CTO in patients with acute myocardial infarction increases long term mortality

Courtesy of Dr. Carlos Fava.

It has been proved that in a setting of acute myocardial infarction with multivessel lesions, only the culprit vessel must be treated (if there is no hemodynamic compromise) at first, and other severe lesions are to be treated during a second session. However, proper conduct in cases with presence of chronic total occlusion (CTO) is still somewhat unclear.

As regards a total population of 836 patients who underwent primary angioplasty, 437 patients (52.3%: 31.3% with 2-vessel disease and 20.9% with 3-vessel disease) presented multivessel disease (MVD) and 146 (17.5%) presented CTO.

A comparative analysis was carried out between patients presenting MVD and those with CTO. The latter were more likely to have a history of diabetes, and had a more frequent history of acute myocardial infarction and angioplasty, but a less frequent history of prior myocardial infarction.

There was no difference as regards final thrombolysis in myocardial infarction (TIMI) flow 2 or 3.

Thirty-day mortality was 4.8% (CTO: 6.8% vs. MVD: 3.8%; p = 0.167); only age was a predictor of mortality (odds ratio [OR]: 1.07; 95% confidence interval [CI]: 1.01-11; p = 0.005).

One-year global mortality and cardiac mortality rates for MVD patients were 11% and 10%, respectively, higher than for patients with CTO in both cases (15.8% vs. 8.6%; p = 0.02, and 15% vs. 7.6%; p = 0.001).

After a 6-year follow-up, 129 patients (29.7%) in the MVD group had died, more than the number of deaths among patients with CTO (38.6% vs. 25.4%; p = 0.005).

CTO was a predictor of long-term mortality (OR: 2.07; 95% CI: 1.3-3.28; p = 0.002), as were age, prior acute myocardial infarction, and angioplasty failure.

Conclusion

The presence of CTO is an independent predictor of long-term mortality in ST-elevation myocardial infarction (STEMI) patients treated with primary angioplasty.

Editorial Comment

The presence of CTO in STEMI patients warns us about the posibility of more comorbidities and a highly negative impact on their progress.

As regards these patients, we need to be stricter in our search for residual ischemia and medical treatment has to be more aggressive. We must also attempt to treat CTO with angioplasty through different strategies, in order to improve survival.

More research on this subject is necessary. Randomized studies should be carried out in order to determine the minimum ischemic value necessary for revascularization.

Courtesy of Dr. Carlos Fava.

Original title: Impact of the Presence of Chronically Occluded Coronary on Long-Term Prognosis of Patients with Acute ST-Segment Elevation Myocardial Infarction.

Reference: Maciej Lesiak et al. Cardiology J 2017;24,2:117-124.

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