Incidence of In-Hospital MACE in Patients Presented with Acute STEMI in The Presence of CTO in Non-IRA
Authors: Saeed Mennatalla Khaled Mohamed , Mostafa Ahmad E , ElSerafy A S , ElEtriby Shehab Adel 
Published: September 2024

Abstract

Background
Previous studies have shown that approximately 40%–60% of patients with STEMI have multivessel diseases (MVD). A concurrent chronic total occlusion (CTO) in a non-IRA is incidentally found in about 8%–15% of patients with STEMI. The presence of a CTO in non-IRA has been associated with a worse prognosis in many studies, whether in the short or long term. This is probably due to many factors including more comorbidities in CTO patients, higher ischemic burden, and the “double Jeopardy theory”.

Aims and objectives
The aim of our study is to evaluate the incidence of in-hospital major adverse cardiovascular events (MACE) in patients presenting with STEMI and CTO in non-IRA.

Methods
This prospective observational study was conducted in the Cardiology Department, Ain Shams University hospitals to study the incidence of In-hospital MACE in STEMI patients presented with CTO in non-IRA. Our study included 111 patients divided into 2 groups: Group A: 52 Patients undergoing primary PCI for STEMI with concurrent CTO of a non-IRA as the study group and Group B: 59 patients undergoing primary PCI without concurrent CTO of any vessel and well-matching baseline clinical characteristics to the study group as the control group.
We collected the Patient's demographic data, risk factors, family history, history of ischemic heart disease, ECG at presentation and predischarge, Predischarge Echocardiography, and Clinical in-hospital course for the development of MACE, which we defined in our study as the development of heart failure, Acute pulmonary edema (APO), arrhythmia, cardiogenic shock, and or death.

Results
Our study showed that only 40% of the cases developed In-hospital MACE, mostly in the form of APO and Cardiogenic Shock. It also revealed there was no statistically significant difference between cases with and without CTO regarding the demographic data except for DM. Diabetes was found higher in cases with CTO than in cases without CTO with p-value = 0.004. There was also a statistically significant difference between both groups with respect to ECG resolution being more common in cases without CTO with a P value of 0.0. In addition, there was a statistically significant difference regarding the Ejection Fraction being significantly lower in cases with CTO with a P value=0.001.
Regarding the incidence of MACE in cases without CTO: there was no statistically significant difference between cases regarding the demographic data except for DM as more cases who developed In-Hospital MACE were found to be Diabetic with a P value= 0.03. Also, we observed a statistically significant difference with respect to ECG resolution as more cases who developed In-Hospital MACE didn't experience ECG resolution after primary PCI with a P value=0.018.
Regarding the incidence of MACE in cases with CTO: we found a statistically significant difference regarding Blood pressure and Heart rate as more cases who developed In-Hospital MACE were found to have lower blood pressure and higher heart rate. In addition, we noticed that there was a statistically significant difference regarding Ejection fraction as 100% of the cases who developed MACE had heart failure with reduced ejection fraction.

Conclusion
In patients presenting with STEMI, we found the incidence of In-hospital MACE was higher in cases with CTO in non-IRA in comparison to cases without CTO in non-IRA including single vessel disease patients and MVD patients mainly in the form of APO and Cardiogenic shock. 50% of cases with CTO developed MACE, and 100% of the CTO cases that developed MACE had reduced ejection fraction.