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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.

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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