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.
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.
Effect estimate: HR 1.60 (95% CI 1.27-2.02)
p-value: p=<0.0001
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.
Abusharekh et al. (Sun,) 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.