|Year : 2020 | Volume
| Issue : 3 | Page : 259-263
Clinical and Angiographic Profile of Young Patients Presenting with Spontaneous Electrocardiogram Resolution of ST-Segment Elevation (Spontaneous Aborted) Myocardial Infarction: A Substudy of the Premature Coronary Artery Disease Registry (Registered Under [CTRI/2018/03/012544])
Rahul S Patil, Laxmi H Shetty, Aman Sinha, JR Vijay Kumar, Manidipa Majumdar, Suvradip Dutta, TR Raghu, CN Manjunath
Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
|Date of Submission||04-May-2020|
|Date of Decision||27-Jul-2020|
|Date of Acceptance||15-Sep-2020|
|Date of Web Publication||23-Dec-2020|
Dr. Rahul S Patil
# E1002, Peninsula Heights Apartments, 17 Main Road, JP Nagar 2nd Phase, Bengaluru - 560 078, Karnataka
Source of Support: None, Conflict of Interest: None
Background: There are very few data regarding clinically defined spontaneous resolution (SR) in ST-segment elevation (STE) acute coronary syndrome (ACS) patients. Most recent European and American practice guidelines fail to give specific recommendations for these patients. Specifically, the timing of intervention in patients with SR remains unclear. Aim and Study: The aim of the study was to study the clinical, social, biochemical, and angiographic profile of Indian youth presenting with spontaneous resolution (SR) of ST-segment elevation (STE). Subjects and Methods: The premature coronary artery disease (PCAD) registry is a prospective, descriptive, observational study of Indians aged below 40 years with coronary artery disease (CAD) conducted between April 2017 and April 2020. Of 3450 patients registered in PCAD registry, a total of 41 (1.2%) out of these 3450 patients presented with STE myocardial infarction (MI), which resolved spontaneously, and hence these patients satisfied entry criteria. Entire clinical and angiographic profile of these patients was documented. Conventional lipids were estimated using commercially available kits. The data were analyzed by statistical software R version 3.5.0 (R Core Team (2018). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria). Results: The mean age of all patients under PCAD registry was 30.49 years. A majority of 38 (92.68%) of the patients were males, 30 (73.17%) were smokers. Of total, four patients (9.75%) were diabetic. Twenty-five out of 41 patients (60.97%) were coming under the below poverty line category. Five patients (12.19%) were Muslims by religion, whereas the remaining were Hindus. The majority (38 patients, 92.68%) were nonvegetarians. The most common index presentation of the transient STE was with anterior wall MI (27 patients, 65.85%). The mean total cholesterol of the entire study population was 172.947 ± 47.11. Thirty-nine out of 41 patients (95.12%) underwent diagnostic coronary angiogram. Ultimately, 32 out of 41 patients (78.05%) were discharged and continued on optimal medical therapy and follow-up and nine patients (21.95%) underwent percutaneous coronary revascularization. Conclusions: Patients with ACS and SR of ST-elevation on electrocardiogram (ECG) exhibit a characteristic profile that differentiates them from the rest of patients with STEMI: younger age, a greater prevalence of males and smokers, and a lesser elevation of the necrosis markers, a greater ejection fraction, and a higher prevalence of single-vessel disease. Contrary to popular belief, coronary angiogram showed a significant proportion of them to be having underlying organic CAD. Our study highlights the need for early intervention in such patients.
Keywords: Myocardial infarction, observational, premature coronary artery disease, prospective
|How to cite this article:|
Patil RS, Shetty LH, Sinha A, Vijay Kumar J R, Majumdar M, Dutta S, Raghu T R, Manjunath C N. Clinical and Angiographic Profile of Young Patients Presenting with Spontaneous Electrocardiogram Resolution of ST-Segment Elevation (Spontaneous Aborted) Myocardial Infarction: A Substudy of the Premature Coronary Artery Disease Registry (Registered Under [CTRI/2018/03/012544]). J Pract Cardiovasc Sci 2020;6:259-63
|How to cite this URL:|
Patil RS, Shetty LH, Sinha A, Vijay Kumar J R, Majumdar M, Dutta S, Raghu T R, Manjunath C N. Clinical and Angiographic Profile of Young Patients Presenting with Spontaneous Electrocardiogram Resolution of ST-Segment Elevation (Spontaneous Aborted) Myocardial Infarction: A Substudy of the Premature Coronary Artery Disease Registry (Registered Under [CTRI/2018/03/012544]). J Pract Cardiovasc Sci [serial online] 2020 [cited 2021 Jan 20];6:259-63. Available from: https://www.j-pcs.org/text.asp?2020/6/3/259/304523
| Introduction|| |
Premature coronary artery disease (PCAD), by definition, occurs at a younger age (before the age of 55 years in men and 65 years in women). In its severe form, PCAD occurs below the age of 40 years. Cardiovascular disease (CVD) is the leading cause (28%) of death in India. The annual CVD mortality in India was predicted to rise to 4.77 million, making India the CVD capital of the world by 2020. The risk of coronary artery disease (CAD) in Asian Indians is four times of the same in Caucasians, six times of Chinese, and twenty times of Japanese. Indians are prone to CAD at a much younger age. Approximately 50% of first heart attacks occur before 55 years, and 25% of the same occur before 40 years of age.
Clinically spontaneous resolution (SR) of ST-segment elevation (STE) myocardial infarction (MI) is commonly diagnosed by both (1) >70% reduction in the sum of ST-segment elevations on consecutive electrocardiograms (ECGs) before administration of definitive reperfusion therapy and (2) >70% resolution in pain assessed using a visual analog score of 0–10.
In STEMI, complete ST-segment resolution (STR) on ECG and relief of chest pain can be due to SR of coronary spasm or intracoronary thrombus. Prinzmental's variant angina is a rare entity. It is characterized by transient STE, without evidence of myocardial necrosis. The pathogenesis of variant angina consists of coronary spasm associated with endothelial dysfunction. Cigarette smoking is the only established risk factor.
There are very few data regarding clinically defined SR in STE acute coronary syndrome (STE-ACS) patients., While the most recent guidelines include patients with clinically defined SR within the context of non-STE-ACS, few specific recommendations are made for these patients. Specifically, the timing of intervention in patients with SR remains unclear.
One large study showed that patients with SR had significantly fewer major adverse outcomes during their hospital course including a lower incidence of heart failure and cardiogenic shock and had a shorter coronary care unit stay (4.4 ± 3.0 vs. 3.9 ± 2.1 days, P < 0.001). Patients with SR had less myocardial damage as assessed by significantly lower peak creatine kinase levels and higher left ventricular ejection fraction. At 30-day follow-up, they had less incidence of heart failure. Researchers reported that timing of revascularization had no effect on the final infarct size at 4 months or the prespecified composite end point of major adverse cardiovascular events..
Therefore, overall, the patients with clinically defined SR seem to have a favorable prognosis. Deferring immediate intervention seems to be safe in patients with clinical indices of spontaneous reperfusion. However, an important gap in knowledge is found in this field that must be filled by future research work.
| Subjects and Methods|| |
The PCAD registry is a prospective, multicenter, descriptive, observational study examining a cohort of young Indian adults aged up to 40 years, with CAD, from the point of index admission between April 2017 and April 2020. Clearance for this study was obtained from the institutional ethics committee of the institute vide letter dated February 23, 2018. Informed written consent was obtained from each patient for the utilization of their clinical data for observational study purpose. This is registered under the Clinical Trials Registry of India (CTRI/2018/03/012544). The inclusion criteria were patients with index admission for ischemic heart disease, as proven by (1) documented episode of ACS and/or (2) chronic stable angina with documented evidence of CAD. Exclusion criteria were patients (1) with myocarditis, cardiomyopathies, and pulmonary embolism; (2) who were previously diagnosed as cases of CAD or on medications such as antiplatelets and statins; and (3) with chronic kidney disease, liver failure, a history of consumption of oral contraceptives, and steroids.
Once admitted into the hospital, patients who satisfied the inclusion criteria for the age group were selected. Demographic factors such as age, gender, and address; socioeconomic factors such as occupation, income, marital history, and religion; CAD risk factors such as the presence of smoking, diabetes, hypertension, and family history, were all recorded. Presentation to hospital, window period from onset of symptoms to arrival in hospital, the primary method of management, course in hospital, and echocardiogram on admission were all documented.
Biochemical and hematological profile was documented. About 5 ml of each patient's venous blood sample was collected in plain vacutainer before the first dose of cardiac drugs was administered and sent for assessment. The blood was subjected to centrifugation at 3500 rpm for 10 min, and the separated serum was used for the estimation of routine lipid profile. Total cholesterol and triglycerides (TGs) were estimated using commercially available kits (Accurex Biomedical Pvt. Ltd., Mumbai, Maharashtra, India). Measurement of direct low-density lipoprotein-cholesterol (LDL-C) was done by enzymatic homogeneous colorimetric assay using Cobas Gen3. C502 analyzer. Coronary angiographic profile and mode of intervention (if any) were all documented.
Categorical variables were presented as count and percentage, whereas continuous variables were presented as mean. Some extreme values of lipid profile were excluded (above the 99th percentile) to prevent the data from asymmetric shape. The data were analyzed by R statistical analysis and computing language version 3.5.1 (R core team, 2018, R Core Team (2018). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria), which is released under the R statistical software is one of the most popular statistical software used by researcher from all fields across the globe. It is release under the GNU General Public License(GPL), version 2, published by the Free Software Foundation.
| Results|| |
A total of 41 out of 3450 patients (1.2%) registered under PCAD registry belonged to the study group. The mean age of all patients under PCAD registry was 30.487 years. The age distribution of the study group is shown in [Figure 1].
There were 38 (92.68%) males and thirty (73.17%) were smokers. Four (9.75%) were diabetic. Moreover, 15 patients (36.58%) were from rural areas. Most common profession among patients was driving (15 patients, 36.58%); around 18 patients (43.90%) were educated over and above 10th standard. Twenty-five (60.97%) were from the below poverty line (BPL) category. The majority (38 patients, 92.68%) had been following nonvegetarian diet [Table 1].
The mean total cholesterol of the entire study population was 172.947 ± 47.11 mg/dl, mean LDL level was 119.473 ± 84.81 mg/dl, mean high-density lipoprotein (HDL) level was 30.34 ± 9.64 mg/dl, and mean TG level was 138.284 ± 87.11 mg/dl. In the study group, 13.79% patients had elevated total cholesterol levels, 13.79% had elevated LDL-C, 58.62% had low HDL cholesterol levels, and 20.69% had elevated TG levels. Physical parameters showed that ten patients (24.39%) had normal body mass index (BMI), 18 patients (43.90%) had high BMI, whereas 13 patients (31.70%) had BMI, which according to revised classification for South Asians fell under overweight (23–25).
The most common index presentation of the transient STE was with anterior wall MI (27 patients, 65.85%), followed by inferior wall MI (nine patients, 21.95%) and one each (2.43%) of anterolateral, anteroinferior, inferolateral, lateral, and high lateral wall MI. Window period from onset of symptoms to presentation to hospital was within 3 h in 27 patients (65.85%), between 3 and 6 h in ten patients (24.39%), and between 6 and 12 h in four patients (9.75%).
The majority of the patients (38, 95.12%) underwent diagnostic coronary angiogram. The angiographic profile of patients with spontaneously aborted MI is shown in [Figure 2]. Nearly 34% of patients had spontaneous recanalization of coronaries. Around 29% had organic CAD. Nearly 22% had normal coronaries, whereas 10% had normal coronaries.
|Figure 2: Angiographic profile of patients' spontaneous aborted myocardial infarction.|
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Eventually, 32 out of 41 patients (78.05%) were discharged and continued on optimal medical therapy and follow-up; nine patients (21.95%) underwent percutaneous coronary revascularization [Table 2].
|Table 2: Ultimate mode of management of premature coronary artery disease|
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Left ventricular ejection fraction recorded for each of patients showed adequate systolic function (>50%) in 28 patients (68.296%), moderate left ventricular (LV) systolic dysfunction (40%–50%) in 13 patients (31.70%), whereas none of the patients had severe LV dysfunction.
| Discussion|| |
Overall, this study shows that ACS with transient STE is more common in younger age, a greater prevalence of males and smokers, a lesser elevation of the necrosis markers, a greater ejection fraction, and a higher prevalence of single-vessel disease.
STE in STEMI patients is an indication for emergency primary percutaneous coronary intervention (PCI). 2013 ACCF/AHA guideline suggests a class I recommendation for door-to-device time goal of ≤90 min for STEMI patients but does not address the reperfusion time for those with spontaneous, complete STR. In STEMI, complete STR on ECG and relief of chest pain can be due to SR of coronary spasm or intracoronary thrombus.
Arroyo Úcar et al. reported that patients with ACS and transient STE exhibit a characteristic profile that differentiates them from the rest of the patients with STEMI: younger age, a greater prevalence of males and smokers, a lesser elevation of the necrosis markers, a greater ejection fraction, and a higher prevalence of single-vessel disease.
PCAD generally makes up to 30%–40% of total ischemic heart disease population. In PCAD registry, 41 out of total of 3450 patients (1.2%) registered belonged to the study group for this particular study. The mean age of all patients under PCAD registry was 30.487 years, the majority (92.68%) were men, 73.17% were smokers, 9.75% of them were diabetic, 36.58% were having a common profession of driving, 60.97% were from BPL category, and the majority of patients (93%) were nonvegetarians. Coming to other traditional cardiovascular risk factors, none of the patients had hypertension or a family history of PCAD, though 13% had obesity.
Of the total study population, 41.41% of patients (mostly smokers) showed polycythemia which is seen more commonly in smokers among the PCAD population.
Going by the average values of individual lipid parameters, predominant dyslipidemia pattern seen in this study group was isolated low HDL.
The most common index presentation of the transient STE was with anterior wall MI (65.85%); ultimately, only 21.95% patients had significant flow-limiting atherosclerotic CAD requiring coronary intervention. The remaining 78% only showed normal, recanalized, or mild disease.
Studies have demonstrated that complete STR before emergency angiography was an independent predictor of TIMI flow pre-PCI as well as 1-year cardiac mortality rate and 1-year CV events rate. Clinically, STR may imply reperfusion of the Myocardial area at risk (AAR) is the territory distal to the infarct related artery (IRA) by both the infarct-related artery and collateral flow.
The majority of the patients (68.296%) had preserved LV systolic function.
In previous studies [A] which compared STE-ACS patients with SR of ST-elevation against patients with STEMI undergoing therapy for immediate reperfusion, patients with SR had significantly less inhospital heart failure (4% vs. 11%) and cardiogenic shock (0% vs. 2%) (P < 0.01 for all). No significant differences were found in inhospital mortality (1% vs. 2%), 30-day major cardiac events (4% vs. 4%), and mortality at 30 days (1% vs. 2%) and 1 year (4% vs. 4%). SR patients had significantly better inhospital outcomes than STE-ACS patients undergoing immediate reperfusion. They had a lower risk of heart failure, cardiogenic shock, arrhythmias, and heart blocks and had shorter coronary care unit stay. Mortality and major adverse cardiac event rates were similar between groups at 30 days as was 1-year mortality.
However, since the exact treatment of ACS with transient STE has not been well established and most ACS guidelines offer no specific recommendations for such cases, the scientific evidence regarding the management of these patients should be derived from randomized clinical trials involving patients with ACS with transient STE. Until such information becomes available, nonrandomized studies fitting for treatment tendencies or systematic reviews of randomized trials (analysis of subgroups according to the initial ECG pattern) could contribute useful evidence for decision taking in this important group of patients.
Limitations of study
First, a larger sample size would be required to improve the significance of these findings. Moreover, second, a long-term prospective study to assess long-term clinical outcomes of each clinical and angiographic subset of these patients would be required to risk stratify these patients and also to learn the best treatment strategy.
| Conclusions|| |
ACS with transient STE exhibits a characteristic profile that differentiates them from the rest of patients with STEMI: younger age, a greater prevalence of males and smokers, a lesser elevation of the necrosis markers, a greater ejection fraction, and a higher prevalence of single-vessel disease. Contrary to the popular old belief that spontaneous clinical resolution of ST-elevation on ECG is due to vasospasm, this study showed that, on angiogram, a significant proportion of them turned out to be having underlying organic CAD. Hence, this study gives emphasis on the strategy of early intervention even in cases of SR of ST elevation in ECG.
Ethical clearance was obtained from the ethical review committee at our institute.
We would like to thank Research Coordinator, Mrs. Rani B J, and Research Assistant, Mr. Prateesh, for technical help.
Financial support and sponsorship
This study was financially supported by Sri Jayadeva Institute of Cardiovascular Sciences and Research.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]