Chronic Total Occlusion of a Non-Culprit Artery in ST-segment Elevation Myocardial Infarction - To Treat or not to Treat?

Background: Chronic total occlusion (CTO) is found in 10-15% of patients with ST-segment elevation myocardial infarction (STEMI) in a non–infarct-related artery and is associated with increased morbidity and mortality.

Objectives: We sought to evaluate whether patients with STEMI and coexistent CTO benefit from percutaneous coronary intervention (PCI) of the CTO lesion as compared with STEMI patients whose CTO was not treated.

Methods: We analyzed 1883 consecutive patients presenting with STEMI and who underwent primary PCI in Rabin Medical Center during the years 2004-2017. 266 patients (29.5%) were found to have CTO in the non-culprit artery during the index procedure, 59 patients (22%) had their non- culprit artery CTO treated either during the index procedure or staged during the following two months. COX regression model was used to adjust for comorbidities. Propensity score matching was used to confirm the results.

Results: Patients with treated and those with non-treated non-culprit CTO were comparable regarding age, gender, and comorbidities. Patients treated for the non-culprit CTO had a significantly better prognosis in terms of combined end-points of death, MI, target vessel revascularization (TVR), coronary artery bypass grafting (CABG), than non-treated non-culprit CTO – HR 0.34, p=0.0001. Results remained significant in 56 propensity score-matched pairs.

Conclusion: Coexistence of CTO in STEMI patients is associated with poorer outcomes. CTO treatment (either during the index procedure or within 2 months period) is associated with better outcomes.