AVR ST Elevation Myocardial Infarction: A Not
So Urgent Cardiac Emergency. A Single
Tertiary Center Experience in Malaysia
Dr. Jian-Chen Lim, MBBS, MRCPUK
Hospital Raja Permaisuri Bainun, Ipoh, Malaysia
Disclosure
• I have nothing to disclose
Introduction
• Hospital Raja Permaisuri Bainun (HRPB) is located in Ipoh, capital of state
of Perak in Malaysia
• The only public hospital which provides cardiology service in the state of
Perak. Population of 2.5 million
• The cardiology referral center for the whole state of Perak
• Thrombolysis is still the mainstay of STEMI reperfusion method in this
state due to limited resources (cath lab and manpower)
• No in-house Cardiothoracic (CTC) service. Nearest public CTC centers
are in other states, ~ 2 hours journey
Background
• AVR STEMI is well recognized as a sign of acute occlusion of the left main
stem (LMS) or proximal left anterior descending(LAD) coronary artery
• But is aVR STEMI always associated with acute thrombotic coronary
occlusion?
• What is the best acute management of aVR STEMI?
Objectives
• To investigate the incidence of an acute total occlusion in culprit coronary
vessel in patients presenting with aVR STEMI
• 3 months clinical outcome of these patients
• Most suitable acute management: whether there’s a need immediate
coronary angiogram + reperfusion
Methods
• A retrospective, single center study on all aVR STEMI admissions
between January 2018 and January 2020
• All electrocardiograms and coronary angiograms were analyzed by
experienced cardiologists
• aVR STEMI was defined as typical acute chest pain with ST elevation in
aVR ≥ 1 mm, ST elevation in aVR ≥ V1, and widespread horizontal ST
depression in other leads
[Link]
Findings
• Total of 1147 STEMI admissions in study period
• 32 of them (2.8%) had aVR STEMI
• None were thrombolysed but all undergone coronary angiography during
index admission
• Mean waiting time from admission to date of coronary angiography was
3.7 days
Patient Characteristics
Characteristic N
Age (years) 62.5±10.1
Male sex 19 (59.4%)
Diabetes mellitus (%) 62.5
Hypertension (%) 84.4
Dyslipidaemia (%) 31.3
Chronic kidney disease (%) 18.8
Smoker (%) 12.5
Mean LVEF(%) 45.4 (± 13.3)
Mean eGFR (ml/ min/ 1.73 m2) 58 (± 25)
Results
NUMBER OF PATIENTS WITH ACUTE OR CHRONIC TOTAL
OCCLUSIONS
Number of Patients
18
14
No Total Occlusion Acute Total Occlusion Chronic Total Occlusion
Results
Angiogram Finding of the AVR STEMI Cases
Others Ostial/PLAD only
2VD with LMS 3% 6%
9%
Isolated LMS
3%
3VD without LMS
41%
3VD with LMS
38%
Ostial/PLAD only 3VD without LMS 3VD with LMS Isolated LMS 2VD with LMS Others
Results
Types of Revascularization (within 3 months of follow up)
9%
22%
PCI (3)
19% CABG (6)
OMT (7)
None / death (3)
19% Awating revascularization (6)
Lost to follow-up (7)
22%
9%
Results
• Mean waiting time for CABG (done within 3 months) from diagnostic
angiogram: 60.3 days
• All PCIs were done in the same setting as diagnostic angiogram
• Out of the 7 patients in OMT, 4 refused CABG
• The other 3 in OMT group:
• 1 patient had poor distal target not suitable for CABG
• 1 patient had poor EF with non-viable myocardium as shown by nuclear perfusion
scan
• 1 patient had only 50-60% stenosis on proximal LAD (moderate CAD)
Results
• Out of the 7 patients in “lost to follow-up” group:
• 6 were offered outpatient CABG
• 1 was transferred to CTC in another center during index admission
• Out of the “awaiting revascularization” group:
• 5 were awaiting outpatient CABG
• 1 was awaiting stage PCI (ostial LAD CTO)
Results
Number of Readmission And Death Within 3 Months Post
Angiogram
3
number of patient
0
Readmit within 1 month Readmit within 3 month Death within admission Death within 3 months
Ostial / pLAD involvement only 0 1 0 0
3VD without LMS 1 2 0 0
3VD with LMS 2 1 1 1
Isolated LMS 0 0 0 0
2VD with LMS 1 0 0 1
Others 0 0 0 0
Results
• All the patients who passed away are with LMS involvement
• 3VD with LMS involvement: 2
• 2VD with LMS involvement: 1
• None of these patients received any form of revascularization
Discussion
• Previously the ignored lead, aVR has garnered more attention recently
• Associated with significant left main or ostial / proximal left anterior
descending (LAD) coronary artery occlusion
• Also has been associated with triple vessel coronary artery disease (3VD)
• Incidence of each is not well established
Discussion
• Our study shows 0 incidence of acute total occlusion
• However, 14 patients (43.8%) had chronic total occlusion
• Differentiated from acute total occlusion with presence of collaterals from other
coronary vessels
• 25 patients (78%) had 3VD either with or without left main involvement
• Many of these patients may not be appropriate candidates for emergent
catheterization (ESPECIALLY AT NIGHT!)
Discussion
• Early revascularization by means of CABG is recommended especially for
those with left main involvement
• Mortality for LMS vs non-LMS involvement: 18.3 % vs 0 % (p = 0.034)
• Patients who had undergone revascularization were alive within 3 months
post angiogram
Limitations
• Studied population is from a single-center cohort experience
• Small sample size: only 32 patients
• Short follow up time; study period cut short due to COVID-19 pandemic
temporary shutdown of cardiology outpatient services
• Some patients lost to follow-up beyond 3 months
• No in-house cardiothoracic team, hence patients were referred out to CTC team in
other states for CABG
Conclusion
• AVR STEMI was not associated with acute thrombotic coronary occlusion
in our study population. Hence, thrombolysis or primary PCI may not be
indicated
• Early catherization is important during index admission (although may not
be within 24 hours of admission)
• Mortality is higher for patients with significant LMS lesion as
compared to non-LMS involvement aVR STEMI patients
• This study helps us to do risk stratification on which types of cases that
need emergent catheterization particularly in a center / state with limited
resources (cath lab and manpower)
