Infarct‐Related Artery as a Donor of Collaterals in ST‐Segment–Elevation Myocardial Infarction With Concomitant Chronic Total Occlusion: Challenge of the Double‐Jeopardy Thesis

BACKGROUND: In ST‐segment–elevation myocardial infarction (STEMI), a concomitant chronic total occlusion (CTO) in a non–infarct‐related artery (NIRA) is associated with adverse outcome. In the case of the infarct‐related artery (IRA) as a donor vessel for collaterals to the CTO, the IRA occlusion may lead to an acute threat to both the immediate IRA and the collaterally supplied CTO area, which has been described as a double‐jeopardy effect. METHODS AND RESULTS: We investigated the role of preformed intercoronary collaterals to the CTO originating from either the IRA or NIRA. Data were obtained from 2 hospitals participating in the prospective FITT‐STEMI (Feedback Intervention and Treatment Times in ST‐Segment Elevation Myocardial Infarction) study. From a total cohort of 2102 patients with acute STEMI, 93 patients had single‐vessel CTO in an NIRA and well‐developed intercoronary collaterals to the CTO. In‐hospital mortality differed significantly with respect to the origin of the collaterals. Mortality was 15.2% with collaterals originating from the NIRA, 29.4% with a collateral origin from the IRA proximal to the acute STEMI occlusion, and 3.3% with a collateral origin from the IRA distal to the acute occlusion (P=0.044). A multivariate regression model confirmed that a proximal collateral origin had a significant higher mortality compared with a branching in the distal position from the acute STEMI occlusion (P=0.027; odds ratio = 20.8 [95% CI, 1.4–304.1]). CONCLUSIONS: In STEMI with CTO in an NIRA, a CTO collateralization from the IRA distal to the acute occlusion is associated with a better prognosis. This finding challenges the double‐jeopardy assumption as the main cause of adverse outcome in STEMI with CTO in an NIRA. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00794001.