Anterior Depressions

Angiographic and Clinical Outcomes Angiographic and Clinical Outcomes Among Patients with Acute Coronary Among Patients with Acute Coronary Syndromes Presenting with Anterior Syndromes Presenting with Anterior

ST-Segment DepressionsST-Segment Depressions

C. Michael Gibson, C. Michael Gibson, Yuri B. PrideYuri B. Pride, Satishkumar Mohanavelu,, Satishkumar Mohanavelu,Stephen D. Wiviott, Elliott M. Antman and Eugene BraunwaldStephen D. Wiviott, Elliott M. Antman and Eugene Braunwald

AHA Scientific Sessions 2008AHA Scientific Sessions 2008New OrleansNew Orleans

Disclosure StatementDisclosure Statement: TRITON-TIMI 38 was supported by a research grant to : TRITON-TIMI 38 was supported by a research grant to the Brigham and Women’s Hospital from Daiichi Sankyo and Eli Lilly.the Brigham and Women’s Hospital from Daiichi Sankyo and Eli Lilly.

None of the individual authors has any relevant conflicts to report.None of the individual authors has any relevant conflicts to report.

Anterior DepressionsBACKGROUND

• Rapid triage of patients with an acute Rapid triage of patients with an acute coronary syndrome (ACS) to an appropriate coronary syndrome (ACS) to an appropriate pharmacologic and / or invasive strategy is pharmacologic and / or invasive strategy is associated with improved outcomesassociated with improved outcomes

• The traditional 12-lead electrocardiogram The traditional 12-lead electrocardiogram (ECG) is one diagnostic modality in the initial (ECG) is one diagnostic modality in the initial evaluation of patients with chest painevaluation of patients with chest pain

• The presence of ST-segment elevation is the The presence of ST-segment elevation is the key branch point in the triage to emergent key branch point in the triage to emergent reperfusion therapyreperfusion therapy

Anterior DepressionsBACKGROUND

Anterior ST-segment depressions

Unstable angina or non-ST-segment elevation

myocardial infarction

Risk stratification

Conservative or early invasive strategy

Acute thrombotic occlusion in the posterior

circulation

Antiplatelet and antithrombotic therapy

Antiplatelet and antithrombotic therapy

EMERGENT REPERFUSION

THERAPY

Anterior DepressionsGOALS

• To determine the angiographic and clinical outcomes among patients presenting with ACS and isolated anterior ST-segment depression on 12-lead ECG

• To compare the clinician diagnosis of STEMI with subsequent angiographic evidence, such as an occluded culprit artery, and serologic evidence of myocardial necrosis

• To determine the diagnostic ECG-to-PCI time among patients with an occluded culprit artery

Anterior DepressionsMAIN TRIAL DESIGN

Double-blind

ACS (STEMI or UA/NSTEMI) & Planned PCI

PRASUGREL60 mg LD/ 10

mg MD

CLOPIDOGREL300 mg LD/ 75

mg MD

1o endpoint: CV death, MI, Stroke

Duration of therapy: 6-15 months

n=13,608

Diagnostic ECG

Angiography / PCI

Anterior DepressionsMETHODS

• Patients with isolated anterior ST-segment depression were included in the analysis

Patients with ST-segment elevation in other arterial territories were excluded

• ECGs and angiograms were evaluated by local investigators

Anterior DepressionsMETHODS

Anterior ST-segment depressions

Unstable angina

TFG 2/3 in culprit artery

NSTEMI

- Tn + Tn

“STEMI”

+ Tn

TFG 0/1 in culprit artery

Anterior DepressionsMETHODS

• Outcomes

Composite of death or MI at 30 days

Fold elevation in cardiac biomarkers

• As a surrogate for infarct size

Recognition of STEMI by local investigators

Time from diagnostic ECG to PCI

Anterior DepressionsPOPULATION

1,198 patientswith isolated

anterior depressions

13,608 patientsenrolled in

TRITON-TIMI 38

243 with UA(20.2%)

641 with NSTEMI(53.5%)

314 with “STEMI”(26.2%)

TFG 2/3TFG 2/3- Tn- Tn

TFG 2/3+ Tn

TFG 0/1TFG 0/1+ Tn+ Tn

Anterior Depressions

BASELINE CHARACTERISTICS

Characteristic

““STEMI”STEMI”

(n=314)(n=314)

UA/NSTEMIUA/NSTEMI

(n=884)(n=884) p-value

Male 71%71% 65%65% 0.054

Age, yrs (mean) 6262 6363 0.35

Diabetes 19%19% 22%22% 0.15

Hypertension 60%60% 71%71% <0.05

Hyperlipidemia 50%50% 54%54% 0.072

Prior MI 15%15% 17%17% 0.55

Smoker 33%33% 30%30% 0.38

BMI, kg/m2 (mean) 2828 2828 0.86

CrCl, ml/min (mean) 101101 9999 0.45

Anterior Depressions

CULPRIT ARTERY IN “STEMI”* PATIENTS

48.4%

33.8%

17.8%

0%

10%

20%

30%

40%

50%

60%

LCx LAD RCA

Pa

tie

nts

n=106 n=56n=152

* TFG 0/1 in culprit artery Positive cardiac biomarkers

Anterior Depressions

8.6%

6.3%

2.9%

0%1%2%3%4%5%6%7%8%9%

10%

UA NS TEMI "S TEMI"

Pati

ents

3-way p=0.006

CLINICAL OUTCOMES

30-day death or MI

n=641 n=314n=243

TFG 2/3TFG 2/3- Tn- Tn

TFG 2/3+ Tn

TFG 0/1TFG 0/1+ Tn+ Tn

Anterior DepressionsINFARCT SIZE

1.5

3.3

0

1

2

3

4

5

Pea

k C

K-M

B /

UL

N C

K-M

B

UA/NSTEMI STEMI

p<0.001

n=884 n=314

Anterior Depressions

INFARCT SIZE BY CULPRIT ARTERY

2.3

1.2 1.3

4.1

2.53

0

1

2

3

4

5

LCx LAD RCA

Pea

k C

K-M

B /

UL

N C

K-M

B

UA/NSTEMI STEMI

p<0.05 for all

Anterior DepressionsMANAGEMENT

• Among patients with an occluded culprit artery and anterior ST-segment depression, only 14/314 (4.5%) were interpreted by the investigator as a STEMI

• The median time from baseline ECG to PCI for patients with an occluded culprit artery was 29.4 hours (IQR 26.1-44.1 hours)

• None of the patients with an occluded artery had an ECG to PCI time <6 hours

Anterior DepressionsLIMITATIONS

• Only patients who survived until angiography were included

Due to survival bias, this dataset may therefore underestimate the number of patients with anterior ST-segment depression who have an occluded artery

• ECGs were read locally, not by a core laboratory, and so subtle ST-segment elevation cannot be excluded

Anterior DepressionsCONCLUSIONS

• More than a quarter of patients with ACS who present with isolated anterior ST-segment depressions in TRITON-TIMI 38 had an occluded culprit artery and positive cardiac biomarkers

• The occluded artery was most often the left circumflex artery

Anterior DepressionsCONCLUSIONS

• Patients with anterior ST-segment depression and an occluded culprit artery had significantly larger infarcts and worse short-term clinical outcomes

• These ECG findings frequently went unrecognized as evidence of a possibly occluded culprit artery

• This suggests the need for improved methods to identify patients with isolated anterior ST-segment depression who have an occluded artery