Key result
NSTEMI with acute total occlusion linked to ~60% higher long-term mortality, resembling STEMI.
Why the study?
Acute total occlusion is diagnosed in a substantial proportion of patients with NSTEMI, but procedural outcomes and long-term mortality compared to STEMI and NSTEMI without acute total occlusion needed evaluation.
Does the presence of acute total occlusion in NSTEMI patients result in similar procedural outcomes and long-term mortality compared to STEMI patients?
Cohort (n=2,269)
No
Does the presence of acute total occlusion in NSTEMI patients result in similar procedural outcomes and long-term mortality compared to STEMI patients?
NSTEMI patients with acute total occlusion have procedural outcomes and long-term mortality resembling STEMI, suggesting that an occlusion-based classification may be more appropriate than the traditional STEMI vs. NSTEMI dichotomy.
Answers are grounded in this paper and cite their sources.
Alerts clinicians to excess mortality in occluded NSTEMI; leaves open whether occlusion-based reclassification refines risk stratification.
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 in patients with STEMI with NSTEMI with vs. without ATO. METHODS AND RESULTS: We included patients with acute myocardial infarction (AMI) undergoing invasive coronary angiography between 2004 and 2019 at our centre. Acute total occlusion was defined as thrombolysis in myocardial infarction (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 AMI 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 patients had a higher frequency of cardiogenic shock and no reflow than ATO(-)NSTEMI with similar rates compared with 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, respectively, as compared with 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: Non-ST-elevation myocardial infarction patients with ATO have unfavourable procedural outcomes, resulting in increased long-term mortality, resembling STEMI. Our findings suggest that the occlusion perspective provides a more appropriate classification of AMI than differentiation into STEMI vs. NSTEMI.
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Abusharekh et al. (2024) conducted a cohort in Acute myocardial infarction (AMI) (n=2,269). NSTEMI with acute total occlusion (ATO(+)NSTEMI) vs. NSTEMI without acute total occlusion (ATO(-)NSTEMI) was evaluated on long-term mortality (HR 1.60, 95% CI 1.27-2.02, p=<0.0001). NSTEMI with acute total occlusion was associated with a 60% increased risk of long-term mortality compared to NSTEMI without occlusion (HR 1.60; 95% CI 1.27-2.02; P<0.0001), resembling STEMI.
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