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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 74-79

Determinants of coronary collateral formation in patients with acute ST-elevation myocardial infarction and total occlusion of infarct-related artery


Department of Cardiology, KGMU, Lucknow, Uttar Pradesh, India

Date of Web Publication28-Jun-2019

Correspondence Address:
Dr. Gaurav K Chaudhary
Department of Cardiology, KGMU, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_12_19

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  Abstract 


Background: The presence or absence of collateral circulation to the infarct-related artery territory significantly impacts the infarct size and resulting left ventricular function and hence the prognosis. However, the determinants of collateral formation have been poorly understood.
Materials and Methods: The present single-center observational study examined 200 patients with acute ST-elevation myocardial infarction (STEMI), irrespective of the status of thrombolysis, undergoing coronary angiogram within 48 h showing complete occlusion of infarct-related coronary artery.
Results: High-grade collaterals (Rentrop Grade 2 and 3) were seen in 17% of patients (n = 34). High-grade coronary collaterals were more often seen in patients belonging to the age group of 46–70 years compared to elderly individuals >70 years of age (38.2% vs. 2.9%,P < 0.009). The occurrence of collaterals to culprit coronary artery either left anterior descending artery or right coronary artery was similar. There was a lower prevalence of high-grade collaterals to infarct-related artery territory in smokers versus nonsmokers (5.9% vs. 43.4%,P < 0.001). The prevalence of collaterals in patients with diabetes was lower compared to nondiabetics (11.8% vs. 47.6%,P < 0.001). There was a significantly higher prevalence and recruitment of collaterals in patients with a history of angina before they developed acute coronary syndrome (88.2% vs. 16.9%,P < 0.001). There was no significant association between hypertensive status and the prevalence of coronary collateral circulation.
Conclusions: The finding of high-grade coronary collaterals was seen more in patients who had angina prior to STEMI. High-grade collaterals were significantly more in middle-aged individuals compared to the elderly. Diabetes mellitus and smoking status were negative predictors of high-grade collaterals.

Keywords: Coronary collateral, predictors, ST Elevation MI


How to cite this article:
Chandra S, Sanganagoudar S, Chaudhary GK, Dwivedi SK, Narain VS, Sethi R, Pradhan A, Vishwakarma P, Sharma A, Bhandari M. Determinants of coronary collateral formation in patients with acute ST-elevation myocardial infarction and total occlusion of infarct-related artery. Heart India 2019;7:74-9

How to cite this URL:
Chandra S, Sanganagoudar S, Chaudhary GK, Dwivedi SK, Narain VS, Sethi R, Pradhan A, Vishwakarma P, Sharma A, Bhandari M. Determinants of coronary collateral formation in patients with acute ST-elevation myocardial infarction and total occlusion of infarct-related artery. Heart India [serial online] 2019 [cited 2019 Sep 19];7:74-9. Available from: http://www.heartindia.net/text.asp?2019/7/2/74/261829




  Introduction Top


The presence or absence of collateral circulation to the infarct-related artery (IRA) territory significantly impacts the infarct size and resulting left ventricular function and hence the prognosis.[1] However, the determinants of collateral formation have been poorly understood. The understanding of collateral formation and its determinants may guide future therapeutic strategies regarding the clinical management of the patient and regarding the promotion of collateral growth and functionality.[2] The current study aims to determine the factors leading to the development of collateral formation in patients with acute ST-elevation myocardial infarction (STEMI) with total occlusion of IRA and their relevance regarding the infarct size limitation. We also aimed to correlate the presence and grade of collaterals with myocardial viability by stress myocardial perfusion imaging.


  Materials and Methods Top


Study design and patient population

This was a single-center observational study conducted at our tertiary care center between January 2017 and November 2017. Patients with acute STEMI, irrespective of the status of thrombolysis, who underwent coronary angiogram within 48 h showing complete occlusion of IRA (i.e., total occlusion of either left anterior descending [LAD] artery or right coronary artery [RCA]), were included. Patients with previous myocardial infarction and a history of coronary angioplasty or coronary artery bypass grafting were excluded. All patients provided written informed consent. The study was approved by the Institutional Ethics Committee.

Data collection

A detailed history and clinical examination was done, and parameters including age, sex, and risk factors, namely hypertension, diabetes, family history, smoking, and tobacco habits, were noted. Angina was graded according to the Canadian Cardiovascular Society (CCS) Angina Grading Scale,[3] and duration of angina was also documented. Subsequently, all patients underwent the following investigations during index hospitalization: blood urea; serum creatinine; serum electrolytes including sodium, potassium, magnesium, and calcium; hemoglobin; 12-lead electrocardiography; detailed two-dimensional echo; and stress myocardial perfusion imaging.

Coronary angiography was performed using the Judkins technique. The non-IRA was first visualized for accurate evaluation of the extent of collateral circulation to the area perfused by the completely occluded IRA. Collateral circulation was graded on a scale of 0–3 according to Rentrop classification,[4] based on the injection that best opacified the occluded vessel: 0 = no opacification; 1 = filling of side branches of the artery perfused by way of collateral vessels without visualization of the epicardial segment; 2 = partial filling of the epicardial segment by way of collateral vessels; and 3 = complete filling of the epicardial segment by way of collaterals. Collateral circulation was then classified into poorly developed or low-grade collaterals with collateral indices of 0 or 1 and well-developed or high-grade collaterals with collateral indices of 2 or 3. Viability of IRA territory was also evaluated in terms of viable, partially viable, and nonviable IRA territory.

Statistical analysis

Categorical variables are presented in number and percentage (%) and continuous variables are presented as mean ± standard deviation. The association between demographic characteristics and grade of collaterals to IRA and viability of IRA territory was evaluated using the Pearson's Chi-square test and Fisher's exact test. Unpaired t-test was used to determine the statistical difference for duration of angina between patients with low and high grade of collaterals to IRA and between patients with viable/partially viable and nonviable IRA territory. Statistical analysis was performed using SPSS 15.0 software (SPSS Inc., Chicago, IL, USA). P < 0.05 was considered statistically significant.


  Results Top


Demographic characteristics

The demographic characteristics of patients are described in [Table 1]. In brief, the study sample included 200 patients between 30 and 85 years old, with a mean age of 53.17 ± 10.64 years. Majority of the patients were between 46 and 60 years. The sex ratio showed that male patient proportion was higher than females, i.e., 83.0% and 17.0%, respectively. Of the total population, patients with acute anterior wall myocardial infarction (AWMI) constituted 60.5%, while acute inferior wall myocardial infarction (IWMI) constituted 39.5%. Diabetics constituted 41.5%, hypertensives constituted 32%, and smokers constituted 37% of the population. Oral tobacco was consumed by 6.5% of the patients. Family history of premature CAD was observed in only 1.5% of the patients. Of note, 29% of the patients had a history of CCS Class II angina and a minority, i.e., 1.5%, had a CCS Class III angina. In 61% of patients, the IRA was LAD artery. High-grade collaterals were observed in 17% of the total population. Further, only 11.5% had a viable/partially viable infarct-related coronary artery territory.
Table 1: Demographic characteristics (n=200)

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Association between grade of collaterals to infarct-related artery and demographic characteristics

The association between grade of collaterals to IRA and demographic characteristics is detailed in [Table 2]. In brief, patients in advanced age groups had fewer collaterals (P = 0.027). There was no significant difference regarding the formation of coronary collateral circulation between males and females (P = 0.958). Furthermore, there was no difference regarding the prevalence of coronary collaterals between two different types of acute STEMI (P = 0.385). Smokers had significantly fewer coronary collaterals as compared to nonsmokers (P = 0.003). Similarly, diabetic patients had significantly fewer collaterals as compared to nondiabetics (P < 0.001). The association between coronary collateral prevalence and oral tobacco chewing or hypertensive status or family history of premature CAD was nonsignificant. Nevertheless, a significantly higher prevalence of high-grade coronary collaterals was observed in patients with a previous history of angina of at least CCS Class II. There was no difference in the prevalence of coronary collaterals between the two IRA territories studied. All the patients who had viable/partially viable IRA territory had a prevalence of high-grade collaterals. In addition, patients with high-grade collaterals had a significantly longer duration of angina [Figure 1].
Table 2: Association between grade of collaterals to infarct-related artery and demographic characteristics

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Figure 1: Duration of angina with grade of collaterals to infarct-related artery

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Association between viability of infarct-related artery territory and demographic characteristics

The association between viability of IRA territory and demographic characteristics is detailed in [Table 3]. In brief, there was no significant difference in viability of IRA territory between males and females and between different types of acute STEMI. Smokers had a significantly lower viability of IRA territory as opposed to nonsmokers. Similarly, diabetic patients had a significantly lower viability of IRA territory as compared to nondiabetics. No association was observed between viability of IRA territory and oral tobacco use or hypertension status. Patients with a history of angina of at least CCS Class II had a significantly higher prevalence of viability of IRA. There was no significant difference in the viability of different IRA territories. In addition, patients with viable/partially viable IRA territories had a significantly longer duration of angina [Figure 1].
Table 3: Association between viability of infarct-related artery territory and demographic characteristics

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  Discussion Top


Our study included 200 patients with acute coronary syndrome, either AWMI or IWMI with total occlusion of either LAD artery or RCA who underwent coronary angiogram within 48 h. About 17% of the total population of the patients demonstrated Grade II/III collaterals according to Rentrop classification, and about 11.5% of the patients had viable or partially viable infarct-related coronary artery territory. Earlier several studies were conducted to identify the determinants of coronary collateral formation.[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] Our findings are in agreement with majority of these studies.

In our study, there was no significant difference regarding the occurrence of collaterals between male and female patients. Coronary collaterals were more often seen in patients belonging to the age group of 46–60 years. It was noted that patients with advanced ages had fewer collaterals. The results are similar to a previous study done by Epstein et al.[18]

Smoking as a risk factor for CAD has an inconsistent relationship to the prevalence of collaterals in many of the earlier studies and analyses. Smoking habit has never been shown to be significantly related to the formation and prevalence of collaterals. Similarly, oral tobacco chewing is a common habit among Indian population. So far, no study has evaluated the association between the oral tobacco chewing and the prevalence of coronary collaterals. The current study failed to show any significant association of oral tobacco chewing with the prevalence of coronary collaterals in acute ACS. Hypertension is also known to cause endothelial dysfunction and impairs arterial remodeling and hence neo-arteriogenesis. The current study failed to show any significant association between hypertensive status and the prevalence of coronary collateral circulation.

The most potent stimulus for the development and recruitment of collaterals appears to be the presence of angina on exertion. The greater the duration of angina better developed the collaterals are as observed by Piek et al.[19] Our study shows a significantly higher prevalence and recruitment of collaterals in patients with a history of angina before they developed acute coronary syndrome.

In the current study, the occurrence of collaterals to culprit coronary artery either LAD artery or RCA was similar unlike the study done by Antoniucci et al. which showed more prevalence of collateral vessels to infarct-related RCA territory.[13] On the contrary, the current study showed a significantly lower prevalence of high-grade collaterals to IRA territory. The occurrence of collateral circulation differs depending on the primary clinical condition for which the patient was evaluated. A study demonstrating a lower prevalence of collaterals in patients with diabetes in the setting of acute coronary syndrome was reported by Elsman et al.[20] The results of our study are in agreement with the previously quoted study.

Of the total population of the patients studied, 11% of patients had viable or partially viable IRA territory on stress myocardial perfusion imaging. The finding goes down well with the previous observation made by Antoniucci et al.[13] Overall, the positive predictors for the viability of infarct-related coronary artery territory were the presence of high-grade collaterals and the presence and greater duration of angina. The factors which negatively correlated with viability were smoking, previous history of diabetes mellitus, and advancing age. Hypertension, tobacco chewing, positive family history of premature CAD, gender, and type of myocardial infarction did not have any significant association with viability of IRA territory in this current study.

The finding of high-grade coronary collaterals in patients with total occlusion of IRA may imply potentially viable myocardium and hence prompt for revascularization of the IRA. However, the value of such an approach outside of the primary PCI settings is uncertain. The outcomes of such an approach either in short term or in long term are unknown. Hence, a study involving larger number of patients with a longer period of follow-up evaluation is required.


  Conclusions Top


There were no significant differences regarding the occurrence of collaterals between male and female patients. Coronary collaterals were more often seen in patients belonging to the age group of 46–60 years. The occurrence of collaterals to culprit coronary artery either LAD artery or RCA was similar. There was a lower prevalence of high-grade collaterals to IRA territory in smokers. The prevalence of collaterals in patients with diabetes was lower. There was no significant association between hypertensive status and the prevalence of coronary collateral circulation. There was a significantly higher prevalence and recruitment of collaterals in patients with a history of angina before they developed acute coronary syndrome. Overall, the positive predictors for the viability of infarct-related coronary artery territory were the presence of high-grade collaterals and the presence and greater duration of angina. The factors which negatively correlated with viability were smoking, previous history of diabetes mellitus, and advancing age.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Steg PG, Kerner A, Mancini GB, Reynolds HR, Carvalho AC, Fridrich V, et al. Impact of collateral flow to the occluded infarct-related artery on clinical outcomes in patients with recent myocardial infarction: A report from the randomized occluded artery trial. Circulation 2010;121:2724-30.  Back to cited text no. 1
    
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3.
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4.
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Pérez-Castellano N, García EJ, Abeytua M, Soriano J, Serrano JA, Elízaga J, et al. Influence of collateral circulation on in-hospital death from anterior acute myocardial infarction. J Am Coll Cardiol 1998;31:512-8.  Back to cited text no. 12
    
13.
Antoniucci D, Valenti R, Moschi G, Migliorini A, Trapani M, Santoro GM, et al. Relation between preintervention angiographic evidence of coronary collateral circulation and clinical and angiographic outcomes after primary angioplasty or stenting for acute myocardial infarction. Am J Cardiol 2002;89:121-5.  Back to cited text no. 13
    
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Vanoverschelde JL, Wijns W, Depré C, Essamri B, Heyndrickx GR, Borgers M, et al. Mechanisms of chronic regional postischemic dysfunction in humans. New insights from the study of noninfarcted collateral-dependent myocardium. Circulation 1993;87:1513-23.  Back to cited text no. 14
    
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Hirai T, Fujita M, Nakajima H, Asanoi H, Yamanishi K, Ohno A, et al. Importance of collateral circulation for prevention of left ventricular aneurysm formation in acute myocardial infarction. Circulation 1989;79:791-6.  Back to cited text no. 16
    
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Di Carli M, Sherman T, Khanna S, Davidson M, Rokhsar S, Hawkins R, et al. Myocardial viability in asynergic regions subtended by occluded coronary arteries: Relation to the status of collateral flow in patients with chronic coronary artery disease. J Am Coll Cardiol 1994;23:860-8.  Back to cited text no. 17
    
18.
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20.
Elsman P, van 't Hof AW, de Boer MJ, Hoorntje JC, Suryapranata H, Dambrink JH, et al. Role of collateral circulation in the acute phase of ST-segment-elevation myocardial infarction treated with primary coronary intervention. Eur Heart J 2004;25:854-8.  Back to cited text no. 20
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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