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CLINICAL STUDY: MYOCARDIAL INFARCTION

Revisiting the culprit lesion in non–Q-wave myocardial infarction

Results from the VANQWISH trial angiographic core laboratory

Richard A. Kerensky, MD^*,*, Michael Wade, MS, Prakash Deedwania, MD, William E. Boden, MD, Carl J. Pepine, MD, MACC^* Veterans Affairs Non–Q-Wave Infarction Strategies in-Hospital (VANQWISH) Trial Investigators

^* Malcom Randall Veterans Affairs Medical Center and the University of Florida College of Medicine, Division of Cardiovascular Medicine, Gainesville, Florida, USA
Veterans Affairs Medical Center and the State University of New York Health Science Center, Syracuse, New York, USA
Veterans Affairs Medical Center, Fresno, California, USA
Division of Cardiology at Hartford Hospital, Hartford, Connecticut, USA

Manuscript received September 1, 2001; revised manuscript received December 27, 2001, accepted February 5, 2002.

^* Reprint requests and correspondence: Dr. Richard A. Kerensky, Division of Cardiovascular Medicine, University of Florida College of Medicine, P.O. Box 100277, Gainesville, Florida 32610-0277, USA.
kerenra{at}mail-cs.med.ufl.edu

OBJECTIVES: We sought to determine the underlying coronary anatomy and characterize the culprit lesion after non–Q-wave myocardial infarction (NQWMI).

BACKGROUND: Although the culprit lesion and infarct-related artery often are easily identified with coronary angiography after Q-wave MI, the culprit lesion after NQWMI has not been well characterized. Small retrospective studies have suggested that the absence of Q-waves on an electrocardiogram is due to incomplete occlusion of the infarct-related artery.

METHODS: Coronary angiograms from 350 patients randomized to the early invasive strategy in the Veterans Affairs Non–Q-Wave Infarction Strategies in-Hospital (VANQWISH) trial were systematically analyzed in an angiographic core laboratory. A consensus panel identified the culprit lesion and the infarct-related artery using prespecified criteria for complex lesion morphology and acute versus chronic occlusions. Severity of angiographic disease and left ventricular function also were analyzed. Patients with a single identified culprit lesion were compared with those who had multiple apparent culprits and those without an identifiable culprit lesion.

RESULTS: A single culprit lesion was identified in only 49% of patients undergoing early angiography after NQWMI. The majority of patients either had no identifiable culprit (37%) or multiple apparent culprit lesions (14%). A single incomplete occlusion of the infarct-related artery was found in only 36% of patients, and an isolated acute occlusion of the infarct-related artery occurred in 13%. Patients without an identifiable culprit lesion had severe coronary disease (obstructive coronary artery disease [CAD] in 84%) but no complex lesion morphology. There was no difference in angiographic severity of disease comparing patients with and without identifiable culprit lesions. Patients with a single incomplete occlusion of the infarct-related artery were more likely to undergo percutaneous transluminal coronary angioplasty than other patients, whereas patients with multiple culprit lesions were more frequently treated with coronary artery bypass grafting.

CONCLUSIONS: Coronary angiography early after NQWMI frequently identifies severe obstructive CAD, but a single identifiable culprit lesion was identified in <50% of patients. Multiple culprit lesions were seen in 14% of patients. An angiographic culprit lesion could not be identified in more than one-third of patients undergoing coronary angiography as part of an invasive strategy.

Abbreviations and Acronyms   CABG   coronary artery bypass grafting   CAD   coronary artery disease   ECG   electrocardiogram   LAD   left anterior descending artery   LCx   left circumflex artery   MI   myocardial infarction   NQWMI   non–Q-wave myocardial infarction   RCA   right coronary artery   TIMI   Thrombolysis In Myocardial Infarction   VANQWISH   Veterans Affairs Non–Q-Wave Infarction Strategies in-Hospital study

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