GalicianMedicalJournal,Vol.23,No.1(2016)
32
N.V.Savchuk
StateofCoronaryArteriesinPatientswith
HeartFailureafterMyocardialInfarction
TheDepartmentofInternalMedicine№2andNursing
Ivano-FrankivskNationalMedicalUniversity,Ivano-Frankivsk,Ukraine
e-mail:[email protected]
Keywords:
acute
myocardial
infarction;
percutaneous
coronary
intervention;
coronary
artery;heart
failure
Abstract.
This article covers the results of study of coronary bed state in patients
with acute myocardial infarction (MI) according to coronary angiography data.
Examinationsshowedthatasingle-vesseldiseaseofcoronarybranchesoccurred
moreoftenthanamultivesselone.Rightcoronaryartery(RCA)andleftanterior
descending artery (LAD) diseases were registered most often out of three main
coronary arteries. RCA narrowing occurred more often in case of the singlevesseldiseasethaninthemultivesselone.Leftmaincoronaryarterytrunk(LMT)
narrowing was found significantly rarer. TIMI flow 3 was found significantly
moreoftenafterpercutaneouscoronaryintervention(PCI).Anaveragelengthof
implanted stents was (23.2±3.1) mm, an average diameter was (2.84±0.28) mm,
an average balloon inflation pressure was (14.0±0.67) atm. According to Syntax
Score evaluation examined patients got (21±1.23) points. These signs have
favorableprognosis.
Copyright©Author(s),2016
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GalicianMedicalJournal,Vol.23,No.1(2016)
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Problemstatementandanalysisoftherecentresearch
Coronary artery disease (CAD) is of great concern in reduction of patients’ lifespan and
qualityoflifeinstructureofcardiovasculardisease[1,2].Coronaryangiographyisthegoldstandard
for CAD diagnosis as it allows investigating the state of the coronary arteries (CA), determining
qualitative and quantitative characteristics of the affected segments, evaluating coronary blood
flowstateandchoosingthecorrecttreatmentapproach[3].Thelevel,locationandnumberofCA
lesions have a prognostic value as they determine the severity of myocardial injury. Left main
coronary artery trunk injury and multivessel disease are the most dangerous. Anterior
interventricularbranchlesion,especiallyintheproximalarea,isthemostunfavorableamongthe
lesionsofthreemaincoronarybranches[5].
Blood flow restoration rate in case of occlusive disease of infarct related coronary artery
(IRCA)hasbeenprovedtobethemainfactorthatdeterminesMIfinalextension.Thisdetermines
treatment approach in case of full coronary occlusive disease, namely achievement of early and
sustained reperfusion of occlusal artery. This will allow preserving myocardium or reducing the
expansion of necrosis area and preventing the development of chronic heart failure (CHF)
myocardial electrical instability as evidenced in numerous randomized controlled clinical
investigations(DANAMI-2,PRAGUE-2,SIAM-III)[6].
The objective of the research was to analyze coronary bed lesions in patients with acute
myocardialinfarction.
Materialsandmethodsoftheresearch
The research was conducted at Ivano-Frankivsk Regional Clinical Cardiology Dispensary.
160 patients (98 men and 62 women) with postinfarction cardiosclerosis were examined. The
patientsweredividedintothreegroups.GroupIconsistedof72patientswithCHFwhohadhadMI
with revascularization performed by IRCA BMS stenting during acute period (average age
constituted 54.7±2.6 years). Group II included 66 patients with CHF who had had MI without
reperfusionduringacuteperiod(averageagewas64.5±2.6years).GroupIIIconsistedof22patients
whohadhadMIwithperformedstentingwithoutCHF(averageageconstituted57.5±2.3years).The
groups were compared by age and sex. Persons with severe concomitant diseases of respiratory
system, digestive system, kidneys, and those with oncology diseases were excluded from the
research. Diagnosis of old myocardial infarction was made according to ESC/ACCF/AHA/WHF
criteria (2012). CHF diagnosis was made in accordance with the recommendations of Ukrainian
Association of Cardiology of the diagnosis and treatment of chronic heart failure (2012).
Compulsorycriterionforpatients’inclusionintheresearchwastheirsigningofinformedconsent.
Inordertomeetagoalobjective,cross-sectionalstudyofdiagnosticcoronaryangiography
protocols was performed to the patients during MI acute period. Patients with steady forms of
coronary heart disease were not included into the sample. Coronary angiography was conducted
at Ivano-Frankivsk Central City Hospital using angiographic system Infinix manufactured by
Toshiba.Coronaryarteryconstrictionmorethan50%wasconsideredhemodynamicallyrelevant
lesion.
StatisticalprocessingoftheresultswasconductedusingacomputerprogramSTATISTIKA8andstatisticalfunctionprogram“MicrosoftExcel”onpersonalcomputerwiththeuseofvariationstatistical method of analysis. Fisher’s exact test was applied to compare the reliability between
researchgroupsregardingoccurrenceofclinicalsymptomsandphysicalchanges.Differenceswere
consideredreliableatр<0.05.
Resultsoftheresearchandtheirdiscussion
Baseline risk of death was determined according to ТІМІ RISK SCORE scale: presence of
independentpredictorswasassessedingrades;thetotalwascorrelatedwiththeriskscore;death
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GalicianMedicalJournal,Vol.23,No.1(2016)
probability was estimated in percentage terms. Characteristics of predictors depending on the
treatmentapproacharepresentedinTable1.
Table1
FrequencyofdeathriskpredictorsinexaminedpatientsaccordingtoTIMIRiskScore
PatientswithCHF
PatientswithCHF
Patientswith
afteroldMIwith
afteroldMIwithout
stentingwithout
stenting
stenting
CHF
(n=72)
Riskpredictors
(n=66)
(n=22)
abs.
%
abs.
%
abs.
%
Age,over65
27
37.5
29
43.9
6
27.3
Arterialhypertension,
53
73.6
42
63.6
8
36.4
diabetesmellitus,CAD
↑STinV2-V5,
leftbundle-branch
8
11.1
6
9.1
-
-
block
KillipII-IV
52
72.2
45
68.2
2
9.1
heartrate>100bpm
12
16.7
9
13.6
5
22.7
BP<100mmHg
10
13.9
11
16.7
6
27.3
Bodyweight<67kg
13
18.1
12
18.2
10
45.5
Noreperfusiontherapy
46
63.9
66
100
12
54.6
inthefirst4hours
Note.Percentageofthetotalnumberofpersonsinthegroupisindicated.
Lesion of infarct related coronary artery
1.4 %
6.9
%
LCA
31.9 %
AIVA
CA
40.3 %
IB
13.9 %
RCA
PIV
5.6 %
Fig.1.Lesionofinfarctrelatedcoronaryarteryinexaminedpatients.
Analyzing protocols of coronarographic study of patients suffering from CHF with
postinfarctioncardiosclerosislesionofLCAtrunkwasobservedin1.4%ofcases,AIVAwasdetected
in 23 (31.9 %) individuals, circumflex artery (CA) – in 10 (13.9) persons. Occlusion of LCA
intermediatebranch(IB)occurredin4(5.6%)individuals.RCAwasaffectedin29(40.3%)patients,
RCA posterior interventricular branch (PIV) was injured in 5 (6.9 %) individuals. TIMI flow 3 was
diagnosed in 69 (95.8 %) patients after percutaneous coronary intervention, TIMI flow 2 was
diagnosedin2(2.8%)personswhileno-reflowsyndromewasdetectedonlyin1(1.4%)person.
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GalicianMedicalJournal,Vol.23,No.1(2016)
Length of implanted stents
13.9 %
48.6 %
37.5 %
<18 mm
18-23 mm
>23 mm
Fig.2.Thelengthofimplantedstentsinexaminedpatients.
Stents<18mminlengthwereappliedin35(48.6%)patients,18-23mmstentswereusedin
27(37.5%)individuals,stents>23mminlengthwereimplantedin10(13.9%)patients.Theaverage
lengthofthestentsconstituted(23.2±3.1)mm.
Diameter of implanted stents
13.9 %
36.1 %
2.5 mm
20.8 %
2.75 mm
3.0 mm
29.2 %
3.5 mm
Fig.3.Thediameterofimplantedstentsinexaminedpatients.
Stents 2.5 mm in diameter were implanted in 26 (36.1 %) patients. Stents 2.75 mm in
diameterwereappliedin29.2%ofpatients.15(20.8%)individualswereimplantedstents3.0mm
indiameter.Stents3.5mmindiameterwereappliedin10(13.9%)persons.Theaveragediameter
of implanted stents constituted (2.84±0.28) mm. The average pressure of balloon inflating was
(14.0±0.67)atm.
Type A stenosis was detected in 27 (37.5 %) patients. Type B1 was observed in 25 (34.7 %)
individuals. Type B2 stenosis was peculiar to 15 (20.8 %) patients. Type C of CA stenosis was
detectedin5(6.9%)patients.
According to Syntax Score the assessment constituted (21±1.23) scores in the examined
patients.
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GalicianMedicalJournal,Vol.23,No.1(2016)
Analyzingprotocolsofcoronarographicstudyofpatients,single-vesseldiseaseRCAlesion
wasdetectedin52.3%ofpatientswhileAIVAlesionwasdiagnosedin31.8%ofcases,CAoccurred
in15.9%ofcases.
Types of stenosis
6.9 %
20.8 %
37.5 %
Type А
Type В1
Type В2
34.7 %
Type С
Fig4.Typesofstenosisintheexaminedpatients.
Table2
Theincidenceofcoronaryarteriesconstrictioninpatientswithacutemyocardial
infarction
Single-vesseldisease
Multivesseldisease
(n=44)
(n=28)
P
n
%
n
%
Coronaryarteries
<0.05
RCA
23
52.3
22
33.3
LCA
AIVA
0
14
0
31.8
1
24
1.5
36.4
>0.05
>0.05
CA
Note.
7
15.9
19
28.8
>0.05
1.Thepercentofthetotalnumberofpatientsinthegroupisindicated.
2.p–probabilityofdifferencebetweenthegroupofpatientswithsingle-vesseldiseaseand
patientswithmultivesseldiseaseofcoronaryarteries.
Multivessel disease was detected in 28 patients. Two-vessel disease was found in 14 (50.0
%) individuals, three-vessel disease occurred in 13 (46.2 %) patients, and two-vessel disease and
LCA trunk lesion was observed in 1 (3.6 %) patient. According to statistical estimation two-vessel
diseaseandthree-vesseldiseaseofthemainbranches(RCA,AIVA,CA)occurredreliablymoreoften
thanthelesionoftwovesselsandthelesionoftwovesselsandLCAtrunk(р<0.001).Generally,66
vessels were significantly constricted in 28 patients with multivessel disease. The study of CA
specificgravitydetectedthathemodynamicallyrelevantRCAconstrictionoccurredmoreoftenin
caseofmultivesseldiseaseandconstituted33.3%(n=22)ofcases,AIVAconstrictionwasobserved
in36.4%(n=24)ofcases,CAconstrictionwasdetectedin28.8%(n=19)ofcases.Theseconstrictions
occurredmoreoftenthanconstrictionofLCAtrunkwhichisprognosticallyunfavorable,dangerous
and controversial concerning treatment approach. Having compared the incidence of main
coronaryarteriesconstriction(Table2),RCAwasfoundtooccursignificantlymoreoftenincaseof
single-vesseldiseasethaninmultivesseldisease.
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GalicianMedicalJournal,Vol.23,No.1(2016)
Conclusions
1. According to coronarographic study, the lesion of one of main CA was observed
significantlymoreoftenthanmultivesseldiseaseinpatientswithCHFafteroldMI.
2. Two-vesselandthree-vesselconstrictionofmaincoronarybrancheswithoutLCAtrunk
lesion was proved to occur more often in patients with CHF after old MI in case of
multivesseldisease.
3. Reperfusion therapy by IRCA BMS stenting improves the course of postinfarction
cardiosclerosisandthereforeshouldbeapriorityapproachtotreatmentofpatientswith
acutemyocardialinfarction.
Prospects for further research involve the study of the long-term prognosis of patients
sufferingfromCHFhavingdifferentCAlesions.
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