Impact of nonculprit vessel myocardial perfusion on outcomes of patients undergoing percutaneous coronary intervention for acute coronary syndromes: analysis from the ACUITY trial (Acute Catheterization and Urgent Intervention Triage Strategy)

JACC Cardiovasc Interv. 2014 Mar;7(3):266-75. doi: 10.1016/j.jcin.2013.08.016.

Abstract

Objectives: This study evaluated the impact of nonculprit vessel myocardial perfusion on outcomes of non-ST-segment elevation acute coronary syndromes (NSTE-ACS) patients.

Background: ST-segment elevation myocardial infarction patients have decreased perfusion in areas remote from the infarct-related vessel. The impact of myocardial hypoperfusion of regions supplied by nonculprit vessels in NSTE-ACS patients treated with percutaneous coronary intervention (PCI) is unknown.

Methods: The angiographic substudy of the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial included 6,921 NSTE-ACS patients. Complete 3-vessel assessments of baseline coronary TIMI (Thrombolysis In Myocardial Infarction) flow grade and myocardial blush grade (MBG) were performed. We examined the outcomes of PCI-treated patients according to the worst nonculprit vessel MBG identified per patient.

Results: Among the 3,826 patients treated with PCI, the worst nonculprit MBG was determined in 3,426 (89.5%) patients, including 375 (10.9%) MBG 0/1 patients, 475 (13.9%) MBG 2 patients, and 2,576 (75.2%) MBG 3 patients. Nonculprit MBG 0/1 was associated with worse baseline clinical characteristics. Patients with nonculprit MBG 0/1 versus MBG 3 had increased rates of 30-day (3.0% vs. 0.7%, p < 0.0001) and 1-year (4.4% vs. 1.0%, p < 0.0001) death. Similar results were found among patients with pre-procedural TIMI flow grade 3 in the culprit vessel, where nonculprit vessel MBG 0/1 (hazard ratio: 2.81 [95% confidence interval: 1.63 to 4.84], p = 0.0002) was the strongest predictor of 1-year mortality.

Conclusions: Reduced myocardial perfusion in an area supplied by a nonculprit vessel is associated with increased short- and long-term mortality rates in NSTE-ACS patients undergoing PCI. Furthermore, worst nonculprit MBG is able to risk-stratify patients with normal baseline flow of the culprit vessel.

Keywords: acute coronary syndrome; epicardial flow; mortality; myocardial perfusion; non-culprit vessel; percutaneous coronary intervention.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Coronary Syndrome / diagnosis*
  • Acute Coronary Syndrome / mortality
  • Acute Coronary Syndrome / surgery
  • Aged
  • Cardiac Catheterization / standards*
  • Coronary Angiography
  • Coronary Circulation / physiology*
  • Double-Blind Method
  • Electrocardiography
  • Emergencies
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Middle Aged
  • Myocardial Perfusion Imaging / methods*
  • Percutaneous Coronary Intervention / methods*
  • Pericardium / physiopathology*
  • Practice Guidelines as Topic
  • Prognosis
  • Prospective Studies
  • Survival Rate / trends
  • Triage / standards*
  • United States / epidemiology