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Clinical implications of coronary arteriographic findings soon after non-Q-wave acute myocardial infarction
Clinical Implications of Coronary Arteriographic Findings Soon After Non-Q-WaveAcute Myocardial Infarction MARCUS
A. DeWOOD,
A significant incidence of death and myocardial infarctlon after non-Q-wave infarction belies the earlier impression that it is less serious than Q-wave infarction. Coronary anglography fn the early stages afler non-Q-wave infarction shows a progressive increase in the number of totally occluded vessels.
MD
This is paralleled by an increase in number of collateral vessels. Thrombus also becomes increasingly prevalent over the week after non-Q-wave infarction, and plays a role in 30 to 40% of infarctions. (Am J Cardiol
A
lthough non-Q-wave myocardial infarction (MI] was orignially considered to be less serious than Qwave infarction, subsequent investigations have indicted that the incidence of death and recurrent MI is as great as that associated with Q-wave infarcts.‘J My co-workers and I were interested in defining coronary arteriographic findings early after non-Q-wave MI. The goals of this study were to determine the presence of complete coronary occlusion in the infarct-related vessel, as well as to determine frequency of coronary collaterals.
1988;81:38F-38F)
Of those 341 patients, 192 were studied within 24 hours of peak symptoms, while 94 underwent investigation in the 24- to 7%hour time period, and 55 were studied after 3 days but within 1 week of non-Q-wave MI. The clinical and laboratory characteristics of the various groups were similar. We were surprised that many patients (approximately 50% in each group) had anterior ST-T changes, and yet lesions were thought to be active elsewhere in the coronary tree-not indicating involvement of the left anterior descending artery. This may have been due to distant ischemia. All patients underwent coronary arteriography and left vcntriculography within 1 week of peak symptoms.
Study Design We tried to define the frequency of coronary occlusion within a week of the peak symptoms in patients who had sustained non-Q-wave MI. We also attempted to determine the frequency of coronary collaterals in the same population. The criteria for non-Q-wave MI were standard: (11 chest pain, (2) ST- and T-wave abnormalities without evolution of new Q waves, and (3) abnormal MB-creatine kinase activity. The investigation was conducted as a combined retrospective and prospective study over a lo-year period. A total of 341 patients were studied: 161 during the retrospective period from 1974 to 1979, and 180 during the prospective period from 1980 to 1984. From the Deaconess Medical Center, Sacred Heart Medical Center, Spokane, Washington. Address for reprints: Marcus A. DeWood, MD, Deaconess Medical Center, 800 West Fifth Avenue, Spokane, Washington 99204. 36F
Results None of the patients had normal results on coronary artcriography. Serious left main disease (over 50% obstruction] was present in 30 of the 341 (9%) patients. Although a few patients had filling defects, most patients simply had tight coronary stenosis (Fig. 1). Most of the patients also had coronary collaterals, probably protecting them (at least partially) from major ST-segment elevation associated with a current of injury (Fig. 2). Essentially, 26% of the patient population studied within the first 24 hours had complete coronary occlusion; 37% in the 24- to 7%hour group had complete coronary occlusion, and slightly over 40% had complete occlusion in the 3 to 7-day group (Fig. 3). The percentage of patients who had 70% to 90% obstruction did not differ significantly between the 3 groups. There was a trend in progression from subtotal to total occlusion. Almost every patient who had complete
April
21
coronary occlusion also had collaterals supplying the distal bed of the occluded vessel. From these data, we conclude that complete coronary occlusion is infrequent during early non-Qwave MI, and that coronary collaterals increase in parallel in patients demonstrating complete coronary occlusiorx3
1988
THE AMERICAN
JOURNAL
OF CARDIOLOGY
Volumie
61
37F
Degree of stenosis in early non-transmural myocarctial infarction 100
80
Coronary Thrombus in Non-Q-Wave Myocardial Infarction Recently, we reviewed all coronary arteriograms4 We compared arteriographic findings with surgical
Hours
FIGURE 1. Right anterior oblique coronary angiogram demonstrating subtotal stenosis of the left anterior descending coronary artery. (Reprinted with permission from the New England Journal of Medicine 1988;315:417-423).
FIGURE 2. Left anterior oblique projection of a right coronary injection. The left anterior descending coronary artery is completely occluded. Collaterals are seen going from the right coronary artery to the distal lefl anterior descending coronary artery and the equal perforating branches.
after
symptom
m
Narrowing
m[
Narrowing
RRTfl
Narrowing
mi
100%
I]
Collateral’
onset
< 70% 70-90% > 90%
Occlusion
FIGURE 3. Prevalence of complete occlusion in patients seen during non-Q-wave myocardial infarction. As is shown, the percentage of patients with complete coronary occlusion increased over time and was dependent on the interval from symptom onset to the time arteriography was performed. Also demonstrated is the extent of coronary collaterals, which almost uniformly matched the increase in complete coronary occlusion. (Reprinted with permission from the New England Journal of Medicine 1988;315:417-423).
FIGURE 4. Coronary arteriogram of the right coronary onstrating intraluminal filling defect. Thrombus was surgery.
srtery demretrieved at
38F
A SYMPOSIUM:
SILENT
MYOCARDIAL
ISCHEMIA
AND
INFARCTION-PAST,
PRESENT
AND
FUTURE
findings to determine how often coronary thrombus was present on arteriography. These data are currently undergoing further refinement. Most of the time, coronary thrombus was identified by a filling defect (Fig. 4). When patients did have complete coronary occlusion and obvious coronary thrombosis (identified by persistent staining of the infarct-related vessel], coronary collaterals usually filled the distal bed.
ated with multivessel disease,3 and preliminary data suggest there is a lower angiographic evidence of coronary thrombosis,4 it is likely that strategies aimed at the treatment of multivessel disease in the absence of coronary thrombosis should be implemented. This is especially so since the mortality associated with non-Qwave MI approaches that of Q-wave MI in the absence of interventions.
Conclusions
References
Although Q-wave MI is associated with a high frequency of complete coronary occlusion and infrequent coronary collaterals, we found that the reverse was true in early non-Q-wave MI. Likewise, preliminary data suggest that coronary thrombosis is much less evident on arteriograms in patients with non-Q-wave MI. Because non-Q-wave MI is frequently associated with continued anterograde perfusion or perfusion via collateral vessels in the setting of complete coronary occlusion, the distal vessel can be visualized. Furthermore, because non-Q-wave MI is frequently associ-
1. Hutter AM jr, DeSanctis RW, Flynn T, Yeatman LA. Nontransmural myocardial infarction. A comparison of hospital and late clinical course of patients with that of matched patients with transmural anterior and trammural inferior myocardial infarction. Am J Cardiol 1981;48:595-602. 2. Krone RJ, Friedman E, Thanavaro S, Miller JP, Kleiger RE, Oliver GC. Long-term prognosis after first Q-wave (transmural) or non-Q-wave (nontransmural) myocardial infarction. Analysis of 593 patients. Am f CardioJ 1983;52:234-239. 3. DeWood MA, Stifter WF, Simpson CS, Spores J, Eugster GS, Judge TP, Hinnen ML. Coronary arteriographic findings soon after non-Q-wave myocardial infarction. N EngJ J Med 1986;315:417-423. 4. DeWood MA. Hinnen ML. Burrouehs R. Notske RN. Soores I. Henslev GR. Coronary thrombus in early nontranimural [non-Q-w&] myddardial iifarction. Assessment by coronary arteriography (abstr]. Circulation 1986;74:II:II277.
A. DeWOOD,
A significant incidence of death and myocardial infarctlon after non-Q-wave infarction belies the earlier impression that it is less serious than Q-wave infarction. Coronary anglography fn the early stages afler non-Q-wave infarction shows a progressive increase in the number of totally occluded vessels.
MD
This is paralleled by an increase in number of collateral vessels. Thrombus also becomes increasingly prevalent over the week after non-Q-wave infarction, and plays a role in 30 to 40% of infarctions. (Am J Cardiol
A
lthough non-Q-wave myocardial infarction (MI] was orignially considered to be less serious than Qwave infarction, subsequent investigations have indicted that the incidence of death and recurrent MI is as great as that associated with Q-wave infarcts.‘J My co-workers and I were interested in defining coronary arteriographic findings early after non-Q-wave MI. The goals of this study were to determine the presence of complete coronary occlusion in the infarct-related vessel, as well as to determine frequency of coronary collaterals.
1988;81:38F-38F)
Of those 341 patients, 192 were studied within 24 hours of peak symptoms, while 94 underwent investigation in the 24- to 7%hour time period, and 55 were studied after 3 days but within 1 week of non-Q-wave MI. The clinical and laboratory characteristics of the various groups were similar. We were surprised that many patients (approximately 50% in each group) had anterior ST-T changes, and yet lesions were thought to be active elsewhere in the coronary tree-not indicating involvement of the left anterior descending artery. This may have been due to distant ischemia. All patients underwent coronary arteriography and left vcntriculography within 1 week of peak symptoms.
Study Design We tried to define the frequency of coronary occlusion within a week of the peak symptoms in patients who had sustained non-Q-wave MI. We also attempted to determine the frequency of coronary collaterals in the same population. The criteria for non-Q-wave MI were standard: (11 chest pain, (2) ST- and T-wave abnormalities without evolution of new Q waves, and (3) abnormal MB-creatine kinase activity. The investigation was conducted as a combined retrospective and prospective study over a lo-year period. A total of 341 patients were studied: 161 during the retrospective period from 1974 to 1979, and 180 during the prospective period from 1980 to 1984. From the Deaconess Medical Center, Sacred Heart Medical Center, Spokane, Washington. Address for reprints: Marcus A. DeWood, MD, Deaconess Medical Center, 800 West Fifth Avenue, Spokane, Washington 99204. 36F
Results None of the patients had normal results on coronary artcriography. Serious left main disease (over 50% obstruction] was present in 30 of the 341 (9%) patients. Although a few patients had filling defects, most patients simply had tight coronary stenosis (Fig. 1). Most of the patients also had coronary collaterals, probably protecting them (at least partially) from major ST-segment elevation associated with a current of injury (Fig. 2). Essentially, 26% of the patient population studied within the first 24 hours had complete coronary occlusion; 37% in the 24- to 7%hour group had complete coronary occlusion, and slightly over 40% had complete occlusion in the 3 to 7-day group (Fig. 3). The percentage of patients who had 70% to 90% obstruction did not differ significantly between the 3 groups. There was a trend in progression from subtotal to total occlusion. Almost every patient who had complete
April
21
coronary occlusion also had collaterals supplying the distal bed of the occluded vessel. From these data, we conclude that complete coronary occlusion is infrequent during early non-Qwave MI, and that coronary collaterals increase in parallel in patients demonstrating complete coronary occlusiorx3
1988
THE AMERICAN
JOURNAL
OF CARDIOLOGY
Volumie
61
37F
Degree of stenosis in early non-transmural myocarctial infarction 100
80
Coronary Thrombus in Non-Q-Wave Myocardial Infarction Recently, we reviewed all coronary arteriograms4 We compared arteriographic findings with surgical
Hours
FIGURE 1. Right anterior oblique coronary angiogram demonstrating subtotal stenosis of the left anterior descending coronary artery. (Reprinted with permission from the New England Journal of Medicine 1988;315:417-423).
FIGURE 2. Left anterior oblique projection of a right coronary injection. The left anterior descending coronary artery is completely occluded. Collaterals are seen going from the right coronary artery to the distal lefl anterior descending coronary artery and the equal perforating branches.
after
symptom
m
Narrowing
m[
Narrowing
RRTfl
Narrowing
mi
100%
I]
Collateral’
onset
< 70% 70-90% > 90%
Occlusion
FIGURE 3. Prevalence of complete occlusion in patients seen during non-Q-wave myocardial infarction. As is shown, the percentage of patients with complete coronary occlusion increased over time and was dependent on the interval from symptom onset to the time arteriography was performed. Also demonstrated is the extent of coronary collaterals, which almost uniformly matched the increase in complete coronary occlusion. (Reprinted with permission from the New England Journal of Medicine 1988;315:417-423).
FIGURE 4. Coronary arteriogram of the right coronary onstrating intraluminal filling defect. Thrombus was surgery.
srtery demretrieved at
38F
A SYMPOSIUM:
SILENT
MYOCARDIAL
ISCHEMIA
AND
INFARCTION-PAST,
PRESENT
AND
FUTURE
findings to determine how often coronary thrombus was present on arteriography. These data are currently undergoing further refinement. Most of the time, coronary thrombus was identified by a filling defect (Fig. 4). When patients did have complete coronary occlusion and obvious coronary thrombosis (identified by persistent staining of the infarct-related vessel], coronary collaterals usually filled the distal bed.
ated with multivessel disease,3 and preliminary data suggest there is a lower angiographic evidence of coronary thrombosis,4 it is likely that strategies aimed at the treatment of multivessel disease in the absence of coronary thrombosis should be implemented. This is especially so since the mortality associated with non-Qwave MI approaches that of Q-wave MI in the absence of interventions.
Conclusions
References
Although Q-wave MI is associated with a high frequency of complete coronary occlusion and infrequent coronary collaterals, we found that the reverse was true in early non-Q-wave MI. Likewise, preliminary data suggest that coronary thrombosis is much less evident on arteriograms in patients with non-Q-wave MI. Because non-Q-wave MI is frequently associated with continued anterograde perfusion or perfusion via collateral vessels in the setting of complete coronary occlusion, the distal vessel can be visualized. Furthermore, because non-Q-wave MI is frequently associ-
1. Hutter AM jr, DeSanctis RW, Flynn T, Yeatman LA. Nontransmural myocardial infarction. A comparison of hospital and late clinical course of patients with that of matched patients with transmural anterior and trammural inferior myocardial infarction. Am J Cardiol 1981;48:595-602. 2. Krone RJ, Friedman E, Thanavaro S, Miller JP, Kleiger RE, Oliver GC. Long-term prognosis after first Q-wave (transmural) or non-Q-wave (nontransmural) myocardial infarction. Analysis of 593 patients. Am f CardioJ 1983;52:234-239. 3. DeWood MA, Stifter WF, Simpson CS, Spores J, Eugster GS, Judge TP, Hinnen ML. Coronary arteriographic findings soon after non-Q-wave myocardial infarction. N EngJ J Med 1986;315:417-423. 4. DeWood MA. Hinnen ML. Burrouehs R. Notske RN. Soores I. Henslev GR. Coronary thrombus in early nontranimural [non-Q-w&] myddardial iifarction. Assessment by coronary arteriography (abstr]. Circulation 1986;74:II:II277.