The assessment of non culprit coronary artery lesions in patients with ST segment elevated myocardial infarction and multivessel disease by control angiography with quantitative coronary angiography

Abstract

Conflicting data is present in the literature about patients who are treated with percutaneous coronary intervention (PCI) due to the exaggeration of the non culprit artery. The precise understanding of the non culprit artery in the setting of ST segment elevated myocardial infarct (STEMI) is important since the time and modality of the treatment is planned accordingly. The aim of this study is to evaluate the lesions in the non culprit coronary artery during primary PCI and control coronary angiography (CAG) using quantitative coronary angiography (QCA) in multivessel STEMI patients. In this study, multivessel disease STEMI patients whom underwent primary PCI between January 2010 and March 2011 were included. Critical stenosis degree was accepted as ≥70 % in the non culprit artery. All patients were evaluated with control CAG 1 month after primary PCI. Assessment with CAG was performed by two blinded cardiologists. QCA program was used to evaluate reference artery diameter (RAD), minimum luminal diameter (MLD) and degree of stenosis. With regard to the degree of stenosis, significant reduction was accepted as ≥15 % while % 5-15 decrease was accepted as moderate. Of the 81 patients, 61 were males and 20 were females (mean age 58.1 ± 10). In the control CAG, the degree of non culprit artery stenosis was found to be decreased (p < 0.001) while RAD and MLD were increased (p < 0.001 and p < 0.001 respectively). Significant decrease in critical non culprit artery lesions was detected in 22 patients (20.9 %) meanwhile moderate reduction was observed in 26 patients (24.7 %). In 14 patients (13.3 %), non culprit artery lesions accepted as critical during primary PCI were found to be non critical during the control CAG. Planned intervention was cancelled and medical treatment was initiated in those 14 patients. Our data indicated using QCA, approximately the half of non culprit lesions were found less critical during control CAG when compared to primary PCI. Therefore, it is concluded that complete revascularization during primary PCI should be avoided in multivessel STEMI patients and critical non culprit artery lesions should be re-evaluated with later control CAG.

Quantitative flow ratio for immediate assessment of nonculprit lesions in patients with ST‐segment elevation myocardial infarction—An iSTEMI substudy

“…In line with previous work, the stenoses, as assessed with 3‐dimensional quantitative coronary angiography (3D‐QCA), appeared more severe in the acute setting than at staged follow‐up . In spite, classification agreement between acute and staged QFR was high and these findings indicate that QFR adds more refined measures to the assessment of coronary stenosis compared to a sole anatomical evaluation by conventional QCA assessment.…”

“…In line with previous work, the stenoses, as assessed with 3-dimensional quantitative coronary angiography (3D-QCA), appeared more severe in the acute setting than at staged follow-up. 12,13 In spite, classification agreement between acute and staged QFR was high and these findings indicate that QFR adds more refined measures to the assessment of coronary stenosis compared to a sole anatomical evaluation by conventional QCA assessment. In a recent work, the diagnostic performance of staged QFR with staged FFR as reference was affected by the presence of microvascular disease, as assessed by the index of microvascular resistance.…”

Management of Culprit and Non-Culprit Lesions in Acute Coronary Syndrome

“…Furthermore, the levels of catecholamine and other hormones with vasocontrictive effect (serotonine, endotheline, thromboxan, and angiotensin) are elevated among STEMI patients; also, increased oxidative stress is lowering the vasodilatator effect of nitric oxide, adenosine, and prostacycline. 2,24,25 Moreover, it should be emphasized that MV-PCI increases the complexity of the procedure, while also increasing the risk of myocardial injury and further hemodynamic deterioration from distal embolization, acute vessel occlusion, intrastent thrombosis, or loss of sidebranch. 6,26 Additionally, the minimal clinical benefit of MV-PCI in the acute phase of ACS can lead to unnecessary prolongation of PCI time, with fatal effects in hemodinamically instable patients.…”

“…Therefore, endothelial dysfunction, elevated sympathetic activity, and its predisposition to thrombosis have a considerable impact on the blood flow dynamics of non-culprit lesions during myocardial infarction. 2 Intraluminal obstruction below 70% visible on CCTA or ICA in the coronary arteries are considered non-critical lesions, while critical lesions are defined by a narrowing larger than 70% of the lumen. However, ICA cannot reliably evaluate the functional severity of these lesions; furthermore, vulnerability features suggesting an increased risk of an acute ischemic event cannot be identified by this method.…”

Cardiovascular imaging 2016 in the International Journal of Cardiovascular Imaging

“…Donmet et al studied in a population of 81 patients the changes over time in non-culprit lesions in patients wih ST segment elevated myocardial infarction using QCA [7]. They found that in approximately 50% of the cases, the non-culprit lesions were found less critical during control angiography when compared to primary PCI.…”