Background:
Patients with ST-elevation myocardial infarction (STEMI) frequently present non-culprit coronary lesions. The reported prevalence of chronic total occlusions (CTO) in STEMI patients varies between 10% and 30%. We therefore analyzed the prevalence and predictors of CTOs in non-culprit vessels in a consecutive single-center cohort.
Methods and Results:
After exclusion of patients with prior aorto-coronary bypass surgery, data of 2,284 patients with STEMI undergoing acute coronary angiography and/or primary PCI were analyzed. The median age was 65 years (IQR 55–75 years); 71.5% were male and 28.5% female. The distribution of culprit vessels was as follows: LM 1.2%, LAD 47.5%, LCX 12.7%, RCA 38.7%.
At least one non-culprit CTO was present in 215 patients (9.4%); 16 patients had CTOs in two non-culprit vessels. The distribution of non-culprit CTOs was LM 0%, LAD 23.6%, LCX 24.9%, RCA 51.5%.
Age (67 [IQR 57–76] vs. 65 [IQR 55–75] years) and sex (74.9% vs. 71.2% male) did not differ significantly between patients with and without non-culprit CTO. The presence of at least one non-culprit CTO was significantly more frequent in patients with infarction in the LCX (15.2%) or LM (14.8%) than in those with LAD (9.9%) or RCA (6.8%) as culprit vessels.
Among 1,867 patients with STEMI as the first manifestation of coronary artery disease, the prevalence of non-culprit CTOs was 9.1%, significantly lower than in patients with a prior history of revascularization (14.8%, p < 0.001).
Independent predictors of at least one non-culprit CTO were prior PCI (OR 1.91 [95% CI 1.36–2.69]; p < 0.001) and infarct vessel LCX (OR 1.66 [95% CI 1.12–2.46]; p = 0.011), whereas infarct vessel RCA was inversely associated (OR 0.66 [95% CI 0.47–0.93]; p = 0.018).
Patients with at least one non-culprit CTO presented more often with cardiogenic shock (27.4% vs. 17.3%, p = 0.001). In-hospital mortality was significantly higher in patients with at least one non-culprit CTO than in those without (16.7% vs. 8.9%, OR 2.05 [95% CI 1.39–3.02, p < 0.001). However, after multivariable adjustment, the presence of a non-culprit CTO did not independently predict in-hospital mortality.
Conclusions:
In 9.4% of all STEMI patients, at least one chronic total occlusion of a non-culprit coronary artery is present, with higher prevalence in cases with infarction of the LCX or left main and in those with pre-existing CAD. Even among patients presenting with STEMI as the first manifestation of CAD, non-culprit CTOs are common (9.1%). In more than one-quarter of patients with non-culprit CTO, STEMI is complicated by cardiogenic shock.
