Total Occlusion of Culprit Artery in NSTEMI

Study Questions:

What are the differences in outcomes between totally occluded and nonoccluded culprit arteries in patients with non–ST-segment elevation myocardial infarction (NSTEMI)?

Methods:

The investigators conducted a literature search, which yielded seven studies with 40,777 patients. The outcomes assessed were clinical presentation (Killip class), left ventricular ejection fraction, time to angiography, major adverse cardiac events (MACE), and all-cause mortality. The generic inverse or Mantel–Haenszel method was used to pool relevant outcomes, and the mean difference or relative risk (RR) was calculated. The differences between the groups were calculated by Fisher’s exact or χ2 test where appropriate.

Results:

A total of 10,415 (25.5%) patients had an occluded culprit artery with a predominant infero-lateral distribution (40% right coronary and 33% left circumflex artery). There was an increased risk of both MACE (short-term RR, 1.41; 95% CI, 1.17-1.70; p = 0.0003; I2 = 26%; medium- to long-term RR, 1.32; 95% CI, 1.11-1.56; p = 0.001; I2 = 25%) and all-cause mortality (short-term RR, 1.67; 95% CI, 1.31-2.13; p < 0.0001; I2 = 41%; medium to long-term RR, 1.42; 95% CI, 1.08-1.86; p = 0.01; I2 = 32%) with total occlusion of the culprit artery.

Conclusions:

The authors concluded that patients with NSTEMI who demonstrate a totally occluded culprit vessel on coronary angiography are at higher risk of mortality and MACE.

Perspective:

This meta-analysis reports that NSTEMI patients who present with total occlusion may represent a higher risk group, as they may suffer from impaired left ventricular function and increased risk of both short-term and medium- to long-term MACE and all-cause mortality. Better risk stratification tools are needed to identify such high-risk acute coronary syndrome patients to facilitate strategies that may improve outcomes. Additional prospective studies are indicated to test whether earlier revascularization may improve outcomes in NSTEMI patients who present with total occlusion.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Coronary Angiography, Coronary Vessels, Myocardial Infarction, Myocardial Revascularization, Outcome Assessment (Health Care), Risk, Stroke Volume, Ventricular Function, Left


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