Collateral function in early acute myocardial infarction

doi:10.1016/0002-9149(83)90511-8

The American Journal of Cardiology

Volume 52, Issue 8, 1 November 1983, Pages 955-959

https://doi.org/10.1016/0002-9149(83)90511-8 Get rights and content

Abstract

The role of the collateral circulation < 6 hours after the onset of acute myocardial infarction (MI) was evaluated in 34 consecutive patients without previous MI. There were 19 patients with and 15 without collaterals. The group was subdivided into those with nonjeopardized collaterals (group A, 14 patients) and those with jeopardized collaterals (group B, 5 patients), and the group without collaterals into those with partially obstructed coronary arteries (group C, 5 patients) and those with totally obstructed coronary arteries (group D, 10 patients). These groups had similar sites of coronary stenoses and MI. Eleven of 14 collaterals in group A were poor, but MI mass measured by peak creatine kinase (CK) was smaller in group A than in group B (p < 0.01) or group D (p < 0.01), and cardiac function was significantly better in group A than in group D (cardiac index, p < 0.05; stroke index, p < 0.01; ejection fraction, p < 0.01; regional wall motion, p < 0.01). Group C was not statistically different from group A in myocardial function and CK. Group B was similar to group D in MI mass and cardiac function (cardiac index, stroke index, ejection fraction and regional wall motion). Thus, patients with nonjeopardized collaterals and those with partially obstructed coronary arteries had less myocardial damage and better cardiac function than did those with jeopardized collaterals and those with totally obstructed coronary arteries. A nonjeopardized collateral circulation may play a role in limiting MI mass and preserving myocardial function in the early stages of acute MI.

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Cited by (73)

Comparison of Myocardial Ischemia on the Ergocycle Versus the Treadmill in Patients With Coronary Heart Disease
2010, American Journal of Cardiology
Citation Excerpt :
However, we have no basis to assume this. Another possibility is that the greater blood pressure achieved during the ergocyle test resulted in improved coronary perfusion pressure through diseased coronary arteries and collateral vessels, with a favorable net effect on the supply–demand equation, despite the increased oxygen cost of a greater SBP.18 In support of this possibility, a recent study showed less exercise-induced myocardial ischemia during thallium-201 imaging in patients with greater, instead of lower, exercise diastolic blood pressure, despite a greater peak RPP and similar severity of CHD.19
We previously observed an attenuation of exercise-induced myocardial ischemia on the ergocycle during a ramp protocol compared to the standard Bruce protocol treadmill test in patients with coronary heart disease. However, it was uncertain whether decreased ischemia on the ergocycle resulted from the warm-up effect of the more gradual ramp protocol or from the mode of exercise itself (cycling vs running). Sixteen stable patients, aged 64 ± 5 years, with documented coronary heart disease (≥70% coronary artery stenosis and/or reversible myocardial perfusion defects) performed 3 symptom-limited exercise tests: the standard Bruce protocol treadmill test and 2 individualized ramp protocols (treadmill and ergocycle). We measured the ischemic threshold (heart rate × systolic blood pressure product at 1-mm ST-segment depression) and oxygen consumption (V̇O₂). The ischemic threshold was higher during cycling (ergocycle ramp, 24,009 ± 5,769 beats/min × mm Hg) compared to running (Bruce treadmill, 20,429 ± 3,508 beats/min × mm Hg; and ramp treadmill, 19,451 ± 3,392 beats/min × mm Hg; p <0.001), independently of exercise intensity (V̇O₂). The peak V̇O₂ did not significantly differ among all tests (p = 0.25) despite a greater peak rate-pressure product achieved with the ergocycle (29,378 ± 6,291 beats/min × mm Hg) compared to either treadmill protocol (Bruce, 26,202 ± 5,831 beats/min × mm Hg; ramp, 25,654 ± 6,492 beats/min × mm Hg; p <0.001). In conclusion, the mode of exercise (ergocycle vs treadmill), rather than the type of protocol (ramp vs Bruce), is associated with an attenuation of electrocardiographic parameters of myocardial ischemia, independently of exercise intensity (V̇O₂) and myocardial demand (rate-pressure product).
Coronary collaterals improve prognosis in patients with ischemic heart disease
2009, International Journal of Cardiology
Citation Excerpt :
Notably, in some patients with adequate collateral flow, an acute coronary occlusion may be tolerated without signs of ischemia [4]. Functional observations confirmed that collaterals may preserve cardiac function during acute infarction [5–7], may limit infarct size [6] and may reduce post-infarct ventricular dilatation after 2 years [8] and post-infarct aneurysm formation after 4 years [9]. Subsequently, by exerting functional protection, collateral flow could alleviate the deleterious effects of atherosclerosis on morbidity and mortality in the long term.
The recruitment of coronary collateral vessels results from an endogenous adaptation to ischemic heart disease (IHD). Presence of collaterals may exert protection at the time of acute or chronic obstructive coronary disease. The protective role of collaterals in patients with extensive coronary artery disease however, has been disputed. We examined the effects of coronary collateral circulation on cardiovascular outcomes, with an emphasis on clinical prognostic value and on a putative role of IHD burden.
Data analyzed were obtained in the REGRESS study, involving 879 male participants undergoing coronary angiography and being followed for 24 months. Presence of coronary collaterals spontaneously visible on angiography was assessed. Events included: myocardial infarction (MI), coronary heart disease death and percutaneous or surgical coronary intervention. Estimates of relative risks of outcome events were calculated using proportional hazard analysis, with adjustments for confounding factors and stratification for initial revascularization strategy and factors reflecting extent of IHD burden.
Event-free survival after two years was 84% in patients without collaterals, and 92% in patients with collaterals (p = 0.0020). The crude HR was 0.48 (95% CI: 0.30–0.77), and 0.38 (0.23–0.65) after adjustment for confounders and cardiovascular risk factors. The protective effect of coronary collaterals was not modified by the extent of IHD burden (interaction p = 0.99).
The angiographical presence of coronary collaterals is a clinical predictor of cardiovascular prognosis. Collaterals exert a protective effect on outcome in a broad spectrum of patients. Our data suggest that this protective effect is independent of disease burden, and remains present in patients with extensive IHD.
Coronary collaterals-insights in molecular determinants and prognostic relevance
2007, International Journal of Cardiology
In the field of molecular cardiology, recently several determinants of coronary collateral circulation have been identified. Knowing these factors may aid risk-stratification and put forward targets for intervention by stimulating development of collateral blood vessels (arteriogenesis). However, prognostic importance of coronary collaterals is not yet beyond debate, and seems to be modified by the extent of atherosclerotic burden. Combining these insights is essential to increase our understanding of these mechanisms and to proceed with developing strategies for risk-stratification and therapeutic stimulation of arteriogenesis.
Usefulness of Plasma Brain Natriuretic Peptide Concentration for Predicting Subsequent Left Ventricular Remodeling After Coronary Angioplasty in Patients With Acute Myocardial Infarction
2006, American Journal of Cardiology
Citation Excerpt :
Reocclusion might not accelerate left ventricular remodeling in cases with successful reperfusion limiting infarct size. Further, development of collateral circulation prevents left ventricular dilation, as previously reported.8–10 Third, the medications were different from those used in the previous study.
To determine the relation between plasma brain natriuretic peptide (BNP) and remodeling in terms of infarct-related artery (IRA) patency, 106 patients with a first anterior wall acute myocardial infarction with a patent IRA at 1 month were studied. The IRA reoccluded at 6 months in 17 patients (reoccluded IRA) and was patent in 89 patients (patent IRA). The 2 groups did not differ with respect to clinical characteristics, hemodynamic variables, and left ventricular function at 1 month, except for left ventricular end-diastolic and systolic volumes, which were significantly greater in the reoccluded IRA group. Plasma BNP concentration in the reoccluded IRA group (336 ± 288 pg/ml) was significantly higher than that in the patent IRA group (116 ± 106 pg/ml) at 1 month. BNP concentration decreased significantly at 6 months in the 2 groups (reoccluded IRA vs patent IRA 152 ± 162 vs 44 ± 58 pg/ml, p <0.05). The increase in left ventricular volume from 1 to 6 months was significantly correlated with plasma BNP concentration at 1 month in the patent IRA group (r = 0.314, p <0.01) and the reoccluded group (r = 0.634, p <0.01). Linear regression analysis showed that the correlation between the 2 parameters in the 2 groups was similar. Based on stepwise multivariate linear regression analysis, only plasma BNP concentration was significantly correlated with the increase in left ventricular volume from 1 to 6 months in the 2 groups. In conclusion, these results suggest that plasma BNP concentration predicts left ventricular dilation independently of IRA patency.
Reduced collateral circulation to the infarct-related artery in elderly patients with acute myocardial infarction
2004, Journal of the American College of Cardiology
Citation Excerpt :
Therefore, age-dependent endothelial dysfunction may contribute to impaired collateral development in the setting of myocardial ischemia. The presence of collateral circulation improves myocardial salvage (3–5)and prevents ventricular remodeling (6), thereby improving in-hospital prognosis independent of coronary reperfusion therapy (6,7,23–26). Because the aging heart might be expected to be less tolerant due to impaired biologic responses against myocardial ischemia, we compared the clinical effect of the presence of collateral circulation to the IRA in patients below and above 70 years of age.
The purpose of this study was to investigate the hypothesis that circulation via collateral vessels to an infarct-related artery (IRA) is impaired with aging in patients with acute myocardial infarction (AMI).
Animal experiments have shown that advanced age blunts the development of new vessels in response to angiogenic cytokines.
Of 3,573 consecutive patients with AMI, 1,934 patients who fulfilled the following criteria were enrolled in this study: 1) coronary angiograms were obtained within 72 h after the onset of AMI; and 2) IRA showed complete occlusion (Thrombolysis In Myocardial Infarction [TIMI] flow grade 0 or 1). Collaterals to the IRA were angiographically evaluated using the Rentrop score. Rentrop scores 1 to 3 were defined as demonstrating significant collaterals.
The prevalence of collaterals decreased with age, from 47.9%, 45.8%, 43.4%, to 34.0% in patients <50 years, 50 to 59 years, 60 to 69 years, ≥70 years, respectively (p < 0.001). Advanced age was an independent factor predicting the absence of collateral circulation to the IRA. In contrast, time to catheterization, history of angina pectoris, and preinfarction angina were independent predictors for the presence of collaterals. Multivariate analysis showed that the absence of collaterals was an independent predictor of in-hospital mortality in elderly patients ≥70 years (odds ratio, 15.6; 95% confidence interval, 3.5 to 69.6), although this finding was not significant in patients <70 years.
Advanced age is associated with decreased angiographic presence of collaterals to the IRA in patients with AMI. This abnormality may contribute to the poor prognosis of elderly patients with AMI.
Physiologically assessed coronary collateral flow and adverse cardiac ischemic events: A follow-up study in 403 patients with coronary artery disease
2002, Journal of the American College of Cardiology
Citation Excerpt :
Aside from the mentioned statistical and technical factors that are likely to have contributed to the fact that three of the 10 cited studies have described no effect or an adverse effect of collaterals on outcome (5–7), biological situations at variance to those chosen in our study design have probably caused contradicting results. Those conditions include selection of the study baseline during acute MI (7,13–15), of patients with chronic (3–6)or without infarction (8,12), focus on collaterals present at the time of (7,13–15)or developing after (3–6)acute MI, or investigation of patients with chronic total occlusions (3–5,12), balloon occluded vessels (8,15), or residual stenoses after thrombolysis (7). In the setting of acute MI, the rate of subsequent ischemic events during the first months of follow-up is much higher (cardiac mortality of 4% to 9% within six months after MI [14]), as compared with chronic stable CAD (mortality of 0.5% to 1%/1.8 years of follow-up in our study).
We sought to evaluate whether coronary collateral flow is clinically relevant for future cardiac ischemic events.
The link between good collateral supply related to less myocardial damage and fewer cardiac events has not been established prospectively beyond doubt.
In 403 patients with stable angina pectoris undergoing percutaneous transluminal coronary angioplasty (PTCA) and quantitative collateral assessment, the occurrence of major adverse cardiac events ([MACE] cardiac death, myocardial infarction, unstable angina pectoris) and stable angina pectoris was monitored during follow-up. Collateral flow index (CFI) was determined using intracoronary pressure or Doppler guidewires. Mean aortic ([P_ao] mm Hg) and distal coronary artery occlusive pressure ([P_occl] mm Hg) during balloon angioplasty (PTCA), or distal coronary flow velocity time integral during ([V_occl] cm) and after ([V_ø-occl] cm) PTCA were measured continuously. Pressure-derived CFI was calculated as follows: (P_occl− 5)/(P_ao− 5). Doppler-derived CFI: V_occl/V_ø-occl. Patients were subdivided into a group with well (CFI ≥ 0.25) and poorly developed collaterals (CFI < 0.25).
Average follow-up was 94 ± 56 (15 to 202) weeks. There were 134 patients with CFI ≥0.25 (61 ± 11 years) and 269 with CFI <0.25 (61 ± 10 years). The overall cardiac ischemic event rate (MACE and stable angina pectoris) during follow-up was 23% in patients with CFI ≥0.25 and 20% in patients with CFI <0.25 (p = NS). However, only 2.2% of patients with good collateral flow suffered a major cardiac ischemic event, compared with 9.0% among patients with poorly developed collaterals (p = 0.01). The incidence of stable angina pectoris was significantly higher in patients with well developed collaterals than in those with poorly developed collaterals (21% vs. 12%; p = 0.01).
In this relatively large population with chronic stable coronary artery disease undergoing quantitative collateral measurement, the beneficial impact of well developed collateral vessels on the occurrence of future major cardiac ischemic events is clearly demonstrated.

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^☆: This project was supported in part by Scientific Research Grant No 58570381 from the Ministry of Education of Japan.

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Coronary heart diseaseCollateral function in early acute myocardial infarction☆

Abstract

Am Heart J

Am J Cardiol

Am Heart J

Am J Cardiol

Location of communication between congrate bed of descending ramus of left coronary and adjacent collateral vascular beds

Oxygen demand and collateral vessels of the heart: factors influencing the severity of myocardial ischemic injury after experimental coronary artery occlusion

Cardiovasc Res

Functional importance of the human coronary collateral circulation

N Engl J Med

The effect of severity of coronary arterial obstructive disease and coronary collateral observations in man

Am J Med

The coronary collateral circulation: determinants and functional significance in ischemic heart disease

Am Heart J

Pathophysiology of coronary circulation

Prog Cardiovasc Dis

Coronary disease: a pathological study

Br Heart J

Changes in left ventricular function after intracoronary streptokinase infusion in clinically evolving myocardial infarction

Am Heart J

Coronary heart disease
Collateral function in early acute myocardial infarction☆