Culprit plaque location within the left circumflex coronary artery predicts clinical outcomes in patients experiencing acute coronary syndromes with percutaneous coronary intervention: Data from the ORPKI registry

Abstract

Background:The left circumflex (LCx) artery is the most diagnostically challenging of the coronary branches in terms of diagnostics because the clinical presentation and electrocardiography (ECG) do not always suggest critical occlusion despite its presence. Therefore, it is important to determine the factors contributing to the clinical manifestation and outcome, such as the culprit location. Aims:To determine the relationship between the location of the culprit plaque and clinical outcomes in the LCx artery.Methods: Data from the Polish Registry of Invasive Cardiology Procedures (ORPKI) from the years 2019-2020 concerning percutaneous coronary intervention (PCI) procedures were extracted and analyzed using appropriate statistical tests.Results: 97 899 clinical records were analyzed. Patients with proximal occlusion received a worse grade using the Killip classification. Patients with Thrombolysis in Myocardial Infarction (TIMI) score 0 had worse clinical presentation in each of the occlusion locations. The periprocedural cardiac arrest and death rates were the highest among patients with proximal circumflex (Cx) occlusion. The death rate among patients with proximal occlusion and non-ST-segment elevation myocardial infarction (NSTEMI) was greater than among patients with distal occlusion and ST-segment elevation myocardial infarction (STEMI).Conclusions: Among patients with proximal occlusions of the Cx artery and TIMI 0 grade flow on initial angiogram, a STEMI-like approach should be undertaken apart from initial ECG findings. This is driven by a higher rate of critical and fatal complications such as cardiac arrest and periprocedural death. Fatal complications occur more often in patients with proximal occlusion of Cx than in medial or distal occlusion. Grade IV according to the Killip classification can suggest a proximal culprit location.

Secondary electrocardiographic stratification of NSTEMI to identify an acutely occluded culprit artery

“…Ayad et al (2021) expanded upon this finding by showing that the incidence of in-hospital arrhythmia was considerably higher among NSTEMI with an occluded culprit artery compared to NSTEMI without a an occluded culprit artery (Ayad et al 2021). Given the connection between left circumflex artery occlusion and NSTEMI with an occluded culprit artery, one previous study reported that NSTEMI patients with an occluded culprit left circumflex artery were more likely to suffer cardiac arrest and even higher mortality compared to STEMI (Chyrchel et al 2022). However, when evaluating long term outcomes, Kos et al (2021), with a median follow-up of 4.7 years, reported that the presence of a an occluded culprit artery, regardless of STEMI or NSTEMI presentation, was not associated with a higher long-term mortality; however, NSTEMI was associated with a higher mortality rate compared with STEMI, independent of angiographic presentation (Kos et al 2021).…”