Abstract
Acute ST-elevation myocardial infarction (STEMI) with simultaneous multiple coronary thrombosis has been described, however; the available information about the clinical presentation and management of this condition is scarce. We searched the Medline and Web of Science databases from 1990 until August 2014 for all case reports, case series, and observational studies that reported simultaneous multi-vessel thrombosis at the time of the primary percutaneous coronary intervention (PCI). We excluded the articles that reported an identifiable cause for coronary thrombosis. A total of 29 articles were retrieved yielding 56 patients. Patients were predominantly males (88%) with a mean age of 59 years. Cardiogenic shock was the predominant presentation (41%). Simultaneous thrombosis of the left anterior descending and right coronary arteries was the commonest angiographic finding (50%). Primary PCI was the main treatment modality and an intra-aortic balloon pump was utilized in 38% of the cases. The in-hospital mortality was 5%. Simultaneous multi-vessel thrombosis at the time of STEMI presents a rare condition. The cases reported in the literature presented with a high incidence of cardiogenic shock. Larger studies are needed to address the proper management and evaluate the outcomes associated with this condition.
1
Introduction
Acute ST-segment elevation myocardial infarction (STEMI) is caused by a complete occlusion of a coronary artery resulting in sudden impairment of perfusion in the territory supplied by the infarct related artery . Simultaneous thrombosis affecting > 1 coronary artery has been reported to occur in about 4.8% of the cases at the time primary percutaneous coronary intervention (PCI) in a single center study .
Simultaneous multi-vessel coronary thrombosis can occur secondary to identifiable causes (e.g. coronary vasospasm, cocaine abuse) . However, in other cases the underlying etiology remains unidentifiable. Multiple plaque rupture has been postulated as the main theory behind the cases without an identifiable cause .
Most of the available data about this group of patients with multi-vessel coronary thrombosis are obtained from case reports and series. In a prior study, the authors conducted a systematic review about multi-vessel coronary thrombosis, however; their study was limited by including patients with identifiable causes of thrombosis, and the search was limited to English articles only . In order to better understand the clinical presentation, commonly used management strategies, and outcomes of patients with simultaneous multi-vessel coronary thrombosis due to unidentifiable causes, we conducted this systematic review of the literature.
2
Materials and methods
A computerized literature search of the Medline and Web of Science databases was conducted without language restriction from January 1990 until August 2014 using the search strategy illustrated in Fig. 1 . To ensure that no potentially important studies were missed, the reference lists from the retrieved articles were also reviewed. This review was conducted in concordance with the recommendations of preferred reporting items for systematic reviews and meta-analyses .
We included all case reports, case series, and observational studies that reported cases of acute STEMI with multi-vessel thrombosis observed on the coronary angiogram at the time of the primary PCI procedure. We excluded cases with chronic total occlusion, wrap around left anterior descending lesions presentations other than STEMI, identifiable causes of coronary artery thrombosis and PCI or thrombolysis related complications (e.g. hematoma or dissection).
Two authors (AM and MS) independently extracted the data on study type, patients’ characteristics, clinical presentation, territory of ST-segment elevation, coronary angiography findings, management, and major outcomes. Any discrepancies were resolved by consensus of the authors. For non-English articles, we used Google Translator (Google, Inc., Mountain View, California).
Simultaneous multi-vessel coronary thrombosis was defined as STEMI associated with direct angiographic visualization of 2 or more thrombi causing partial or complete occlusion of at least 2 major epicardial coronary arteries. New onset heart failure was defined as a new diagnosis of at least New York Heart Association-Class II heart failure symptoms, a drop in ejection fraction below 45%, initiation of symptomatic heart failure therapy (e.g. furosemide) upon discharge, or re-admission with symptomatic heart failure.
We calculated a summation for each individual variable. We also calculated the mean for linear variables and percentages for categorical variables. Data were insufficient to conduct a meta-analysis for the outcomes.
2
Materials and methods
A computerized literature search of the Medline and Web of Science databases was conducted without language restriction from January 1990 until August 2014 using the search strategy illustrated in Fig. 1 . To ensure that no potentially important studies were missed, the reference lists from the retrieved articles were also reviewed. This review was conducted in concordance with the recommendations of preferred reporting items for systematic reviews and meta-analyses .
We included all case reports, case series, and observational studies that reported cases of acute STEMI with multi-vessel thrombosis observed on the coronary angiogram at the time of the primary PCI procedure. We excluded cases with chronic total occlusion, wrap around left anterior descending lesions presentations other than STEMI, identifiable causes of coronary artery thrombosis and PCI or thrombolysis related complications (e.g. hematoma or dissection).
Two authors (AM and MS) independently extracted the data on study type, patients’ characteristics, clinical presentation, territory of ST-segment elevation, coronary angiography findings, management, and major outcomes. Any discrepancies were resolved by consensus of the authors. For non-English articles, we used Google Translator (Google, Inc., Mountain View, California).
Simultaneous multi-vessel coronary thrombosis was defined as STEMI associated with direct angiographic visualization of 2 or more thrombi causing partial or complete occlusion of at least 2 major epicardial coronary arteries. New onset heart failure was defined as a new diagnosis of at least New York Heart Association-Class II heart failure symptoms, a drop in ejection fraction below 45%, initiation of symptomatic heart failure therapy (e.g. furosemide) upon discharge, or re-admission with symptomatic heart failure.
We calculated a summation for each individual variable. We also calculated the mean for linear variables and percentages for categorical variables. Data were insufficient to conduct a meta-analysis for the outcomes.
3
Results
Using the search strategy indicated in Fig. 1 , a total of 29 articles satisfied our inclusion criteria with a total of 56 patients; 48 patients from 26 case reports and series while 8 patients from 2 prospective studies ( Supplementary Table ) . The mean age of the patients was 59 years. Patients were mainly males (88%), current smokers (59%), and with history of hypertension (50%). Two patients had atrial fibrillation on the presentation electrocardiogram (ECG) , while another patient had history of atrial fibrillation without evidence of atrial fibrillation on ECG upon presentation .
Cardiogenic shock was the commonest clinical presentation occurring in 41% of the cases, followed by ventricular arrhythmias (25%). In Table 1 , we report the demographics and clinical presentations of the patients while Table 2 summarizes the territory of ST-segment elevation seen on the ECG along with coronary arteries showing the thrombus burden on the coronary angiogram. In one study, the information regarding the culprit vessels and management was lacking . With exclusion of that study, 58% of the patients were found to have total occlusion of all culprit vessels, 26% had partial occlusion of one vessel and total occlusion of the other, while 18% had partial occlusion of all culprit vessels.
| A) Demographics | % |
|---|---|
| Age, years ⁎ | 32–88 (59) |
| Male | 88 |
| Current smoker | 59 |
| Diabetes mellitus | 25 |
| Hypertension | 50 |
| Hyperlipidemia | 21 |
| Family history of CAD | 18 |
| Prior history of CAD | 16 |
| Previous MI | 13 |
| Previous PCI | 11 |
| B) Clinical presentation | |
| Cardiogenic shock | 41 |
| Ventricular arrhythmia | 25 |
| Bradyarrhythmia | 18 |
| Pulmonary edema | 11 |
| Territory with ST-segment elevation on ECG | % |
|---|---|
| Inferior | 29 |
| Anterior | 21 |
| Inferior + anterior | 16 |
| Anterior + lateral | 11 |
| Inferior + lateral | 9 |
| Inferior + posterior | 5 |
| Coronary arteries with thrombus burden | |
| RCA + LAD | 50 |
| RCA + LCX | 32 |
| LAD + LCX | 13 |
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