Coronary artery disease
Impact of Multivessel Coronary Disease on Long-Term Mortality in Patients With ST-Elevation Myocardial Infarction Is Due to the Presence of a Chronic Total Occlusion

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In acute ST-elevation myocardial infarction (STEMI), patients with multivessel disease (MVD) are considered to be a subgroup with an increased risk of mortality compared with patients with single-vessel disease (SVD). To evaluate the effect of MVD on 1-year mortality in patients with STEMI, we studied 1,417 consecutive patients with STEMI who were admitted between 1997 and 2002 and treated with primary percutaneous coronary intervention. Further, we hypothesized that the effect of MVD on mortality is due to the presence of a chronic total occlusion in a noninfarct-related artery. Patients with MVD and/or a chronic total occlusion had multiple differences in baseline and angiographic characteristics that were associated with worse outcome. Mortalities in patients with SVD, MVD, and a chronic total occlusion were 8%, 16%, and 35%, respectively. After correction for the baseline differences, MVD was an independent predictor of mortality (odds ratio 1.5, 95% confidence interval 1.1 to 2.1). However, when chronic total occlusion was included in the model, MVD was no longer an independent predictor for mortality, whereas chronic total occlusion was a strong and independent predictor for 1-year mortality in patients with STEMI treated with percutaneous coronary intervention (odds ratio 3.8, 95% confidence interval 2.5 to 5.8). In conclusion, patients with STEMI and MVD have a higher 1-year mortality rate compared with patients with SVD, which is mainly determined by the presence of a chronic total occlusion in a noninfarct-related artery. In the setting of primary percutaneous coronary intervention, the presence of a chronic total occlusion, and not the mere presence of MVD, is an independent predictor of mortality.

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Methods

Between January 1997 and December 2002, 1,463 consecutive and unselected patients were admitted to our hospital with STEMI and underwent coronary angiography with a view to perform percutaneous coronary intervention. This cohort has been previously described.12 STEMI was diagnosed when patients had symptoms of an acute MI lasting 30 minutes to 6 hours, accompanied by an electrocardiogram with ST-segment elevation >1 mm (0.1 mV) in ≥2 contiguous leads. All patients were treated with heparin and

Results

Among the 1,417 patients, 578 patients (41%) had MVD. Clinical characteristics are presented in Table 1. Patients with MVD were older, more often had a previous MI and a history of diabetes, and more often presented with cardiogenic shock compared with patients with SVD.

There were differences in angiographic characteristics between patients with SVD and those with MVD (Table 1). Patients with MVD had a higher incidence of coronary calcifications (30% vs 16%, p <0.001) and reperfusion failure

Discussion

We found that, despite the reperfusion therapy of choice, patients with MVD have a higher 1-year mortality rate compared with patients with SVD after primary percutaneous coronary intervention for acute STEMI. This is the first study to demonstrate that the higher 1-year mortality rate in patients with MVD is mainly determined by the presence of a chronic total occlusion in a noninfarct-related artery and not due to the mere presence of MVD. Our results confirm previous studies reporting the

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