Author + information
- Usaid K. Allahwala, MBBS,
- Sanjit S. Jolly, MD,
- Vladimír Džavík, MD,
- John A. Cairns, MD,
- Sasko Kedev, MD,
- Kumar Balasubramanian, MSc,
- Goran Stankovic, MD,
- Raul Moreno, MD,
- Nicholas Valettas, MD,
- Olivier Bertrand, MD,
- Shahar Lavi, MD, PhD,
- James L. Velianou, MD,
- Tej Sheth, MD,
- Brandi Meeks, MEng,
- Emmanouil S. Brilakis, MD, PhD and
- Ravinay Bhindi, MBBS, PhD∗ ()
- ↵∗Department of Cardiology, Royal North Shore Hospital, Reserve Road St. Leonards, Sydney 2065, Australia
In patients with a ST-segment elevation myocardial infarction (STEMI), the prevalence of chronic total occlusion (CTO) in a non–infarct-related artery (non-IRA) is 8% to 15% (1) with 2-fold greater morbidity and mortality than in those with single-vessel disease (SVD) (2). The TOTAL (Thrombectomy Versus PCI Alone) trial was an international, multicenter, randomized trial of routine manual thrombectomy compared with percutaneous coronary intervention (PCI) alone in 10,732 STEMI patients treated with primary PCI (3). We sought to determine whether the presence of a CTO imparts a poorer prognosis above that of concurrent multivessel disease (MVD) at 365 days. A landmark analysis was also conducted, excluding those patients who had had a primary event within the first 30 days. For the CTO substudy, patients were divided into 3 groups based on the operator’s angiographic assessment: 1) SVD, defined as <50% diameter stenosis in all non-IRAs; 2) MVD without a CTO, defined by at least 1 lesion with diameter stenosis 50% to 99% in 1 or more major non-IRA, and no lesions with 100% stenosis (1); and 3) CTO, defined as the presence of a 100% occlusion of a non-IRA.
Of 10,063 patients with complete angiographic reporting of all non-IRA, 658 (6.6%) had a CTO, 5,162 (51.3%) had SVD, and 4,243 (42.1%) had MVD. The relative frequencies of the location of the CTOs were right coronary artery (39%), left circumflex coronary artery (31%), left anterior descending coronary artery (23%), and double CTO (7%). CTO patients were older, more likely to be male, have greater rates of established cardiovascular risk factors, and worse hemodynamic profiles at presentation compared with SVD or MVD.
The presence of a CTO was associated with a significantly higher rate of cardiovascular death (10.8%) compared with SVD (2.6%; hazard ratio [HR]: 4.4, 95% confidence interval [CI]: 3.3 to 5.9; p < 0.001) or MVD (4%; HR: 2.85, 95% CI: 2.2 to 3.8; p < 0.001) (Figure 1). Patients with a CTO also had significantly higher rates of recurrent AMI, cardiogenic shock, major bleeding, and stroke (Table 1). Rates of target vessel revascularization were higher in those with a CTO (8.5%) as compared with SVD (3%; p < 0.001), but not compared with those with MVD (7.5%; p = 0.2). In multivariate analysis, the presence of a CTO was an independent predictor of cardiovascular death (HR: 2.0, 95% CI: 1.5 to 2.7; p < 0.001). In the landmark analysis, there were 605 patients with CTO, 5,065 patients with SVD and 4,132 with MVD. The presence of a CTO remained associated with greater rates of cardiovascular death compared with SVD and MVD (3% vs. 0.7% vs. 1.5%; p < 0.001 respectively). This represented a 4-fold greater risk of cardiovascular mortality compared with SVD (p < 0.001).
The present study demonstrated that with contemporary primary PCI techniques and optimal medical therapy, the presence of a CTO in a non-IRA remains a strong predictor of cardiovascular morbidity and mortality in both the short and long term following a STEMI. These results are in keeping with the findings of other trials (1). In particular, the presence of a CTO significantly increases the risk of cardiovascular death, above that of MVD, suggesting that this is not a reflection of a greater burden of coronary disease, but may in fact confer independent prognostic risk. These patients, with the so-called “double jeopardy” of a non-IRA CTO in the context of a STEMI, intuitively have a poorer early prognosis, owing to larger ischemic territories and, consequently, higher rates of cardiogenic shock at presentation. In the landmark analysis, even after excluding those patients, the presence of a CTO significantly increased the risk of cardiovascular mortality, illustrating that the adverse effect of a CTO persists beyond the index presentation. The rates of target vessel revascularization were almost 3 times higher in the CTO group than in the SVD group, although there was no difference between the CTO and MVD group. Although data on revascularization of the CTO was not prospectively collected, this may be a confounder because routine complete revascularization was not mandated, and treating physicians were not blinded.
The CTO TOTAL substudy is the largest STEMI study to our knowledge and first landmark analysis assessing the impact of a non-IRA CTO in patients managed with contemporary therapies, illustrating the adverse prognostic impact of non-IRA CTO on both short- and long-term outcomes. The implications of these findings, including revascularization of CTOs requires further assessment.
Please note: Dr. Jolly has received grants from Boston Scientific and Medtronic. Dr. Cairns has received research grants from Medtronic Canada and Boston Scientific. Dr. Brilakis has received consulting/speaker honoraria from Abbott Vascular, ACIST, Amgen, Asahi, Cardiovascular Systems, Inc., Elsevier, GE Healthcare, Medicure, and Nitiloop; research support from Boston Scientific and Osprey; and has served on the board of directors of Cardiovascular Innovations Foundation and the board of trustees of the Society of Cardiovascular Angiography and Interventions. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation