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The aim of the study was to evaluate the relationship between early well-developed coronary collateral circulation (CCC) and clinical outcomes in patients with late presentation(>24 hours) myocardial infarction (MI).
Retrospective multicenter longitudinal study on 190 patients with a late presentation MI and angiographic evidence of a thrombotic occlusion(TIMI 0) of a major coronary artery from 2009 to 2016. The Rentrop and Werner score were used for the angiographic categorization of CCC. Two experienced cardiologists retrospectively evaluated the angiographies in a blinded manner to classify the CCC into grades. Primary end point: Major adverse cardiac events (MACE) at 12 months defined as:Cardiovascular mortality (CVM) or heart failure hospitalization. The secondary end point was CVM at 12 months.
Poor CCC was detected in 46% of the patients. The Kappa indices of agreement for variability for the classification of CC C was excellent(k = 0.88;95% CI,0.82-1.00). Patients with good CCC more commonly had a right coronary (RC) occlusion(p<0.05). There were no significant differences between both groups neither in baseline characteristics (Sex,age, cardiovascular risk factors, previous treatment and comorbidities) nor in medical treatment at discharge.The median follow up was 3.4 years (interquartile range 1.1-5.5 years). 38 patients lost to follow up. MACE at 12 months (30.1% vs 4.9%, p<0.001); CVM at 12 months (24.2% vs 2.5%, p<0.001) and cardiogenic shock (10 % vs 1.2%, p=0.02) were significantly higher in poor CCC group compared to good CCC group. On follow-up poor CCC patients were more often rated at NYHA ≥III (11.3% vs 0%, p=0.006) Neither successful revascularization of the culprit vessel (MACE: 14%vs18%,p=0.5 and CVM:11.9%vs12.4,p=0.9) nor complete revascularization (MACE 18%vs16%,p=0.7 and CVM:12.2% vs 11.7%,p=0.9) showed an improvement in outcomes. However when myocardial viability of the culprit vessel territory had been proven both variables were significantly related to parameters.MACE at 12 months was independently associated in the multivariate analysis to Killip classification at presentation (OR 2.7, 95% CI 1.2-5.9), left ventricular ejection fraction (LVEF) (OR 0.89, 95% CI 0.83-0.96), not to be treated with antagonist aldosterone drugs (OR 8.8, 95% CI 1.06-43) and grade of collateral circulation (OR 12.4, 95% CI 2.1-54). CVM at 12 months was independently associated in the multivariate analysis to Killip at presentation, LVEF and not to be treated with antagonist aldosterone drugs. Kaplan-meier curves showed that MACE and CVM were significantly higher (p<0.01) in poor CC compared to early developed CCC group according to log rank test.
The presence of an early well-developed coronary collateral circulation in patients with late presentation MI is associated with lower MACE at 12 month follow up.
CORONARY: Acute Myocardial Infarction