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Angiographic and Clinical Outcomes Among Patients With Acute Coronary Syndromes Presenting With Isolated Anterior ST-Segment Depression

A TRITON–TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel–Thrombolysis In Myocardial Infarction 38) Substudy

Yuri B. Pride, MD^_*, Patricia Tung, MD, MPP^_*, Satishkumar Mohanavelu, MS, Cafer Zorkun, MD^_*, Stephen D. Wiviott, MD, Elliott M. Antman, MD, Robert Giugliano, MD, Eugene Braunwald, MD, C. Michael Gibson, MS, MD^,_* for the TIMI Study Group

^_* Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
TIMI Study Group, Cardiovascular Divisions, Departments of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

^_* Reprint requests and correspondence: Dr. C. Michael Gibson, Cardiovascular Division, Beth Israel Deaconess Medical Center, 350 Longwood Avenue, First Floor, Boston, Massachusetts 02115 (Email: mgibson{at}perfuse.org).

Objectives: This study sought to determine angiographic and clinical outcomes among patients with acute coronary syndrome (ACS) presenting with isolated anterior ST-segment depression on 12-lead electrocardiogram (ECG).

Background: In patients with ACS, anterior ST-segment depression on 12-lead ECG may represent plaque rupture with: 1) acute thrombotic occlusion with elevation of cardiac biomarkers (+Tn); 2) a patent artery with +Tn; or 3) a patent artery with –Tn.

Methods: The TRITON–TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel–Thrombolysis In Myocardial Infarction 38) enrolled 13,608 ACS patients. Those with isolated anterior (leads V₁ to V₄) ST-segment depression were analyzed. Angiograms and ECGs were interpreted by local investigators.

Results: There were 1,198 (8.8%) patients with isolated anterior ST-segment depression. Of those, 314 (26.2%) had an occluded culprit artery (TIMI flow grade 0/1) and +Tn, 641 (53.5%) had a patent culprit artery (TIMI flow grade 2/3) and +Tn, and 243 (20.3%) had TIMI flow grade 2/3 and –Tn. Among patients with an occluded artery, the culprit artery was most often the left circumflex artery (48.4%). The 30-day incidence of the composite of death and MI was significantly higher among patients with an occluded artery (8.6%) than among those with a patent culprit artery and either +Tn (6.3%) or –Tn (2.9%) (3-way p = 0.006). Among patients with an occluded artery, the median time from ECG to percutaneous coronary intervention was 29.4 h (interquartile range 26.1 to 44.1 h).

Conclusions: Among ACS patients presenting with isolated anterior ST-segment depression, over one-quarter had an occluded culprit artery and elevated cardiac biomarkers. These patients had significantly worse clinical outcomes, and few underwent urgent angiography.

Key Words: acute coronary syndrome • ST-segment elevation myocardial infarction • electrocardiography

Abbreviations and Acronyms   ACS = acute coronary syndrome   ECG = electrocardiogram   PCI = percutaneous coronary intervention   STEMI = ST-segment elevation myocardial infarction   TFG = Thrombolysis In Myocardial Infarction flow grade   TIMI = Thrombolysis In Myocardial Infarction   Tn = cardiac biomarkers