Acute myocardial infarction and lesion location in the left circumflex artery: importance of coronary artery dominance.

AIMS Due to the limitations of 12-lead ECG, occlusions of the left circumflex artery (LCX) are more likely to present as non-ST-elevation acute coronary syndrome (NSTEACS) compared with other coronary arteries. We aimed to study mortality in patients with LCX lesions and to assess the importance of coronary artery dominance on triage of these patients. METHODS AND RESULTS From the Eastern Danish Heart Registry, 3,632 NSTEACS and 3,907 ST-elevation myocardial infarction (STEMI) consecutive, single-vessel disease patients were included. LCX was the culprit in 25% of NSTEACS and 14% of STEMIs (p<0.001). LCX lesions presented predominantly as STEMI in left dominant coronary arteries compared with NSTEACS (46% vs. 30%, p<0.001). Higher 30-day mortality was found in LCX-STEMI compared with LCX-NSTEACS (HR 7.9, 95% CI: 3.2-19.7, p<0.001) with no difference in long-term mortality (HR 0.9, 95% CI: 0.7-1.2, p=0.5). LCX-NSTEACS were not associated with higher mortality compared with other NSTEACS lesions. CONCLUSIONS The 12-lead ECG seems sufficient for triage of patients with LCX lesions as a majority of patients with a large LCX due to a dominant left coronary artery present as STEMI. Patients with LCX-NSTEACS do not have higher mortality compared with patients with LCX-STEMI or NSTEACS with lesions in other coronary territories.

[1]  G. Vetrovec,et al.  Left circumflex occlusion in acute myocardial infarction (from the National Cardiovascular Data Registry). , 2011, The American journal of cardiology.

[2]  L. Newby,et al.  Incidence, distribution, and prognostic impact of occluded culprit arteries among patients with non-ST-elevation acute coronary syndromes undergoing diagnostic angiography. , 2009, American heart journal.

[3]  C. Terkelsen,et al.  Health Care System Delay and Heart Failure in Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention: Follow-up of Population-Based Medical Registry Data , 2011, Annals of Internal Medicine.

[4]  G. Louridas,et al.  Wall shear stress in normal left coronary artery tree. , 2006, Journal of biomechanics.

[5]  Stef van Buuren,et al.  MICE: Multivariate Imputation by Chained Equations in R , 2011 .

[6]  J. Marrugat,et al.  Long-term prognosis of first myocardial infarction according to the electrocardiographic pattern (ST elevation myocardial infarction, non-ST elevation myocardial infarction and non-classified myocardial infarction) and revascularization procedures. , 2011, The American journal of cardiology.

[7]  R. Gibbons,et al.  Do patients with left circumflex coronary artery-related acute myocardial infarction without ST-segment elevation benefit from reperfusion therapy? , 1995, The American journal of cardiology.

[8]  J. Boura,et al.  Acute angiographic analysis of non-ST-segment elevation acute myocardial infarction. , 2004, The American journal of cardiology.

[9]  G. Stone,et al.  Correlation between index electrocardiographic patterns and pre‐intervention angiographic findings: Insights from the HORIZONS‐AMI trial , 2012, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.

[10]  I. White,et al.  Imputing missing covariate values for the Cox model , 2009, Statistics in medicine.

[11]  Robert J Glynn,et al.  Bias due to missing exposure data using complete‐case analysis in the proportional hazards regression model , 2003, Statistics in medicine.

[12]  E. Antman,et al.  Angiographic and clinical outcomes among patients with acute coronary syndromes presenting with isolated anterior ST-segment depression: a TRITON-TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis In Myocardial Infarction 38) su , 2010, JACC. Cardiovascular interventions.

[13]  Min Chul Kim,et al.  Impact of total occlusion of an infarct-related artery on long-term mortality in acute non-ST-elevation myocardial infarction patients who underwent early percutaneous coronary intervention. , 2012, International heart journal.

[14]  G. Beller,et al.  A comprehensive analysis of myocardial infarction due to left circumflex artery occlusion: comparison with infarction due to right coronary artery and left anterior descending artery occlusion. , 1988, Journal of the American College of Cardiology.

[15]  A. Lincoff,et al.  Magnitude and consequences of missing the acute infarct-related circumflex artery. , 2009, American heart journal.

[16]  D. Atar,et al.  ESC Guidelines for the Management of Acute Myocardial Infarction in Patients Presenting With ST-Segment Elevation , 2013 .

[17]  Milan Sonka,et al.  Plaque development, vessel curvature, and wall shear stress in coronary arteries assessed by X-ray angiography and intravascular ultrasound , 2006, Medical Image Anal..

[18]  J. Ottervanger,et al.  Circumflex artery-related acute myocardial infarction: limited ECG abnormalities but poor outcome , 2007, Netherlands heart journal : monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation.

[19]  M. Savage,et al.  Surface electrocardiogram in the detection of transmural myocardial ischemia during coronary artery occlusion. , 1989, The American journal of cardiology.

[20]  D Freimark,et al.  Acute myocardial infarction with isolated ST-segment elevation in posterior chest leads V7-9: "hidden" ST-segment elevations revealing acute posterior infarction. , 1999, Journal of the American College of Cardiology.

[21]  R E Ideker,et al.  Myocardial Infarct Size and Location in Relation to the Coronary Vascular Bed at Risk in Man , 1981, Circulation.

[22]  F. Neumann,et al.  Diagnosis of acute myocardial infarction in angiographically documented occluded infarct vessel : limitations of ST-segment elevation in standard and extended ECG leads. , 2001, Chest.

[23]  E. Peterson,et al.  CorrespondenceResearch CorrespondenceAnatomic Distribution of the Culprit Lesion in Patients With Non–ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention: Findings From the National Cardiovascular Data Registry , 2008 .

[24]  Fred S Apple,et al.  Third universal definition of myocardial infarction , 2012 .

[25]  A. Jacobs,et al.  Cardiogenic shock with non-ST-segment elevation myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK? , 2000, Journal of the American College of Cardiology.

[26]  G. Vetrovec,et al.  Clinical outcomes in patients with acute left circumflex/obtuse marginal occlusion presenting with myocardial infarction. , 2011, Journal of interventional cardiology.