Author + information
- Received April 11, 2013
- Revision received August 8, 2013
- Accepted August 30, 2013
- Published online March 1, 2014.
- Alexandra J. Lansky, MD∗∗ (, )
- Vivian G. Ng, MD∗,
- Stephanie Meller, MD∗,
- Ke Xu, PhD†,
- Martin Fahy, MSc†,
- Frederick Feit, MD‡,
- E. Magnus Ohman, MD§,
- Harvey D. White, MD‖,
- Roxana Mehran, MD¶,
- Michel E. Bertrand, MD#,
- Walter Desmet, MD∗∗,
- Martial Hamon, MD†† and
- Gregg W. Stone, MD†
- ∗Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
- †Division of Cardiology, Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York
- ‡Division of Cardiology, New York University School of Medicine, New York, New York
- §Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- ‖Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
- ¶Division of Cardiology, Mount Sinai Medical Center, New York, New York
- #Department of Cardiology, Hôpital Cardiologique, Lille, France
- ∗∗Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium
- ††Department of Cardiology, University Hospital, Normandy, France
- ↵∗Reprint requests and correspondence:
Dr. Alexandra J. Lansky, Interventional Cardiovascular Research, Valve Program, Yale University School of Medicine, P.O. Box 208017, New Haven, Connecticut 06520-8017.
Objectives This study evaluated the impact of nonculprit vessel myocardial perfusion on outcomes of non–ST-segment elevation acute coronary syndromes (NSTE-ACS) patients.
Background ST-segment elevation myocardial infarction patients have decreased perfusion in areas remote from the infarct-related vessel. The impact of myocardial hypoperfusion of regions supplied by nonculprit vessels in NSTE-ACS patients treated with percutaneous coronary intervention (PCI) is unknown.
Methods The angiographic substudy of the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial included 6,921 NSTE-ACS patients. Complete 3-vessel assessments of baseline coronary TIMI (Thrombolysis In Myocardial Infarction) flow grade and myocardial blush grade (MBG) were performed. We examined the outcomes of PCI-treated patients according to the worst nonculprit vessel MBG identified per patient.
Results Among the 3,826 patients treated with PCI, the worst nonculprit MBG was determined in 3,426 (89.5%) patients, including 375 (10.9%) MBG 0/1 patients, 475 (13.9%) MBG 2 patients, and 2,576 (75.2%) MBG 3 patients. Nonculprit MBG 0/1 was associated with worse baseline clinical characteristics. Patients with nonculprit MBG 0/1 versus MBG 3 had increased rates of 30-day (3.0% vs. 0.7%, p < 0.0001) and 1-year (4.4% vs. 1.0%, p < 0.0001) death. Similar results were found among patients with pre-procedural TIMI flow grade 3 in the culprit vessel, where nonculprit vessel MBG 0/1 (hazard ratio: 2.81 [95% confidence interval: 1.63 to 4.84], p = 0.0002) was the strongest predictor of 1-year mortality.
Conclusions Reduced myocardial perfusion in an area supplied by a nonculprit vessel is associated with increased short- and long-term mortality rates in NSTE-ACS patients undergoing PCI. Furthermore, worst nonculprit MBG is able to risk-stratify patients with normal baseline flow of the culprit vessel.
- acute coronary syndrome
- epicardial flow
- myocardial perfusion
- non-culprit vessel
- percutaneous coronary intervention
The ACUITY trial was sponsored and funded by The Medicines Company and Nycomed. Dr. Feit has received consulting fees from The Medicines Company; and is a shareholder in Boston Scientific, Johnson & Johnson, Medtronic, and The Medicines Company. Dr. Ohman has received grant support from Daiichi Sankyo, Eli Lilly, and Gilead Sciences; has received consulting fees from Abiomed, AstraZeneca, Biotie, Ikaria, Ivivi, Janssen, Liposcience, Pozen, Sanofi-Aventis, The Medicines Company, and WebMD; and has served on the Speakers’ Bureaus of Gilead Sciences and Liposcience. Dr. White has unrestricted research grant support from AstraZeneca, Merck Sharp & Dohme, Roche, Regado Biosciences, Sanofi-Aventis, Eli Lilly, The Medicines Company, the National Institutes of Health, GlaxoSmithKline, and Daiichi Sankyo. Dr. Mehran has received institutional research grant support from The Medicines Company, Bristol-Myers Squibb/sanofi, and Lilly/Daichii Sankyo; and has received consulting fees from Abbott Vascular, AstraZeneca, Boston Scientific, Covidien, Janssen (Johnson & Johnson), Regado Biosciences, Maya Medical, and Merck & Co. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 11, 2013.
- Revision received August 8, 2013.
- Accepted August 30, 2013.
- American College of Cardiology Foundation