Acute coronary occlusion with vs. without ST-elevation: impact on procedural outcomes and long-term all-cause mortality

Mohammed Abusharekh (Essen)1, J. Kampf (Essen)1, I. Dykun (Essen)1, S. Kashif (Recklinghausen)2, V. Backmann (Essen)1, F. Al-Rashid (Essen)1, R. A. Janosi (Essen)1, M. Totzeck (Essen)1, T. Lawo (Recklinghausen)2, T. Rassaf (Essen)1, A.-A. Mahabadi (Essen)1

1Universitätsklinikum Essen Klinik für Kardiologie und Angiologie Essen, Deutschland; 2Elisabeth-Krankenhaus GmbH Kardiologie Recklinghausen, Deutschland


Background: Acute total occlusion (ATO) is diagnosed in a substantial proportion of patients with Non-ST-elevation myocardial infarction (NSTEMI). We compared procedural outcomes and long-term mortality of patients with ST-elevation myocardial infarction (STEMI) with NSTEMI with vs. without ATO.

Methods: We included patients with acute myocardial infarction undergoing invasive coronary angiography between 2004 and 2019 at our center. ATO was defined as TIMI 0-1 flow in the infarct-related artery or TIMI 2-3 flow with highly elevated peak troponin (>100-folds the upper reference limit). Association between presentation and long-term mortality was evaluated using multivariable adjusted Cox regression analysis.

Results: From 2269 acute myocardial infarction patients (mean age 66±13.2 years, 74% male), 664 patients with STEMI and 1605 patients with NSTEMI (471 [29.3%] with ATO) were included.ATO(+)NSTEMI had higher frequency of cardiogenic shock and no-reflow than ATO(-)NSTEMI
with similar rates compared to STEMI patients (cardiogenic shock: 2.76 vs. 0.27 vs. 2.86%,p<0.0001, p=1; no-reflow: 4.03 vs. 0.18 vs. 3.17%, p<0.0001, p=0.54). ATO(+)NSTEMI and STEMI were associated with 60% and 55% increased incident mortality, as compared to ATO(-)NSTEMI (ATO(+)NSTEMI: 1.60[1.27-2.02], p<0.0001, STEMI: 1.55[1.24-1.94], P<0.0001).Likewise, left ventricular ejection fraction (48.5±12.7 vs. 49.1±11 vs. 50.6±11.8%, p=0.5, p=0.018)and global longitudinal strain (-15.2±-5.74 vs. -15.5±-4.84 vs. -16.3±-5.30%, p=0.48, p=0.016) in ATO(+)NSTEMI were comparable to STEMI but significantly worse than in ATO(-)NSTEMI.

Conclusion: NSTEMI patients with ATO have unfavorable procedural outcomes, resulting in increased long-term mortality, resembling STEMI. Our findings suggest that the occlusion perspective provides more appropriate classification of acute myocardial infarction than differentiation into STEMI vs. NSTEMI.
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