Key result
Acute total occlusion in NSTEMI is linked to lower LVEF but similar 30-day mortality and readmissions.
Why the study?
It is unclear whether NSTEMI patients with acute total occlusion have a worse prognosis and warrant an earlier invasive strategy.
Does the presence of acute total occlusion in NSTEMI patients undergoing PCI worsen 30-day clinical outcomes?
Cohort (n=2,500)
Yes
Does the presence of acute total occlusion in NSTEMI patients undergoing PCI worsen 30-day clinical outcomes?
In NSTEMI patients undergoing PCI, the presence of acute total occlusion is associated with larger infarct size (higher troponin, lower LVEF) but does not significantly worsen 30-day mortality or readmission rates.
Similar 30-day outcomes despite larger infarcts suggest no immediate practice change in NSTEMI; leaves open questions on mechanisms and longer-term risks.
Introduction Acute coronary syndromes (ACS) remain a leading cause of morbidity and mortality worldwide. In patients presenting with ST-segment elevation myocardial infarction (STEMI), which suggests an acute epicardial coronary occlusion and transmural myocardial necrosis, the efficacy of immediate reperfusion is well established. However, a subset of patients presenting without ST-segment elevation on the 12-lead ECG will have acute total occlusion (ATO) of the infarct related artery (IRA) at time of angiography. They represent a group of patients that are at risk of developing irreversible myocardial injury and left ventricular dysfunction because of delayed reperfusion. It is currently unclear if this subgroup of patients has a worse prognosis and warrant an earlier invasive strategy. Purpose To compare clinical characteristics and 30-day outcomes of NSTEMI patients with and without ATO. Methods Consecutive patients with NSTEMI undergoing percutaneous coronary intervention (PCI) captured by the Coronary Angiogram Database of South Australia (CADOSA) across 4 tertiary hospitals in South Australia between 2012-2022 were included. Acute total occlusion was defined as thrombolysis in myocardial infarction (TIMI) 0–1 flow in the infarct-related artery. Results Among 2,500 NSTEMI patients, 637 (25%) had ATO on coronary angiography, and these patients were significantly younger than NSTEMI patients without ATO (62±12 vs 65±13, p<0.001) and with a high prevalence of smoking (40% vs 32%, p=0.1). The right coronary artery was the most frequent IRA in the ATO group (35%) followed by the left circumflex artery 32%. Patients with ATO had a higher peak troponin level (1928 ± 2134 vs 748 ± 1224, p < 0.001). Left ventricular ejection fraction at discharge was lower in the ATO group when adjusted for age (p=0.011). There was no difference in all-cause mortality and readmission for myocardial infarction, heart failure or stroke at 30 days between groups. Conclusion One quarter of NSTEMI patients have ATO and they are younger and frequently smoke. Further studies evaluating longer term outcomes in this population are needed.
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Low et al. (2025) conducted a cohort in NSTEMI (n=2,500). Acute total occlusion vs. No acute total occlusion was evaluated on All-cause mortality and readmission for myocardial infarction, heart failure or stroke at 30 days. Acute total occlusion, present in 25% of NSTEMI patients, was associated with higher peak troponin (1928 vs 748, p<0.001) but no difference in 30-day mortality or readmission compared to non-ATO.
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