Anterior Depressions

Angiographic and Clinical Outcomes

Among Patients with Acute Coronary
Syndromes Presenting with Anterior
ST-Segment Depressions
C. Michael Gibson, Yuri B. Pride, Satishkumar Mohanavelu,
Stephen D. Wiviott, Elliott M. Antman and Eugene Braunwald

AHA Scientific Sessions 2008

New Orleans

Disclosure Statement: TRITON-TIMI 38 was supported by a research grant to

the Brigham and Women’s Hospital from Daiichi Sankyo and Eli Lilly.
None of the individual authors has any relevant conflicts to report.
 BACKGROUND
Anterior Depressions

• Rapid triage of patients with an acute

coronary syndrome (ACS) to an appropriate
pharmacologic and / or invasive strategy is
associated with improved outcomes
• The traditional 12-lead electrocardiogram
(ECG) is one diagnostic modality in the initial
evaluation of patients with chest pain
• The presence of ST-segment elevation is the
key branch point in the triage to emergent
reperfusion therapy
 BACKGROUND
Anterior Depressions

Anterior ST-segment depressions

Unstable angina or Acute thrombotic

non-ST-segment elevation occlusion in the posterior
myocardial infarction circulation

Antiplatelet and Antiplatelet and

antithrombotic therapy antithrombotic therapy

Risk stratification EMERGENT

REPERFUSION
Conservative or early THERAPY
invasive strategy
 GOALS
Anterior Depressions

• To determine the angiographic and clinical

outcomes among patients presenting with
ACS and isolated anterior ST-segment
depression on 12-lead ECG
• To compare the clinician diagnosis of STEMI
with subsequent angiographic evidence,
such as an occluded culprit artery, and
serologic evidence of myocardial necrosis
• To determine the diagnostic ECG-to-PCI
time among patients with an occluded culprit
artery
 MAIN TRIAL DESIGN
Anterior Depressions

Diagnostic ECG
ACS (STEMI or UA/NSTEMI) & Planned PCI

n=13,608
Double-blind

CLOPIDOGREL PRASUGREL
300 mg LD/ 75 60 mg LD/ 10
mg MD
Angiography / PCI mg MD

Duration of therapy: 6-15 months

1o endpoint: CV death, MI, Stroke

 METHODS
Anterior Depressions

• Patients with isolated anterior ST-segment

depression were included in the analysis
Patients with ST-segment elevation in other
arterial territories were excluded

• ECGs and angiograms were evaluated by

local investigators
 METHODS
Anterior Depressions

Anterior ST-segment depressions

TFG 2/3 in culprit artery TFG 0/1 in culprit artery

- Tn + Tn + Tn

Unstable angina NSTEMI “STEMI”

 METHODS
Anterior Depressions

• Outcomes
 Composite of death or MI at 30 days
 Fold elevation in cardiac biomarkers
• As a surrogate for infarct size

 Recognition of STEMI by local investigators

 Time from diagnostic ECG to PCI
 POPULATION
Anterior Depressions

13,608 patients
enrolled in
TRITON-TIMI 38

1,198 patients
with isolated
anterior depressions

243 with UA 641 with NSTEMI 314 with “STEMI”

(20.2%) (53.5%) (26.2%)

TFG 2/3 TFG 2/3 TFG 0/1

- Tn + Tn + Tn
 BASELINE
Anterior Depressions CHARACTERISTICS

“STEMI” UA/NSTEMI
Characteristic (n=314) (n=884) p-value
Male 71% 65% 0.054
Age, yrs (mean) 62 63 0.35
Diabetes 19% 22% 0.15
Hypertension 60% 71% <0.05
Hyperlipidemia 50% 54% 0.072
Prior MI 15% 17% 0.55
Smoker 33% 30% 0.38
BMI, kg/m2 (mean) 28 28 0.86
CrCl, ml/min (mean) 101 99 0.45
 CULPRIT ARTERY IN
Anterior Depressions “STEMI”* PATIENTS

60%
48.4%
50%

40% 33.8%
Patients

30%
17.8%
20%

10%
n=152 n=106 n=56
0%
LCx LAD RCA

* TFG 0/1 in culprit artery

Positive cardiac biomarkers
 CLINICAL OUTCOMES
Anterior Depressions

10% 30-day death or MI 8.6%

9%
8% 3-way p=0.006
7% 6.3%
P atients

6%
5%
4% 2.9%
3%
2%
1% n=641 n=314
n=243
0%
UA NS T E MI "S T E MI"
TFG 2/3 TFG 2/3 TFG 0/1
- Tn + Tn + Tn
 INFARCT SIZE
Anterior Depressions

5
Peak CK-MB / ULN CK-MB

p<0.001
4
3.3
3

2 1.5
1
n=884 n=314
0

UA/NSTEMI STEMI
 INFARCT SIZE BY
Anterior Depressions CULPRIT ARTERY

5
Peak CK-MB / ULN CK-MB

4.1
4 p<0.05 for all
3
3 2.5
2.3
2
1.2 1.3
1

0
LCx LAD RCA

UA/NSTEMI STEMI
 MANAGEMENT
Anterior Depressions

• Among patients with an occluded culprit

artery and anterior ST-segment depression,
only 14/314 (4.5%) were interpreted by the
investigator as a STEMI
• The median time from baseline ECG to PCI
for patients with an occluded culprit artery
was 29.4 hours (IQR 26.1-44.1 hours)
• None of the patients with an occluded artery
had an ECG to PCI time <6 hours
 LIMITATIONS
Anterior Depressions

• Only patients who survived until angiography

were included
Due to survival bias, this dataset may therefore
underestimate the number of patients with
anterior ST-segment depression who have an
occluded artery

• ECGs were read locally, not by a core

laboratory, and so subtle ST-segment
elevation cannot be excluded
 CONCLUSIONS
Anterior Depressions

• More than a quarter of patients with ACS

who present with isolated anterior ST-
segment depressions in TRITON-TIMI 38
had an occluded culprit artery and positive
cardiac biomarkers

• The occluded artery was most often the left

circumflex artery
 CONCLUSIONS
Anterior Depressions

• Patients with anterior ST-segment

depression and an occluded culprit artery
had significantly larger infarcts and worse
short-term clinical outcomes
• These ECG findings frequently went
unrecognized as evidence of a possibly
occluded culprit artery
• This suggests the need for improved
methods to identify patients with isolated
anterior ST-segment depression who have
an occluded artery