Total Occlusion of the Culprit Artery in Non-ST-segment Elevation Acute Coronary Syndrome: an Analysis of the Influencing Factors and Long-term Outcome Following Percutaneous Coronary Intervention

Background About one-fourth of patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are found with total occlusion of the culprit artery, and their outcomes are poor. However, there is little research in this population in China. Objective To identify the possible influencing factors of total occlusion of the culprit artery and long-term outcomes following percutaneous coronary interventions (PCI) in patients with NSTE-ACS. Methods Three hundred and seven NSTE-ACS patients with PCI treatment were recruited from the Third People's Hospital of Chengdu from January 2018 to December 2019, among whom, 42 with total occlusion of the culprit artery (pre-PCI TIMI grade 0 or 1, occlusion group) , and other 265 without (pre-PCI TIMI grade 2 or 3, non-occlusion group) . The baseline characteristics and results of regular follow-ups were collected. The endpoints were major adverse cardiac and cerebrovascular events (MACCE) , including all-cause death, recurrent myocardial infarction, revascularization, and new stroke. Multivariate Logistic regression was used to identify the potential influencing factors of total occlusion of the culprit artery. The Kaplan-Meier was used to estimate the cumulative incidence of MACCE. Multivariate Cox regression was adopted to assess the influence of total occlusion of the culprit artery on prognosis. Results Compared with non-occlusion group, occlusion group had higher prevalence of non-ST-segment elevation acute myocardial infarction and the left circumflex coronary artery as the culprit vessel, as well as higher levels of hypersensitive troponin T, creatine kinase isoenzyme and B-type natriuretic peptide at admission (P<0.05) . Moreover, occlusion group had lower level of systolic blood pressure and left ventricular ejection fraction (LVEF) , as well as the left anterior descending coronary artery as the culprit vessel at admission (P<0.05) . The results of multivariate Logistic regression analysis showed LVEF〔OR=1.064, 95%CI (1.018, 1.112) , P=0.006〕 was associated with total occlusion of the culprit artery in NSTE-ACS. Occlusion group had higher cumulative incidence of MACCE, revascularization or new stroke than non-occlusion group (P<0.05) . After adjusting for confounding factors, multivariate Cox regression analysis revealed that total occlusion of the culprit artery was associated with MACCE〔OR=2.684, 95%CI (1.229, 5.862) , P=0.013〕 and revascularization〔OR=3.024, 95%CI (1.320, 6.931) , P=0.009〕 in NSTE-ACS. Conclusion LVEF may be an associated factor of total occlusion of the culprit artery in patients with NSTE-ACS. Therefore bedside echocardiography is recommended as a routine examination before coronary angiography in patients with NSTE-ACS. In addition, total occlusion of the culprit artery is an influencing factor of MACCE, revascularization, and new stroke in these patients

Sex-specific Analysis of the Management and Outcome of Elderly Patients with Acute Myocardial Infarction

Background There may be sex-specific differences in the treatment and outcome of elderly people with acute myocardial infarction (AMI) . However, few studies have reported sex-specific differences in management and prognosis of older Chinese people with AMI. Objective To assess the sex-specific differences in management strategies, in-hospital mortality and cardiovascular mortality within one year after discharge in older Chinese people with AMI. Methods We consecutively enrolled 1 579 elderly (>60 years of age) patients with AMI admitted to 11 tertiary general hospitals in Chengdu between January 2017 and June 2019, including 1 056 men and 523 women. Sex-specific analysis of clinical characteristics, management strategies and 1-year outcome were performed. Kaplan-Meier estimator was used to describe the incidences of cardiovascular death within one year after discharge between men and women and the associated factors were explored using multivariate Cox proportions hazards regression analysis. Results Female patients had lower prevalence of smoking, and alcohol consumption, history of percutaneous coronary intervention and chronic obstructive pulmonary disease, typical symptoms including chest pain and chest tightness, and use of dual antiplatelet agents and statins, and lower mean creatinine levels than male patients (P<0.05) . Moreover, female patients had older mean age, diabetes, and higher mean heart rate, greater prevalence of Killip class≥Ⅱ, and higher mean level of total cholesterol, longer mean symptom-onset-to-balloon time and first medical contact to balloon dilation time, and higher in-hospital mortality rate (P<0.05) . Furthermore, the cardiovascular mortality rate within one year after discharge was higher in women (P<0.05) . Multivariate Cox proportions hazards regression analysis showed sex〔HR=1.830, 95%CI (1.029, 3.255) , P=0.040〕, age〔HR=1.063, 95%CI (1.031, 1.095) , P<0.001〕, ST-segment elevation myocardial infarction〔HR=2.382, 95%CI (1.380, 4.113) , P=0.002〕, cardiogenic shock〔HR=2.474, 95%CI (1.259, 4.859) , P=0.009〕, creatinine〔HR=1.004, 95%CI (1.001, 1.006) , P=0.003〕 and PCI〔HR=0.228, 95%CI (0.135, 0.386) , P<0.001〕 were associated with cardiovascular death within one year after discharge. Conclusion The rates of reperfusion treatment in older women and men with AMI were similar, but there were differences in treatment efficiency and outcome. Older women with AMI had lower in-hospital treatment efficacy, longer total myocardial ischemia time, lower prevalence of pharmacological treatment, and higher in-hospital all-cause mortality and cardiovascular mortality within one year after discharge