1409-1417.
Patel VG, Brayton KM, Tamayo A et al.: Angiographic success and procedural complications in patients undergoing percutaneous coronary chronic total occlusion interventions: a weighted meta-analysis of 18,061 patients from 65 studies. JACC Cardiovasc Interv 2013 Feb; 6(2): 128-136.
Hoebers LP, Claessen BE, Elias J et al.: Meta-analysis on the impact of percutaneous coronary intervention of chronic total occlusions on left ventricular function and clinical outcome. Int J Cardiol 2015; 187: 90-96.
Grantham JA, Jones PG, Cannon L, Spertus JA: Quantifying the early health status benefits of successful chronic total occlusion recanalization: Results from the FlowCardia’s Approach to Chronic Total Occlusion Recanalization (FACTOR) Trial. Circ Cardiovasc Qual Outcomes 2010 May; 3(3): 284-290.
Teng HI: The Long-Term Clinical Impact of Revascularization of Coronary Chronic Total Occlusion in Patients with Non-ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2016; 67(16_S): S25-S26.
Dimitrov N, Karamfilov K, Simova II, Iliev R: Complete Versus Target-Vessel Revascularization in NSTEMI Patients. J Am Coll Cardiol 2015; 65(17_S): S7-S8.
van der Schaaf RJ, Claessen BE, Hoebers LP et al.; EXPLORE investigators: Rationale and design of EXPLORE: a randomized, prospective, multicenter trial investigating the impact of recanalization of a chronic total occlusion on left ventricular function in patients after primary percutaneous coronary intervention for acute ST-elevation myocardial infarction. Trials 2010 Sep 21; 11: 89.
