Anterior Depressions Angiographic and Clinical Outcomes Among Patients with Acute Coronary Syndromes...
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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