CLINICAL STUDY: CORONARY ARTERY DISEASE
Exaggeration of nonculprit stenosis severity during acute myocardial infarction: implications for immediate multivessel revascularization
Colm G. Hanratty, MD, MRCP*,
Yutaka Koyama, MD*,
Helge H. Rasmussen, FRACP, DMSc* ,
Greg I. C. Nelson, FRACP* ,
Peter S. Hansen, PhD, FRACP* and
Michael R. Ward, PhD, FRACP* ,*
* Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
Department of Medicine University of Sydney, Sydney, Australia
Manuscript received December 4, 2001;
revised manuscript received May 9, 2002,
accepted May 24, 2002.
* Reprint requests and correspondence: Dr. Michael R. Ward, Department of Cardiology, Royal North Shore Hospital, St. Leonards, NSW 2065, Australia. mrward{at}doh.health.nsw.gov.au
OBJECTIVES: This study was designed to assess the prevalence and clinical significance of exaggerated nonculprit lesion stenosis in the setting of acute (<12 h) myocardial infarction (AMI).
BACKGROUND: Although microvascular spasm may reduce nonculprit artery flow during AMI, it is unknown whether increased tone may exaggerate nonculprit lesion severity.
METHODS: In patients with additional angiography within nine months of AMI, and significant nonculprit lesions imaged in matching views, stenosis severity was compared between studies in a random blinded fashion using validated quantitative coronary angiography software. Baseline demographics, medications, hemodynamics at each study, and clinical status at follow-up (infarct/unstable angina/stable angina) were used to determine the independent influence of the infarct presentation on stenosis exaggeration.
RESULTS: From 548 patients with AMI (1/99 to 6/01, 321 with multivessel disease), 112 had additional angiography; of these 48 had 59 lesions suitable for analysis. Between infarct and noninfarct angiograms there was a significant change in minimal lumen diameter (1.53 ± 0.51 mm vs. 1.78 ± 0.65 mm, p < 0.001) and percentage stenosis (49.3 ± 14.5% vs. 40.4 ± 16.6%, p < 0.0001) of the nonculprit lesion without significant change in reference segment diameter, which was not predicted by changes in medication or hemodynamics. Twenty-one percent of patients had lesions >50% at AMI that were <50% at non-AMI angiography. Infarct versus noninfarct setting was the only significant independent predictor of change in nonculprit stenosis.
CONCLUSIONS: Significant exaggeration of nonculprit lesion stenosis severity occurs at infarct angiography, which may affect revascularization decision making in an appreciable number of patients.
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Abbreviations and Acronyms
| | AMI | | acute myocardial infarction | | CABG | | coronary artery bypass grafting | | IRA | | infarct related artery | | MLD | | minimal luminal diameter | | PCI | | percutaneous coronary intervention | | PP | | primary PCI | | QCA | | quantitative coronary angiography | | RCA | | right coronary artery | | RP | | rescue PCI |
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