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

Abstract

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 in patients with ST-elevation myocardial infarction (STEMI) with NSTEMI with vs. without ATO. 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. 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: 2.76vs. 0.27vs. 2.86%, p<0.0001, p=1; no-reflow: 4.03vs. 0.18vs. 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±12.7vs. 49.1±11vs. 50.6±11.8%, p=0.5, p=0.018) and global longitudinal strain (-15.2±-5.74vs. -15.5±-4.84vs. -16.3±-5.30%, p=0.48, p=0.016) in ATO(+)NSTEMI were comparable to STEMI but significantly worse than in ATO(-)NSTEMI. 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.