Management of Culprit and Non-Culprit Lesions in Acute Coronary Syndrome

Evaluation of Nonculprit Coronary Artery Lesions in Patients with Acute ST-Segment Elevation Myocardial Infarction

Background:

Multivessel coronary artery disease is a common finding during the primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction (STEMI). It might be a cause for recurrent attacks. This study aimed to evaluate nonculprit lesions (NCLs) encountered in the three major epicardial coronary arteries.

Methods:

Patients with STEMI who underwent PPCI and matched the study inclusion criteria were enrolled. They were evaluated clinically, biomedically, and coronary angiographically. The coronary angiography analysis was examined by four cardiologists using the Quantitative Coronary Artery Analysis software. The data was analyzed statistically.

Results:

Of the 154 patients included in the study, 130 (84.4%) were males and 24 (15.6%) were females, with a mean age of 52.92 ± 13.14 years. Five hundred seventy-four NCLs were found in 132 (85.7%) patients. Nonobstructive lesions with stenosis less than 70% of vessel diameter were more frequent than obstructive lesions. The left circumflex coronary artery (LCX) was the first one of the three major arteries to be affected by obstructive NCLs. The obstructive NCLs were 128 in number; found in 78 (50.4%) patients; 65 (50.8%) of them were in LCX; 32 (25%) were in left anterior descending (25%); and 31 (24.2%) were in right coronary artery.

Conclusions:

NCLs are common among STEMI patients. LCX obstructive NCLs are comparable to those in the other two major epicardial coronary arteries, with respect to frequency and severity of luminal stenosis.

Inflammatory Biomarkers and Endothelial Alteration in Patients with Heart Failure and Acute Coronary Syndromes

Introduction: Systemic inflammation plays a key role in the pathophysiology of acute coronary syndrome (ACS), having a direct effect in promoting the progression and rupture of vulnerable coronary plaques. The aim of this study was to investigate the association between inflammatory biomarkers and the type of ACS (ST-elevation myocardial infarction – STEMI, non-ST-elevation myocardial infarction – NSTEMI, or unstable angina – UA) in patients with confirmed heart failure.

Material and Methods: This study included a total of 266 patients admitted to the Clinical Department of Cardiology of the County Emergency Clinical Hospital of Târgu Mureș – Cardiac Intensive Care Unit (CICU) for ACS of various types (UA, NSTEMI or STEMI) between January 1, 2017 and December 31, 2020, in whom the diagnosis of heart failure was established based on clinical and paraclinical data. From the total number of patients, 36 were hospitalized for UA and 230 for MI, of which 165 were STEMI and 65 were NSTEMI.

Results: Only hs-CRP and IL-6 were significantly higher in MI compared to UA. Mean hs-CRP was 4.9 ± 4.5 mg/mL in patients with UA vs. 20.4 ± 42.2 mg/mL in patients with MI (p = 0.001), and mean IL-6 was 7.2 ± 13.8 pg/mL in UA vs. 31.6 ± 129.2 pg/mL in MI (p <0.0001). ICAM seems to have had a greater discriminating power between STEMI and other types of ACS in those with heart failure, having a value more than double in those with STEMI (216.1 ± 149.6 ng/mL vs. 448.2 ± 754.4 ng/mL, p <0.0001).

Conclusions: In patients with heart failure, the increase of inflammatory biomarkers such as hs-CRP is associated with the development of an acute myocardial infarction but not with its type. Adhesion molecules, especially ICAM, are elevated in patients with STEMI compared to other types of ACS, indicating a potential role of endothelial alteration in the development of an ACS when it adds to systemic inflammation linked to heart failure.