Article

Prediction of clinical outcome after mechanical revascularization in acute myocardial infarction by markers of myocardial reperfusion

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  • RWTH Aachen University / Medical Statistics
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Abstract

We sought to evaluate and compare recently suggested parameters of reperfusion after angioplasty in acute myocardial infarction (AMI) for risk stratification during long-term follow-up. Abnormal myocardial perfusion has a detrimental impact on survival. Several parameters of reperfusion have been evaluated in controlled study populations for risk stratification. In 253 consecutive patients undergoing intervention in AMI on a native coronary vessel, angiographic myocardial blush grade (MBG), corrected TIMI (thrombolysis in myocardial infarction) frame count (CTFC) and persistent ST-segment elevation (STE) were determined to evaluate reperfusion. This was a high-risk population, including referral for treatment failure at a primary center in 29.2%, failed thrombolysis in 22.1% and cardiogenic shock in 13.4% of cases. In addition to age, patient referral, LBBB and heart rate on admission, MBG 0 to 1 (odds ratio [OR] = 3.23, p < 0.001), CTFC (OR = 1.01, p = 0.015) and persistent STE >2 leads (OR = 3.46, p = 0.010) were univariate predictors of mortality during a 22.1 +/- 15.6 months follow-up. Myocardial blush grade 0 to 1 (OR = 2.17, p = 0.033) and persistent STE (OR = 3.61, p = 0.017) persisted as independent predictors of mortality, whereas CTFC failed. Differences in mortality between reperfusion groups at 30 days remained throughout the complete follow-up. In sequential Cox models, the predictive power of clinical data alone for mortality (model chi-squared 55.8) was strengthened by adding MBG (model chi-squared 64.2) and ECG postintervention (model chi-squared 69.2). Myocardial blush grade 0 to 1 and persistent STE are independent predictors for long-term mortality after angioplasty in AMI. Corrected TIMI frame count is a less powerful predictor. Combining both parameters to consider quality of reperfusion in the myocardium at risk and extent of the infarct zone increases the predictive power.

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... Advantages of CTFC are its high reproducibility, low intra-and inter-observer errors and it furthermore enables a quantitative estimation of flow [14][15][16]. Although Gibson et al. [17,18] showed a relatively high predictive value of CTFC for mortality, this could not be demonstrated in other studies [19,20]. CTFC requires more dedicated cineangiographic filming because the standardized distal landmarks need to be visualized before contrast arrival and filming must be performed in specific projection angles. ...
... In concordance with findings by Bhatt et al. [19], we did not find a significant association between mortality and CTFC. This is in contrast to several other studies like the TIMI 4 trial [17,20]. However, the TIMI 4 trial had a larger patient population and patients were treated by thrombolysis instead of PCI. ...
... However, the TIMI 4 trial had a larger patient population and patients were treated by thrombolysis instead of PCI. Furthermore, the predictive power of CTFC and its relationship with coronary blood flow has been questioned in several studies [19,20]. Vogelzang et al. [22] showed a correlation between mortality and QuBE value, however we could not reproduce these findings in our cohort. ...
... The best way to achieve this goal is rapid determination and reperfusion of infarct related artery by means of percutaneous coronary intervention (PCI). In 90% of patients, epicardial blood flow is provided by PCI [2,3]. However, a significant proportion of patients may suffer impaired myocardial reperfusion and an associated poor prognosis despite providing of epicardial coronary blood flow [4,5]. ...
... This protects patients against major adverse cardiac events [21]. Epicardial blood flow is provided by primary PCI in 90% of patients [2,3]. However, a significant proportion of patients may suffer impaired myocardial reperfusion and an associated poor prognosis despite providing of epicardial coronary blood flow [4,5]. ...
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Coronary artery disease (CAD) and its serious clinical form, ST segment elevated myocardial infarction (STEMI) has been the leader within the death causes around the world and in our country. In STEMI, the main objective is providing the myocardial reperfusion. In our study, it was aimed to investigate the predictive value of tenascin-C level for the degree of myocardial reperfusion in patients with STEMI. In our study, 58 patients admitted to our hospital with acute anterior STEMI were included. All the patients had underwent primary percutaneous intervention for the single-vessel disease at left anterior descending coronary artery. After admission to coronary care unit tenascin-C levels were measured. Subjects were classified according to their myocardial blush grades (MBG); MBG 0, MBG 1 and MBG 2 were groupped as Group I, MBG 3 was groupped as Group II. The groups were compared according to their tenascin-C levels and other parameters. Between group I (n = 31, mean age 55 ± 12.5) and group II (n = 27, mean ages 49.3 ± 11.1); tenascin-C, troponin I and CK-MB levels were significantly higher in group I compared to the group-II (P < 0.001; P < 0.001 and P < 0.05; respectively). In group I, left ventricular ejection fraction (LVEF) was significantly lower (P < 0.001), left ventricular end-diastolic volume and left ventricular end-systolic volume were significantly higher (P = 0.03) as compared to group II. In group I, ST-segment resolution at ECG was worse (P = 0.003). In correlation analyzes, tenascin-C was significantly positively correlated with troponin-I (r = 0.596; P < 0.001) and CRP (r = 0.615, P < 0.001). Tenascin-C was significantly negatively correlated with MBG, LVEF and ST-segment resolution (r = -0.626, P < 0.001, r = -0.411, P = 0.002 and r = -0.631; P < 0.001, respectively). Based on our study, it can be estimated that in patients with high tenascin-C levels myocardial reperfusion was inadequate, even underwent successfull PCI. In this context, increased tenascin-C may help predict not only left ventricular remodelling and prognosis but also the effectiveness of primary PCI.
... The widely available use of primary PCI has significantly improved the clinical outcome of STEMI patients. Nevertheless, prognosis of these patients seems to be related not only to the epicardial flow obtained after revascularization but to the microvascular flow achieved as well (6,7). A number of tools exist that provide insight regarding the restoration of perfusion in an acute setting, namely the ECG ST-segment resolution and the TMPG. ...
... Table 1. independent prognostic information after an AMI (4,7,8). However, the ejection fraction, a strong predictor of death after MI (21), depends on the load and might be normal in patients with akinetic areas with hyperkinetic remote myocardium. ...
... In this patient population, arrhythmias are also a major cause of mortality and morbidity. Repolarization heterogeneities on surface electrocardiograms (ECG) are considered as predictors of malignant ventricular arrhythmias and sudden cardiac death in patients with STEMI 5,6 . The terminal part of repolarization, measured as the interval from the peak to the end of the T wave (Tpe), is a relatively novel indicator of risk of ventricular arrhythmias, and accumulating data suggest that T peak-to-end interval and Tpe/QT ratio are more sensitive arrhythmia markers than the older index QT dispersion 7,8 . ...
... The mean age of patients with MBG 3 was significantly lower than the other patients (64±12 years MBG 0-1 group, 58±14 years in MBG 2 and 55±10 years in MBG 3 group; p<0.001). Median time from onset of symptoms to revascularization was 4 [1][2][3][4][5][6][7][8][9][10][11][12] hours, slightly lower in MBG 3 compa-red MBG 0-1 (p=0.022). The rate of ST segment resolution more than 50% at the 90 th minute after revascularization was higher in the group with MBG 3 than MBG 0-1 and MBG 2 (40% in MBG 0-1 group, 93% in MBG 2 group and 99% in MBG 3 group; p<0.001). ...
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Introduction: Myocardial perfusion, when assessed by myocardial blush grade (MBG) is an independent predictor of major adverse cardiac outcomes. The terminal part of repolarization, measured as the interval from the peak to the end of the T wave (Tpe), is a relatively novel indicator of ventricular arrhythmias. The relations between MBG and Tpe interval have not been examined before. We aimed to evaluate the relationship between MBG and Tpe and Tpe/QT ratio after successful primary percutaneous coronary intervention (PCI) in acute ST-segment elevation myocardial infarction (STEMI). Patients and methods: In this study, 149 consecutive patients with STEMI and underwent primary PCI were included. The Tpe interval was defined as the interval from the peak of T wave to end of T wave, and measurements were performed from precordial leads on ECGs at admission and 90 minutes after revascularization. Patients with no myocardial blush were graded as MBG 0, those with minimal myocardial blush were graded as MBG 1, those with moderate myocardial blush were graded as MBG 2 and patients with normal myocardial blush were graded as MBG 3. Results: Comparisons were made between the MBG 0-1, MBG 2 and MBG 3 groups. In all groups, post-procedural Tpe interval were significantly shorter than pre-procedural Tpe intervals (for all groups p<0.001). Post-procedural Tpe interval in MBG 3 group was significantly shorter than MBG 0-1 and MBG 2 groups (Tpe=81±11 ms in MBG 0-1 group, 81±11 ms in MBG 2 group and 72±10 ms in MBG 3 group; p<0.001, for all groups). Post-procedural Tpe/QT ratios decreased in all three MBG groups (p<0.001, for all groups). Tpe/QT ratios were smaller with the increasing MBG (p<0.001). Conclusions: Tpe interval and Tpe/QT ratio are closely associated with MBG after successful primary percutaneous coronary intervention in STEMI.
... Outcome measures in all the included studies included all-cause mortality and MACE follow-up time to all studies being 1 year. 11,13,14,18,19,25,26 ...
... All articles involved STEMI patients only. 11,13,14,18,19,25 They all adequately described the populations, and clinical and demographic factors that were significantly different between the two groups compared were identified. There were also no identified significant deviations from the in-study definitions of STEMI. ...
Article
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Background: Ineffective myocardial perfusion despite angiographic success after angioplasty occurs frequently and is associated with an increased risk of mortality. Hence, this study determined whether myocardial perfusion measured by myocardial blush grade (MBG) identifies ST-elevation MI (STEMI) patients at high risk for poor outcomes after successful angioplasty. Methods: The search employed strategies designed for research databases. An article was eligible if it included adults who underwent coronary angioplasty for STEMI, post-angioplasty MBG was assessed, and mortality or major adverse cardiovascular events (MACE) were determined. Risk for bias was assessed using the Quality In Prognosis Studies tool and forest plots in a Mantel-Haenszel fixed effects model were created using RevMan5.4. Results/discussion: Eight observational studies with an overall low risk of bias were included, involving 8,044 patients. MBG 0/1 with no to poor myocardial perfusion had a negative prognostic value for mortality (OR 2.68; 95% CI [2.22–3.23]) and MACE (OR 1.20; 95% CI [1.01–1.41]). Furthermore, MBG 2 with moderate myocardial perfusion and MBG 3 with normal myocardial perfusion were associated with increased survival with a logHR of 0.47 (95% CI [0.43–0.52]) and 0.20 percutaneous coronary intervention (95% CI [0.18–0.23]). These results imply MBG is a useful prognostic marker for STEMI patients. Conclusion: MBG 0/1 after primary angioplasty is a strong negative prognostic marker for long-term all-cause mortality and MACE among STEMI patients, and a post-primary angioplasty MBG of 2 or 3 is a robust prognostic marker for long-term survival.
... it has also been demonstrated that there is a correlation between infarct size and MBG, and low-grade MBG is associated with increased mortality in the long term. 15 In a study published in 2007, Kaya et al. investigated the prognostic significance of TIMI flow and MBG measurements in patients with acute coronary syndromes. They found that MBG was a good predictor of mortality during a five-year follow-up. ...
... One of the most common methods used to measure myocardial perfusion is the TIMI frame count. 15 A low TFC has been identified as a predictor of myocardial recovery in patients with acute coronary syndromes. 6 23 In addition, unlike other P2Y12 inhibitors, prasugrel requires only one hydrolysis in order to transform into its active metabolite. ...
Article
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Background: ST-segment elevation myocardial infarction (STEMI) is a clinical syndrome with high mortality. The main purpose of STEMI treatment is to achieve optimal revascularization for tissue perfusion. Besides the innovations in revascularization strategies, developments in antithrombotic therapy resulted in a significant reduction in STEMI-related mortality. Reperfusion can be demonstrated by resolution of ST-segment elevation (STR), TIMI frame count (TFC), and myocardial blush grade (MBG). Aim of the study: In our study, we investigated the effects of P2Y12 inhibitors clopidogrel, prasugrel, and ticagrelor on reperfusion parameters such as TFC, MBG, and STR, after primary percutaneous coronary intervention (pPCI) in STEMI. Material and Methods: The study was a retrospective analysis of STEMI patients who underwent successful pPCI. A total of 120 patients were included in the study as 3 equal groups according to the type of P2Y12 inhibitor administered in loading dose in the acute phase, and reperfusion parameters were compared between the groups. Results: There was no statistically significant difference between the groups in terms of baseline demographic, clinical, and angiographic parameters. Evaluation of reperfusion parameters indicated that STR, MBG, angina relief after pPCI and corrected TFC (cTFC) were significantly different between the groups (p <0.05). In post-hoc analysis, the percentage of change in STR, MBG, angina relief after pPCI, and cTFC was significantly higher in the prasugrel group (p <0.017). Conclusion: In STEMI patients undergoing pPCI, the analysis of tissue level reperfusion parameters indicates a superior effect of prasugrel compared with other P2Y12 inhibitors used to achieve reperfusion.
... Myocardial blush grade (MBG) represents an angiographic measurement of microvascular (capillary) perfusion. It reflects myocardial response to ischemic injury and reperfusion and is associated with both short-and long-term outcomes after acute MI (Haager et al., 2003;van 't Hof et al., 1998). A time-of-day variation to ischemic injury may therefore be reflected in a circadian variation of MBG. ...
Article
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In patients with ST-segment elevation myocardial infarction (STEMI), the time of onset of ischemia has been associated with myocardial infarction (MI) size. Myocardial blush grade (MBG) reflects myocardial response to ischemia/reperfusion injury, which may differ according to time of the day. The aim of our study was to explore the 24-hour variation in MBG and MI size in relation to outcomes in STEMI patients. A retrospective multicenter analysis of 6970 STEMI patients was performed. Time of onset of STEMI was divided into four 6-hour periods. STEMI patients have a significant 24-hour pattern in onset of symptoms, with peak onset around 09:00 hour. Ischemic time was longest and MI size, estimated by peak creatine kinase concentration, was largest in patients with STEMI onset between 00:00 and 06:00 hours. Both MBG and MI size were independently associated with mortality. Time of onset of STEMI was not independently associated with mortality when corrected for baseline and procedural factors. Interestingly, patients presenting with low MBG between 00:00 and 06:00 hours had a better prognosis compared to other groups. In conclusion, patients with symptom onset between 00:00 and 06:00 hours have longer ischemic time and consequently larger MI size. However, this does not translate into a higher mortality in this group. In addition, patients with failed reperfusion presenting in the early morning hours have better prognosis, suggesting a 24-hour pattern in myocardial protection.
... Los objetivos en el tratamiento del infarto agudo de miocardio con elevación del segmento ST (IAMEST) se han centrado en la apertura de la arteria coronaria [1][2][3] . Sin embargo, la permeabilidad de la arteria no garantiza una adecuada perfusión tisular y, de hecho, hasta el 30% de los pacientes con flujo epicárdico aparentemente normal (Thrombolysis In Myocardial Infarction [TIMI] 3) tienen una perfusión tisular inadecuada como consecuencia de un daño en la microcirculación [4][5][6] . ...
Article
Introduction and objectives An analysis was made of variability in the measurement of the angiographic index blush between a university hospital and an independent core laboratory, as well as its correlation with perfusion analised by intracoronary myocardial contrast echocardigraphy (MCE) and the ventricular function at the sixth month. Methods The study comprised 40 patients with a first ST-segment elevation myocardial infarction, single-vessel disease and open infarct-related artery. Perfusion was quantified by angiography (median fifth day, range 3-7) with blush in our laboratory and in an independent core laboratory. MCE was performed. Ejection fraction at the sixth month was determined with magnetic resonance imaging. Results We found a weak correlation (r=0.38) between both laboratories. In the comparison of blush measurements concordance was 80%, kappa=0.43 if normality was defined by blush 2-3; and concordance 55%, kappa= 0.1 for blush 3. Neither perfusion analised by MCE (r= 0.23, P=.2) nor ejection fraction by resonance (r=0.20, P=.3) did correlate to blush. Conclusions After infarction in patients with TIMI 3, variability is observed in blush measurements between a university hospital and an independent core laboratory, therefore it seems advisable to centralize blush measures in highly specialized core laboratories. A weak correlation was detected with perfusion analised by MCE and with late systolic function.
... Long-term mortality following PPCI is predicted by persistent ST elevation and MBG grades 0 to 1, while CTFC is a weaker predictor. Concomitant use of these features may improve their predictive power [55]. ...
Article
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The incidence of the no-reflow (NR) phenomenon varies depending on the diagnostic criteria used. If only just the angiographic criteria are considered (i.e., a degree of thrombolysis in myocardial infarction ≤2), it will be found that the incidence of NR is quite low; on the other hand, when the myocardial NR is taken into account (i.e., a decrease in the quality of the myocardial reperfusion expressed by the degree of myocardial blush), the real incidence being is higher. Thus, the early establishment of the a diagnosis of NR as well asand the administration of the specific treatment, can lead to its reversibility. Otherwise, regardless of the follow-up period, patients with NR have a poor prognosis. In the present work, we offer a comprehensive perspective on diagnostic tools for NR phenomenon detection, for improving the global management for of patients with arterial microvasculature damage, which is a topic of major interest in the cardiology field, due to its complexity and its linking with severe clinical outcomes.
... 16,17 The no-reflow phenomenon and CTFC≥40 associates with a poor patient outcome such as increased mortality, 30-day mortality, in-hospital MACE, and left ventricular remodeling as well as MI recurrence and heart failure. [18][19][20][21][22][23] The rate of the no-reflow phenomenon was 5.4% in our study, which was less than that in other studies; e.g. 10.8% in the Huczeck study. ...
Article
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Background: Due to the positive relation between platelet size and platelet reactivity, a high value of the mean platelet volume (MPV) is an independent risk factor to predict acute myocardial infarction (AMI) and its adverse outcome. Few data are available to determinate the prognostic value of MPV in ST-elevation myocardial infarction (STEMI) patients treated with percutaneous coronary intervention (PCI). The primary purpose of this study was to evaluate the clinical value of MPV to predict impaired reperfusion and in-hospital major adverse cardiovascular events (MACE) in acute STEMI treated with primary PCI. Methods: This study included 203 STEMI patients referring for blood sampling before primary PCI to estimate MPV and determine the thrombolysis in myocardial infarction (TIMI) flow grade, corrected TIMI frame count (CTFC), and in-hospital MACE. Results: The frequency of in-hospital MACE in the group of patients with a high MPV (≥10.3 ng/dl) was significantly more than that of the group with a low MPV (<10.3 ng/dl) (37.8% vs. 4.4%, P<0.001). The no-reflow phenomenon was more frequent in the patients with a high MPV than that of the patients with a low MPV (17.8% vs. 1.9%, P<0.001). The mean MPV in the group of patients with CTFC≥40 was significantly more than that of the group of patients with CTFC<40 (10.9±0.92 vs. 9.45±0.85, P=0.001). After adjustment for baseline characteristics, a high MPV remained a strong independent factor to predict the no-reflow phenomenon (Odds Ratio [OR]=2.263, 95% Confidence Interval [CI]=1.47 to 5.97; P<0.002), in-hospital MACE (OR=2.49, 95% CI=1.34 to 4.61; P<0.004), and CTFC≥40 (OR=2.09, 95% CI=1.22 to 3.39; P<0.003). Conclusion: These findings confirmed that not only could admission MPV predict impaired reperfusion and in-hospital MACE in acute STEMI patients treated with PCI, but also it could be considered a practical way to determine higher-risk patients.
... 16,17 The no-reflow phenomenon and CTFC≥40 associates with a poor patient outcome such as increased mortality, 30-day mortality, in-hospital MACE, and left ventricular remodeling as well as MI recurrence and heart failure. [18][19][20][21][22][23] The rate of the no-reflow phenomenon was 5.4% in our study, which was less than that in other studies; e.g. 10.8% in the Huczeck study. ...
Article
Full-text available
Background: Due to the positive relation between platelet size and platelet reactivity, a high value of the mean platelet volume (MPV) is an independent risk factor to predict acute myocardial infarction (AMI) and its adverse outcome. Few data are available to determinate the prognostic value of MPV in ST-elevation myocardial infarction (STEMI) patients treated with percutaneous coronary intervention (PCI). The primary purpose of this study was to evaluate the clinical value of MPV to predict impaired reperfusion and in-hospital major adverse cardiovascular events (MACE) in acute STEMI treated with primary PCI. Methods: This study included 203 STEMI patients referring for blood sampling before primary PCI to estimate MPV and determine the thrombolysis in myocardial infarction (TIMI) flow grade, corrected TIMI frame count (CTFC), and in-hospital MACE. Results: The frequency of in-hospital MACE in the group of patients with a high MPV (≥10.3 ng/dl) was significantly more than that of the group with a low MPV (<10.3 ng/dl) (37.8% vs. 4.4%, P<0.001). The no-reflow phenomenon was more frequent in the patients with a high MPV than that of the patients with a low MPV (17.8% vs. 1.9%, P<0.001). The mean MPV in the group of patients with CTFC≥40 was significantly more than that of the group of patients with CTFC<40 (10.9±0.92 vs. 9.45±0.85, P=0.001). After adjustment for baseline characteristics, a high MPV remained a strong independent factor to predict the no-reflow phenomenon (Odds Ratio [OR]=2.263, 95% Confidence Interval [CI]=1.47 to 5.97; P<0.002), in-hospital MACE (OR=2.49, 95% CI=1.34 to 4.61; P<0.004), and CTFC≥40 (OR=2.09, 95% CI=1.22 to 3.39; P<0.003). Conclusion: These findings confirmed that not only could admission MPV predict impaired reperfusion and in-hospital MACE in acute STEMI patients treated with PCI, but also it could be considered a practical way to determine higher-risk patients.
... Online Figure 2 We observed a "time-dependent" relationship be- Prasad et al. Although microvascular injury may be a surrogate for a larger infarct size, several studies have reported an independent prognostic value of indexes of myocardial perfusion (18,19). We have previously demonstrated that both MBG and STR strongly correlate with survival and that assessment of both yields incremental prognostic information beyond either measure alone (20). ...
Article
Objectives: This study sought to investigate the effect of treatment delay on microvascular reperfusion in ST-segment elevation myocardial infarction (STEMI) patients from the large, multicenter, prospective HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial. Background: Despite restoration of epicardial blood flow during primary percutaneous coronary intervention (PCI), one-third of patients do not obtain myocardial perfusion due to impairment in the microvascular circulation. Methods: We examined the effect of symptom onset-to-balloon time (SBT) and door-to-balloon time (DBT) on myocardial reperfusion during primary PCI in STEMI, utilizing resolution of ST-segment elevation (STR) and the myocardial blush grade (MBG). The primary analysis was the relationships between SBT ≤2, >2 to 4, and >4 h and DBT ≤1, >1 to 1.5, >1.5 to 2, and >2 h with MBG and STR. Clinical risk was assessed using a modified version of the Thrombolysis In Myocardial Infarction risk score for STEMI. Results: In 2,056 patients, absent microvascular perfusion (MBG 0/1) and STR (STR <30%) after primary PCI was significantly more common in patients with longer SBT, in patients with both low and high clinical risk profiles. By multivariable analysis, SBT (p < 0.0001), anterior infarction (p < 0.0001), reference vessel diameter (p = 0.005), lesion minimum lumen diameter (p < 0.0001), hyperlipidemia (p = 0.03), and current smoking (p = 0.001) were independent predictors of MBG 0/1, whereas SBT (p = 0.007), anterior infarction (p < 0.0001), and history of renal insufficiency (p = 0.0002) were independent predictors of absent STR. DBT (p < 0.0001) was an independent predictor of MBG 0/1. MBG 0/1 and STR<30% identified patients with increased 3-year mortality. Conclusions: The present study suggests that delay in mechanical reperfusion therapy during STEMI is associated with greater injury to the microcirculation.
... After primary angioplasty for STEMI, only a minority of patients achieves normal myocardial tissue perfusion (1,2), and decreased myocardial perfusion is associated with significantly higher rates of short-and long-term mortality (1,2,12). Furthermore, post-intervention infarct artery MBG can be used to stratify patients with TIMI flow grade 3 after reperfusion into different risk categories (13,14). Epicardial and myocardial perfusion abnormalities in regions subtended by the noninfarct-related arteries in patients with STEMI also carry prognostic significance (3)(4)(5)7,15,16). ...
Article
Objectives This study evaluated the impact of nonculprit vessel myocardial perfusion on outcomes of non–ST-segment elevation acute coronary syndromes (NSTE-ACS) patients. Background ST-segment elevation myocardial infarction patients have decreased perfusion in areas remote from the infarct-related vessel. The impact of myocardial hypoperfusion of regions supplied by nonculprit vessels in NSTE-ACS patients treated with percutaneous coronary intervention (PCI) is unknown. Methods The angiographic substudy of the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial included 6,921 NSTE-ACS patients. Complete 3-vessel assessments of baseline coronary TIMI (Thrombolysis In Myocardial Infarction) flow grade and myocardial blush grade (MBG) were performed. We examined the outcomes of PCI-treated patients according to the worst nonculprit vessel MBG identified per patient. Results Among the 3,826 patients treated with PCI, the worst nonculprit MBG was determined in 3,426 (89.5%) patients, including 375 (10.9%) MBG 0/1 patients, 475 (13.9%) MBG 2 patients, and 2,576 (75.2%) MBG 3 patients. Nonculprit MBG 0/1 was associated with worse baseline clinical characteristics. Patients with nonculprit MBG 0/1 versus MBG 3 had increased rates of 30-day (3.0% vs. 0.7%, p < 0.0001) and 1-year (4.4% vs. 1.0%, p < 0.0001) death. Similar results were found among patients with pre-procedural TIMI flow grade 3 in the culprit vessel, where nonculprit vessel MBG 0/1 (hazard ratio: 2.81 [95% confidence interval: 1.63 to 4.84], p = 0.0002) was the strongest predictor of 1-year mortality. Conclusions Reduced myocardial perfusion in an area supplied by a nonculprit vessel is associated with increased short- and long-term mortality rates in NSTE-ACS patients undergoing PCI. Furthermore, worst nonculprit MBG is able to risk-stratify patients with normal baseline flow of the culprit vessel.
... MBG is a simple visual angiographic assessment of myocardial perfusion in the infarct area, first described by van't Hof et al [4]. The occurrence of MBG 0/1 is associated with a larger infarct size, lower left ventricular ejection fraction, increased mortality and congestive heart failure [5][6][7][8]. Therefore, MBG is often used as an end point in clinical trial. ...
Article
Background: SYNTAX score II (SS-II) has been demonstrated to predict long-term outcomes in unprotected left main or multiple vessels in patients with coronary artery disease. But its prognostic value for patients with ST elevation myocardial infarction (STEMI) remains unknown. The poor myocardial perfusion (myocardial blush grade, MBG 0/1) after primary percutaneous coronary intervention (PPCI) has a negative prognostic value in patients with STEMI. We aimed to assess SS-II and its possible relationships with MBG 0/1 in patients with STEMI treated with PPCI. Methods: The study included 477 patients with STEMI who underwent PPCI between October 2010 and May 2014. The SS-II and MBG were determined in all patients. MBG were divided into MBG 0/1 (poor myocardial perfusion) and MBG 2/3 (normal myocardial perfusion). Patients were divided into 3 tertiles: SS-II low (≤ 20), SS-II intermediate (20-26) and SS-II high (≥ 26). Results: Compared with the SS-II intermediate and SS-II low tertiles, the SS-II high tertile had more MBG 0/1 (46.1%, 32.1% and 21.8%, p<0.001, respectively). On multivariate logistic regression analysis, SS-II was an independent predictor of MBG 0/1 (Hazard ratio [HR]: 1.084, 95% CI: 1.050 to 1.119; p<0.001). Receiver operating characteristic (ROC) analysis identified SS-II > 24 as the best cut-off value predicting MBG 0/1 (sensitivity of 66%, specificity of 54%). Conclusions: High SS-II is an independent predictor of MBG 0/1 in patients with STEMI undergoing PPCI.
... De Luca et al. 18 used STR and MBG (concordant relation) to assess myocardial perfusion in patients with STEMI after primary PCI. Haager et al. 19 evaluated myocardial blush grade 0-1 (p = 0.033) and persistent ST segment elevation (p = 0.017) as independent predictors for long-term mortality after angioplasty in AMI. Sorajja et al. 17 assessed the 30 days and 1 year clinical outcomes of 456 patients using STR >70% and MBG after primary PCI and concluded that both STR and MBG are measures of reperfusion success that strongly correlate with survival and assessment of both yields greater prognostic information than either one alone. ...
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Background: Platelet aggregation occurs as a central role in acute coronary syndrome (ACS), and glycoprotein GP IIb/IIIa inhibitors may enhance the benefits expected from early recanalisation. Aim: To compare the degree of platelet aggregation inhibition achieved by Eptifibatide versus high dose Tirofiban, and its clinical effects regarding myocardial reperfusion parameters: myocardial blush grade (MBG) and ST-segment resolution (STR) >70%, and regarding peri procedural complications, bleeding and major adverse cardiac events (MACE). Methods: Between the period of June 2010–January 2012, 46 patients with acute myocardial infarction whose symptom onset is within 12 h of presentation and ECG showing ST-segment elevation 1 mm in two contiguous limb leads or 2 mm in two contiguous precordial leads or acute left bundle branch block were included. Exclusion criteria were active bleeding, thrombocytopenia, bleeding diathesis, anticoagulation or thrombolitics, recent major surgery or stroke, cardiogenic shock, and pregnancy. Patients were randomized alternatively (1:1) into two groups before primary percutaneous cardiac intervention (PCI) to receive the specific glycoprotin IIb/IIIa inhibitor as follows: (I) Tirofiban group: intravenous high bolus dose of 25 mcg/kg over 3 min followed by maintenance infusion of 0.15 mcg/kg/min. (II) Eptifibatide group: intravenous two boluses 10 min apart (each one is 180 mcg/kg) followed by maintenance of 2 mcg/kg/min. Platelet aggregation inhibition was measured by light transmission aggregometer, angiographic assessment was done before and after final interventions for TIMI flow and myocardial blush grade before and after the procedure. Electrocardiographic assessment standard 12-lead ECG on admission, immediately after PCI. Resolution of ST segment elevation was expressed as a percentage of the initial ST segment elevation. Resolution of ⩾70% was defined as complete resolution. Clinical safety assessment was done in terms of the incidence of: bleeding complications and major adverse cardiac events (MACE): death, non-fatal myocardial infarction (MI), and target vessel revascularization (TVR). Results: The total patients in our study included 46 patients, 40 males (87%) and six females (13%) with a mean age of 55 ± 10, Tirofiban group: included 23 patients, 19 males (82.5%) and four females (17.4%) with a mean age of 57 ± 9.65. Eptifibatide group: included 23 patients, 21 males (87%) and two females (8.7%) with a mean age of 53.48 ± 8.6. Platelet aggregation inhibition during PCI was significantly correlated with STR (p 0.013, r 0.71). The cut-off point for platelet aggregation inhibition as a predictor of STR >70% was 89.5% (sensitivity 92.3%, specificity 69.2%, PPV 75% and NPV 10%, AUC 0.87). Platelet aggregation inhibition during PCI was positively correlated with MBG (p 0.045, r 0.453). The cut-off point for platelet aggregation inhibition as a predictor of MBG 2–3 was 87.5% (sensitivity 73.6%, specificity 66.7%, PPV 93.9% and NPV 76.9%, AUC 0.81). Platelet aggregation inhibition 60 min after bolus was (93.57 ± 2.07% versus 87.62 ± 3.2%, p 70% than high dose Tirofiban. • There was no significant differences between Eptifibatide and high dose Tirofiban regarding thrombocytopenia, major or minor bleeding, MACE and 30 days mortality.
... Além disso, pacientes com aumento da elevação do segmento ST após angioplastia primária (reelevação do segmento ST) parecem correr maior risco de morte e ICC, em decorrência de extensão do infarto, embolização distal ou injúria de reperfusão 46,47 . Haager et al. 48 , ao avaliar o valor preditivo do MBG, do CTFC e da R∑eST na mortalidade a curto e longo prazos em pacientes com IAM de alto risco e submetidos a ICPP, também demonstraram que, diferentemente da R∑eST, o CTFC não persistiu como preditor independente de mortalidade, embora esse índice tenha sido significativamente maior nos pacientes que evoluíram negativamente com esse desfecho. ...
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INTRODUÇÃO: Apesar do excelente desempenho e da segurança da angioplastia primária em restabelecer o fluxo sanguíneo epicárdico normal (fluxo TIMI, grau 3), uma significante proporção desses pacientes com infarto agudo do miocárdio (IAM) tem prejuízo na integridade micro-vascular e na perfusão miocárdica. É possível que os meios de contraste utilizados durante o procedimento interfiram na perfusão miocárdica por alterarem mecanismos celulares implicados nesse processo. OBJETIVO: Comparar os meios de contraste iodixanol (não-iônico isosmolar) e ioxaglato (iônico de baixa osmolaridade) na perfusão miocárdica tecidual em pacientes com IAM submetidos a intervenção coronária percutânea primária (ICPP). MÉTODO: Ensaio clínico randomizado com uma população de 201 pacientes com IAM, com tempo dor-porta < 12 horas, submetidos a ICPP. O desfecho primário do estudo foi a presença de no-reflow, definido como corrected TIMI frame count (CTFC) > 40 quadros, e o desfecho secundário foi a composição de morte cardíaca, reinfarto e acidente vascular cerebral (AVC) durante a hospitalização. RESULTADOS: CTFC > 40 após ICPP ocorreu em 22,9% dos pacientes no grupo do ioxaglato e em 19,8% no grupo do iodixanol (p = 0,611). O desfecho secundário ocorreu em 9,5% dos pacientes no grupo do ioxaglato e em 9,4% no grupo do iodixanol (p > 0,99). CONCLUSÃO: O presente estudo não demonstrou diferenças significativas na incidência de no-reflow entre os meios de contraste ioxaglato e iodixanol nos pacientes com IAM submetidos a ICPP. Também não foram observadas diferenças significativas na incidência dos desfechos clínicos combinados de morte, reinfarto ou AVC.
... Indeed, capillary blood flow is not measured directly by angiography, and a significant proportion of TIMI grade 3 flow patients actually present with NR [14]. Therefore, other angiographic measures that have been developed to assess microvascular perfusion include the TIMI frame count and myocardial blush grade (MBG) [15]. MBG is another newly developed angiographic imaging technique for assessing myocardial microvasculature and tissue reflow [13]. ...
... The usefulness of coronary blood flow assessment after PCI has been largely demonstrated, as slow flow and therefore high thrombolysis in myocardial infarction frame count values are associated with poor clinical outcomes in myocardial infarction. 25,26 In our study, coronary blood velocity at MoHT decreased to half the normothermic values. In the context of coronary events, different factors, such as incomplete revascularization or microvascular obstruction, might induce slow blood flow. ...
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Background Hypothermia has been associated with therapeutic benefits including reduced mortality and better neurologic outcomes in survivors of cardiac arrest. However, undesirable side effects have been reported in patients undergoing coronary interventions. Using a large animal model of temperature management, we aimed to describe how temperature interferes with the coronary vasculature. Methods and Results Coronary hemodynamics and endothelial function were studied in 12 pigs at various core temperatures. Left circumflex coronary artery was challenged with intracoronary nitroglycerin, bradykinin, and adenosine at normothermia (38°C) and mild hypothermia (34°C), followed by either rewarming (38°C; n=6) or moderate hypothermia (Mo HT ; 32°C, n=6). Invasive coronary hemodynamics by Doppler wire revealed a slower coronary blood velocity at 32°C in the Mo HT protocol (normothermia 20.2±11.2 cm/s versus mild hypothermia 18.7±4.3 cm/s versus Mo HT 11.3±5.3 cm/s, P =0.007). Mo HT time point was also associated with high values of hyperemic microvascular resistance (>3 mm Hg/cm per second) (normothermia 2.0±0.6 mm Hg/cm per second versus mild hypothermia 2.0±0.8 mm Hg/cm per second versus Mo HT 3.4±1.6 mm Hg/cm per second, P =0.273). Assessment of coronary vasodilation by quantitative coronary analysis showed increased endothelium‐dependent (bradykinin) vasodilation at 32°C when compared with normothermia (normothermia 6.96% change versus mild hypothermia 9.01% change versus Mo HT 25.42% change, P =0.044). Results from coronary reactivity in vitro were in agreement with angiography data and established that endothelium‐dependent relaxation in Mo HT completely relies on NO production. Conclusions In this porcine model of temperature management, 34°C hypothermia and rewarming (38°C) did not affect coronary hemodynamics or endothelial function. However, 32°C hypothermia altered coronary vasculature physiology by slowing coronary blood flow, increasing microvascular resistance, and exacerbating endothelium‐dependent vasodilatory response.
... Myocardial Blush Grade (MBG) scoring was then applied to those with TIMI III flow to assess their myocardial reperfusion, whereas MBG 0=no myocardial blush or contrast density, MBG 1=minimal myocardial blush or contrast density, MBG 2=moderate myocardial blush or contrast density but less than that obtained during angiography of a contralateral or ipsilateral non-infarct-related coronary artery MBG 3=normal myocardial blush or contrast density, comparable with that obtained during angiography of a contralateral or ipsilateral non-infarct-related coronary artery. MBG 0/1 indicated impaired microvascular and myocardial reperfusion and MBG 2/3 indicated good microvascular and myocardial reperfusion [8,9]. ...
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Objectives: To investigate the value of Mean Platelet Volume (MPV) in predicting immediate angiographic myocardial reperfusion and short-term Major Adverse Cardiac Events (MACE) in primary Percutaneous Coronary Intervention (PCI) patients. Background: Impaired immediate angiographic reperfusion is a common complication in patients of ST-Elevation Myocardial Infarction (STEMI) treated by primary PCI, which carries an increased risk of further development of MACE. MPV-which is an indicator of platelet reactivity-may play an important role in occurrence of such complications.
... Myocardial Blush Grade (MBG) scoring was then applied to those with TIMI III flow to assess their myocardial reperfusion, whereas MBG 0=no myocardial blush or contrast density, MBG 1=minimal myocardial blush or contrast density, MBG 2=moderate myocardial blush or contrast density but less than that obtained during angiography of a contralateral or ipsilateral non-infarct-related coronary artery MBG 3=normal myocardial blush or contrast density, comparable with that obtained during angiography of a contralateral or ipsilateral non-infarct-related coronary artery. MBG 0/1 indicated impaired microvascular and myocardial reperfusion and MBG 2/3 indicated good microvascular and myocardial reperfusion [8,9]. ...
... Persistent STE and myocardial blush grade (MBG) grades 0 to 1 independently predict long-term mortality after P-PCI, while CTFC-corrected Thrombolysis in Myocardial Infarction (TIMI) frame count-is a weaker predictor. Simultaneous use of these parameters may increase their predictive power [35]. Despite the ease and rapidity of obtaining STR, it at times presents itself as an inaccurate method to the diagnosis of no-reflow [36]. ...
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Successful reperfusion of an infarct-related coronary artery by primary percutaneous intervention or fibrinolysis during acute ST-elevation myocardial infarction (STEMI) does not always restore myocardial tissue perfusion, a phenomenon termed “no-reflow.” Herein we discuss the pathophysiology of this highly prevalent phenomenon and highlight the most salient aspects of its clinical diagnosis and management as well as the limitations of presently used methods. There is a great need for understanding the dynamic nature of no-reflow, as its occurrence is associated with poor cardiovascular outcomes. The no-reflow phenomenon may lend an explanation to the lack of further improvements in in-hospital mortality in STEMI patients despite decreases in door-to-balloon time. Hence, no-reflow potentially presents an important target for investigators interested in improving outcomes in STEMI.
... Hyperglycemia on admission is an independent and potent risk factor of adverse events after ST-segment elevation myocardial infarction (STEMI), even after adjustment for prior diabetes and glycosylated hemoglobin level [1-3]. At the same time unsuccessful tissue-level reperfusion is the primary determinant of unfavorable clinical outcome after STEMI [4]. ...
Article
To determine whether adequate myocardial perfusion status after transluminal recanalization is associated with prompt improvement of QT dispersion (QTd). Transluminal recanalization of the infarct-related coronary artery in acute myocardial infarction aims to promptly restore myocardial perfusion, to maximize electrical and mechanical recovery. QTd represents the heterogeneity of ventricular repolarization, which may affect electrical stability. Forty patients who underwent primary percutaneous coronary intervention for their first anterior acute ST-elevation myocardial infarction were prospectively enrolled. Myocardial reperfusion status was assessed by myocardial blush grade (MBG) on the final angiogram after successful recanalization (Thrombolysis In Myocardial Infarction Grade 3 flow). Preprocedural QTd was similar in patients with final MBG 0-1, 2, and 3 (76 ± 24, 67 ± 13, and 69 ± 13 milliseconds, respectively; P = 0.661). After recanalization, QTd decreased in patients with MBG 3 (39 ± 16 milliseconds, P < 0.001) but not in patients with MBG 0-1 (74 ± 20 milliseconds) or MBG 2 (82 ± 16 milliseconds). Multivariate analysis showed that postprocedural MBG was an independent predictor of QTd after recanalization (standardized regression coefficient = -0.628, P < 0.001). Adequate tissue perfusion may be crucial for electrical stability of the myocardium after reperfusion.
Article
Introduction and objectives It has been suggested that abnormal perfusion as derived from cardiovascular magnetic resonance imaging (CMR) is a transient dysfunction of microcirculation after myocardial infarction (MI) with TIMI 3 flow. We hypothesized that defects of myocardial perfusion may persist during the following months. Methods Forty-seven patients with MI and sustained TIMI 3 flow underwent intracoronary myocardial contrast echocardiography (MCE) 1 week and 6 months after infarction. Abnormal perfusion by MCE was regarded as > 1 hypoperfused segment. Results At the first week, 20 patients showed abnormal perfusion as derived from MCE. At the sixth month 10 patients displayed chronic abnormal perfusion. These patients had greater left ventricular volumes and lower ejection fraction at the sixth month by CMR (P<.01). Conclusions MCE detects perfusion defects which can persist in chronic phase – this relates to more severe systolic dysfunction and increased left ventricular volumes.
Article
Background: Angiographic coronary flow parameters and resolution of ST segment changes play an important role in the evaluation of reperfusion in patients with acute ST segment elevation myocardial infarction (STEMI). In previous studies on the relation between angiographic and electrocardiographic (ECG) parameters of coronary reperfusion, several alternative methods to assess ST segment resolution were used. Thus, the relation between the TIMI Myocardial Perfusion Grade (TMPG) and different methods to evaluate ST segment resolution seems to be of interest. Aim: To evaluate the relationship between TMPG and absolute and relative ST segment resolution after successful primary percutaneous coronary intervention (pPCI). Methods: We studied a population of STEMI patients successfully treated with pPCI. Reperfusion of the coronary microcirculation was determined using 4-grade TMPG scale in coronary angiography performed after successful pPCI. ST segment resolution was analysed in two manners: 1) by calculating the sum of ST segment elevation in infarct leads and depression in reciprocal leads after pPCI (absolute resolution, SSTD); 2) as a percent reduction of summed ST segment deviation from the baseline value (relative resolution, SSTD%). Maximum ST segment elevation in a single lead on the postprocedural ECG was measured to categorise the risk of death. ST segment elevation > 1 mm for an inferior infarct or > 2 mm for an anterior infarct was considered the criterion of high risk (high risk ECG). Results: The study population included 183 patients treated with pPCI. We found a significant but weak negative correlation between TMPG and SSTD (r = -0.27, p = 0.0002). Significant differences in median SSTD were observed between TMPG 0 vs. TMPG 2 and TMPG 3 groups (p = 0.0034 and 0.0121, respectively) and also between TMPG 1 and TMPG 2 (p = 0.02). A significant but very weak positive correlation was found between TMPG and SSTD% (r = 0.16,p = 0.0286). However, further analyses showed that differences in median SSTD% between patients with different TMPG values were statistically insignificant (p = 0.1756). In patients with TMPG 2/3, a high risk ECG was absent considerably more often (p = 0.0007). However, angiographic features of successfully vs. unsuccessfully reperfused microcirculation did not correspond to the presence of a high risk ECG in about 34% of cases. Conclusions: TMPG is more closely related to absolute compared to relative ST segment resolution. A high risk ECG was absent in most patients with TMPG 2 or 3. However, in about one third of cases TMPG did not correspond to the presence of ECG high risk features. These data suggest that TMPG is complementary to ST segment resolution in the assessment of coronary reperfusion.
Article
Introduction and objectives The relationship between microcirculatory myocardial perfusion grade (MPG), myocardial salvage and long-term mortality after acute ST-segment elevation myocardial infarction (STEMI) and full restoration of epicardial blood flow by primary percutaneous coronary intervention (PCI) remains poorly understood. Methods This study included 1213 patients with STEMI and Thrombolysis in Myocardial Infarction (TIMI) grade-3 flow after primary PCI. The MPG was determined and paired scintigraphic studies (before and 7–14 days after the intervention) were performed. The primary outcome was 5-year mortality. Results The MPG was 0-1 in 217 patients, 2 in 195, and 3 in 801. In patients with an MPG of 0-1, 2 and 3, respectively, the median infarct size was 13% (interquartile range [IQR] 5.6-28%), 12% (IQR 4-27%) and 7% (IQR 1-19%) of the left ventricle, respectively (P<.001), the myocardial salvage index (i.e. the proportion of the initial area at risk that recovered) was 0.44 (IQR 0.22-0.73), 0.46 (IQR 0.25-0.75) and 0.58 (IQR 0.31-0.85), respectively (P<.001), and the Kaplan-Meier estimated 5-year mortality was 16.6% (i.e. 28 deaths), 15.3% (i.e. 25 deaths) and 7.8% (i.e. 48 deaths), respectively. The odds ratio (OR) for death for an MPG of 0-1 vs. 3 was 2.32 (95% confidence interval [CI] 1.42-3.8; P<.001) and for an MPG of 2 vs. 3, 2.3 (95% CI 1.38-3.85; P=.001). The Cox proportional hazards model identified MPG as independently associated with mortality at 5 years: the hazard ratio for an MPG of 3 vs. 0-2 was 0.65 (95% CI 0.41-0.97; P=.037). Conclusions In patients with STEMI and TIMI grade-3 flow after primary PCI, suboptimal microcirculatory myocardial perfusion (i.e. MPG ≤2) was associated with poorer myocardial salvage, a larger infarct, and higher 5-year mortality than observed in patients whose tissue perfusion was reestablished (i.e. MPG=3).
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We assessed the impact of aspiration thrombectomy (AT) in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention (PPCI) on major adverse cardiac events at 30 days and 1-year mortality in 517 consecutive patients who were included in the prospective, nationwide, multicenter, observational Acute Coronary Syndrome Israeli Survey in 2010. Two hundred seventeen patients (42%) underwent AT (AT-PPCI) and 300 patients conventional (C) PPCI. Both groups had similar infarct-related artery distribution and ostial or proximal culprit lesion. Patients in AT-PPCI versus C-PPCI had lower systolic blood pressure and worse Killip class on admission, more frequent Thrombolysis In Myocardial Infarction flow 0 or 1 before PPCI (80% vs 56%), less frequent restoration of flow after indwelling a guidewire in the infarct-related artery (32% vs 52%), and more use of IIb/IIIa glycoprotein inhibitors (69% vs 49%), respectively (p ≤0.05 for all comparisons). Thirty-day major adverse cardiac events was similar in the AT-PPCI and C-PPCI groups, 10.6% versus 9.7%, p = 0.73; adjusted odds ratio 0.97, 95% confidence interval 0.45 to 2.10, p = 0.95. One-year mortality was lower in the AT-PPCI versus C-PPCI group, 3.7% versus 6.7%, p = 0.13; adjusted hazard ratio 0.31, 95% confidence interval 0.10 to 0.96, p = 0.042. In conclusion, this study of consecutive patients with ST elevation myocardial infarction undergoing PPCI demonstrates that AT was an independent predictor of reduced 1-year mortality.
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During High Tech congress 2004, different questions have been discussed concerning the assessment of cardiac ischemia, quality of reperfusion and result of angioplasty. Coronary angiogram alone is not enough to decide the optimal therapeutic strategy. Ischemia-driven decision is a much better option. How should we assess the more accurately the need for ischemia-driven revascularization? Angiographic success (TIMI 3 flow grade) after angioplasty is near 95%, but is not sufficient to assess precisely the quality of myocardial reperfusion. Which more efficient tools are available? At last, which angiographic or clinical criteria should we use to assess the result of angioplasty?
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We evaluated the effects of myocardial perfusion after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) on gender-based mortality rates. Research has demonstrated a gender-specific response of cardiomyocytes to ischemia and a potential increase in myocardial salvage in women compared with men. Myocardial blush grade (MBG), an angiographic surrogate of myocardial perfusion, is an independent predictor of early and late survival after AMI. Whether the incidence and prognosis of myocardial perfusion differs according to gender among patients with AMI undergoing PCI is unknown. MBG and short- and long-term mortality were evaluated in 1,301 patients (male = 935; female = 366) with AMI randomized to primary angioplasty ± abciximab versus stent ± abciximab. Following PCI, >96% of patients achieved final Thrombolysis In Myocardial Infarction 3 flow, of which MBG 2/3 was present in 58.3% of women versus 51.1% of men (p = 0.02). Worse MBG was an independent predictor of mortality in women at 30 days (7.4% for MBG 0/1 vs 2.4% for MBG 2/3, p = 0.04) and at 1-year (11.0% for MBG 0/1 vs 3.4% for MBG 2/3, p = 0.01); however, MBG was not associated with differences in mortality for men. In conclusion, impaired myocardial perfusion following PCI for AMI, indicated by worse MBG, is an independent predictor of early and late mortality in women but not in men. These findings imply an enhanced survival benefit from restoring myocardial perfusion for women compared with men during primary angioplasty and may have clinical implications for interventional strategies in women.
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Although technical advances enable normal epicardial coronary artery blood flow to be restored in most patients suffering myocardial infarction, restoration of blood flow is not always followed by improved myocardial perfusion. Recently, therefore, interest in the assessment of myocardial perfusion has grown, and a number of different assessment methods are available. The aim of this article was to provide an evaluation of the additional information that can be obtained from the widely used technique of conventional coronary angiography. We present a review of the data on epicardial coronary artery blood flow (both semiquantitative and quantitative) and on microvascular blood flow that can be obtained using coronary angiography and discuss their prognostic significance.
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A descriptive and retrospective study on mortality, rate as caused by acute myocardial infarction was conducted with patients admitted to the intensive care ward of the M. Ascunce General Hospital, Camagüey, from January 2001 to December 2002. The medical histories of 50 patients who had died from were the sources. The amount of patients admitted (245) and of patients who had died from causes other than myocardial infarction (349) were also considered. With all theses data a form was filled in and, when processed statically, the degree of reliability was lesser than 0.5. The grater percentage of deceased patients (64, 1 %) was found to be between ages 65 and 85. High blood pressure and smoking were responsible for 92 % of the death rate where as some three to five other risk factors were responsible for 92 % of the death rate. The majority of patients (62 %) was given intensive care-but little thrombolitic therapy-six hours after. The prevailing medications were amines (68 %), plaque antiagglutinins (60 %) and nitrites (52 %). The most frequent serious complications was cardiogenic shock (64 %). AMI accounted for 44, 23 % of mortality and for 9, 17 % of the death rate at the intensive care ward.
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The primary goal in reopening an infarct-related artery is the restoration of myocardial tissue-level perfusion. In a variable proportion of patients with ST-elevation myocardial infarction, however, microcirculatory impairment may persist after epicardial coronary artery recanalization. This phenomenon is known as microvascular obstruction (MVO). Ischemic injury, reperfusion injury, and distal embolization along with the individual response to each of these mechanisms are variably involved in the pathogenesis of MVO in the single patient. Importantly, MVO is associated with a worse prognosis both at short- and long-term follow-up. MVO can be assessed in the cath-lab by simple angiographic indexes, such as Thrombolysis in Myocardial Infarction grade score and Myocardial Blush Grade, or by invasive measures of coronary flow pattern. Imaging techniques, such as myocardial contrast echocardiography or cardiac magnetic resonance, and ST-segment resolution on standard electrocardiogram are used in the days following reperfusion with the patient in the coronary care unit. In this article, we review the available data regarding pathogenesis, diagnosis and the prognostic significance of MVO after primary percurtaneous coronary intervention in ST-elevation myocardial infarction patients, with a brief highlighting on the crucial role of its prevention and its early detection.
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In a significant proportion of percutaneous coronary interventions (PCI) performed in the setting of acute myocardial infarction, despite apparently adequate restoration of blood flow in the target epicardial vessel, optimal myocardial reperfusion at tissue level is not achieved. This phenomenon, defined as no-reflow, has been consistently associated with negative outcomes; it involves many pathogenetic factors, including microvascular dysfunction and embolization of thrombus and plaque debris from the culprit lesion during PCI, particularly during stent deployment. Several strategies - either pharmacological or mechanical - have been developed in order to prevent or reduce the incidence of no-reflow, but this phenomenon still remains a major issue in primary coronary intervention. The MGuard stent is a relatively new device intended to ameliorate tissue reperfusion by reducing distal embolization: it consists of a balloon-expandable, bare metal stent platform, whose outer surface is covered by a mesh of polyethylene terephthalate (PET), so that after expansion the thrombus is entrapped between the stent struts and the vessel wall. This stent has been tested in lesions with a high embolic risk, as on vein grafts or in the setting of acute coronary syndromes. In this paper, we will review and discuss the data available about this device, with a particular focus on its use in primary PCI.
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Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) usually restores TIMI 3 flow in the occluded artery, but microvascular impairment may persist in >30% of patients. Less is known about microvascular reperfusion in STEMI patients treated with thrombolysis followed by early PCI. We aimed to assess the association between TIMI myocardial perfusion (TMP) at the end of the PCI procedure and left ventricular function (LVEF) and infarct size after three months in such patients. Patients with STEMI treated with thrombolysis and early PCI were included. TMP grade was assessed at the end of the PCI procedure, and MRI was performed after three months. Of the 89 patients included, 92% (n=82) had TIMI 3 flow at the end of the PCI procedure, while only 62% (n=55) had TMP grade 2 or 3. Patients with TMP grade 2-3 had significantly higher LVEF (59% [53-67] vs. 50% [41-56], p<0.0001) and smaller infarct size (8.3 ml [2.7-15.5] vs. 20.7 ml [13.0-36.0], p<0,0001) after three months. In STEMI patients treated with thrombolysis and early PCI, the TMP grade at the end of the PCI procedure was significantly associated with LVEF and infarct size after three months.
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Detection of abnormal myocardial perfusion is crucial to the prognosis of patients with coronary artery disease (CAD) after they have undergone percutaneous coronary intervention (PCI). The objective of this study is to evaluate the effect of myocardial perfusion by three different methods—intra-coronary myocardial contrast echocardiography (ICMCE), corrected thrombolysis in myocardial infarction frame count (CTFC), and coronary blood flow velocity (BFV)—and to determine the value of these different methods in the evaluation of the effect of myocardial perfusion post-PCI. For the study sixty-eight patients were divided into four groups based on selective coronary angiography results: group A (normal coronary artery), group B (75%–95% coronary artery stenosis), group C (coronary artery stenosis >95%) and group D (acute total coronary occlusion). The effect of myocardial reperfusion was evaluated using the above mentioned three methods 15 min after PCI. IC-MCE was also performed before PCI in group D. The quantitative parameters of MCE involved: contrast peak intensity, time to peak intensity and area under the curve, representing myocardial blood volume, reperfusion velocity and myocardial blood flow, respectively. No difference was found in CTFC between the coronary artery stenosis group and the normal group. BFV was slower in group D than in group A(P P P P
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Fragmented QRS complex (fQRS) is associated with worse outcomes in several cardiovascular conditions. However, alterations in fQRS in patients with ST elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI) and association of fQRS with myocardial blush grade (MBG) has not been investigated until now. In this study, we aimed to investigate the association of MBG after primary PCI with evolution of fQRS. Our study consisted of 401 consecutive patients with STEMI who underwent primary PCI. Patients were categorized into two subgroups according to persistence or new-onset of fQRS (Group 1) and absence or resolution of fQRS (Group 2) at 48 hours after primary PCI. The evolution of fQRS on pre- and post-PCI ECG and their relation with myocardial reperfusion parameters were investigated. Patients in group 1 showed older age, higher rate of smoking, lower HDL-cholesterol, lower LVEF, higher angina-to-door time, higher TIMI frame count, and high rate of patients with MBG <3 compared to patients with group 2 (P < 0.05). In correlation analysis, LVEF showed positive correlation with MBG (r = 0.448, P < 0.001) and negative correlation with the number of leads with fQRS (r = -0.335, P < 0.001). In multivariate regression analysis, new-onset or persistance of fQRS after primary PCI is significantly associated with MBG <3, peak CK-MB level, pre-PCI fQRS at anterior localization and smoking. Our findings showed that despite complete ST-segment resolution in all patients, fQRS is independently associated with impaired microvascular myocardial perfusion. So, fQRS, as a simple and easily available noninvasive marker, may be useful in stratification of high-risk patients with increased extent of infarcted myocardium who underwent primary PCI.
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Background: Analysis of myocardial blush grade (MBG) and coronary flow velocity pattern has been used to obtain direct or indirect information about microvascular damage and reperfusion injury after percutaneous transluminal coronary angiography for acute myocardial infarction. Objective: To evaluate the relation between coronary blood flow velocity pattern and MBG immediately after angioplasty plus stenting for acute myocardial infarction. Design: The coronary blood flow velocity pattern in the infarct related artery was determined immediately after angioplasty in 35 patients with their first acute myocardial infarct using a Doppler guide wire. Measurements were related to MBG as a direct index of microvascular function in the infarct zone. Results: Coronary flow velocity patterns were different between patients with absent myocardial blush (n = 14), reduced blush (n = 7), or normal blush (n = 14). The following variables (mean (SD)) differed significantly between the three groups: systolic peak flow velocity (cm/s): absent blush 10.9 (4.2), reduced blush 14.2 (6.4), normal blush 19.2 (11.2); p = 0.036; diastolic deceleration rate (ms): absent blush 103 (58), reduced blush 80 (65), normal blush 50 (19); p = 0.025; and diastolic–systolic velocity ratio: absent blush 4.06 (2.18), reduced blush 2.02 (0.55), normal blush 1.88 (1.03); p = 0.002. In a multivariate analysis MBG was the only variable with a significant impact on the diastolic deceleration rate (p = 0.034,) while age, infarct location, time to revascularisation, infarct vessel diameter, and maximum creatine kinase had no significant impact. Conclusions: The coronary flow velocity pattern in the infarct related epicardial artery is primarily determined by the microvascular function of the dependent myocardium, as reflected by MBG.
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Background: Myocardial perfusion grade (MPG) is an accepted method of evaluating myocardial perfusion. However, it does not take into the account, the extent of the perfusion. We hypothesized that myocardial blush area times MPG (total blush) would be more accurate than simple MPG, and yield better prognostic information. Methods: About 34 patients were recruited after they had consented to both coronary angiography (CAG) and single photon emission computed tomography (SPECT), and divided into two groups. A special dedicated computer was employed to calculate the total blush. The CAG was performed as a conventional way. Scintigraphic technetium 99m methoxyisobutyl-isonitrile rest and stress images were evaluated quantitatively. The comparison was made between stenosis versus chronic total occlusion (CTO), MPG 1, 2 versus MPG 3, percutaneous intervention (PCI) successful versus failure. A correlation was made between ejection fraction (EF) and myocardial perfusion by MPG, total blush, SPECT, and syntax score. Results: The perfusion indices of total blush, summed difference score (SDS) and syntax score were insignificant between the two groups (P > 0.05). However, the left ventricular end diastolic volume was significantly larger in CTO (P < 0.05). The patients with stenosis had better MPG than with CTO (P < 0.05). The increased MPG was associated with increased total blush, higher syntax score, and EF (P < 0.05). Successful PCI resulted in better perfusion indicated by increased total blush, and MPG (P < 0.05) but successful PCI did not change syntax score, EF and SDS significantly. Multivariate linear analysis with EF as the dependent factor and syntax score, SDS, total blush, blush area, and MPG as the independent factors showed a significantly higher degree of correlation (R = 0.87, P < 0.05). Conclusion: After PCI the total blush and EF improved significantly indicating its potential application in the future.
Article
Introduction: During the past 20 years, significant progress has been made in the recanalization of ACS with ST elevation. It is now accepted that the reopening of the large coronary vessels in the acute phase of infarction by thrombolysis or angioplasty is necessary but not sufficient, because in 20-50% of cases, the coronary recanalization is an illusion of reperfusion. This phenomenon is called "no reflow". Objective: The main objective of our study was to identify predictors of poor perfusion or "no reflow" in the acute phase of myocardial infarction. Methods: Observational prospective study, in the department of cardiology and internal medicine, university hospital of Blida, over a period of 28 months from 1st September 2010 to 31st January 2013. We identified all patients hospitalized for myocardial infarction in acute phase, who underwent primary angioplasty or thrombolysis with angiographic control during a good TIMI flow. The endpoint was regression of ST segment (regression<50% ST-segment defined no reflow). Results: Three hundred and seventy-nine patients were included. The mean age was 56.3±2.1, 87.8% of patients were male. In total, 35.9% hypertensive, 27.1% diabetic type 2, 50.1% and 10.8% dyslipidemia, smoking. One hundred and forty-seven (38.8%) developed a no reflow. Mortality was 3.9%, strongly correlated with no reflow (P=0.001). Predictors of no reflow after multivariate analysis were: age (OR 98, 0.961-0.996 95%, P=0.02), heart rate (1.01, 95% CI 0.998-1.02, P=0.035), the type 2 diabetes (odds ratio 1.87, CI 1.2-3.0, P=0.08), reaching the core (OR 7, 95% CI 1.2-18.4, P=0.027), direct stenting (OR 0.48, 95% CI 0.31-0.78, P=0.003). An interesting subgroup of patients was identified namely the subgroup strategy deferred primary angioplasty with stenting best reperfusion (OR 3.7, 95% CI 1.5-8.8, P=0.04), a lower rate of reocclusion of culprit artery and a lower rate of stenting with 23/51 (45.1%) versus 136/136 (100%) of immediate stenting group with a P<0.001. Conclusion: No reflow is a common phenomenon, strongly correlated with mortality predictors are age, heart rate, diabetes, achieving the core and direct stenting. The distal embolization in primary angioplasty is an important phenomenon, a delayed stenting strategy appears to limit this phenomenon.
Article
Background: Quantitative modification of TIMI myocardial perfusion grade (TMPG) by the method of frame counting may improve its sensitivity and the false negative rate for post-reperfusion microvascular dysfunction (MVD) in ST segment-elevated myocardial infarction (STEMI) patients. Methods: The durations of contrast-washout from infarction area of 139 patients were measured by counting the cine-frame numbers between the appearance and disappearance of myocardial blush. The achieved new index, TMP Frame Counting (TMP-FC) was referenced by cardiac magnetic resonance, by which MVD was defined as microvascular obstruction on gadolinium late-enhancement imaging. Results: Median TMP-FC differed significantly between patients with and without MVD (126 frames, IQR 105-160 vs. 86 frames, IQR 75-100, p<0.001). By receiver-operating characteristic analysis, the cutoff of TMP-FC at ≥95.5 frames represented an independent predictor of MVD (OR=11.61, p<0.001). TMP-FC had similar specificity (75%) and positive predictive value (88%), but significantly improved sensitivity (85.3%) and negative predictive value (70.2%) for MVD compared with TMPG (88.6%, 86.5%, 33.7% and 38.2%, respectively) and other traditional angiographic assessments, leading to a better overall accuracy (area under the curve: 0.801 compared with 0.612 from TMPG, p<0.001) for the evaluation of microvascular patency. TMP-FC was positively correlated with MVD extent (r=0.5, p<0.001). Abnormal TMP-FC was associated with larger infarction size (28.67±13.72% vs. 16.51±10.68% of left ventricular mass, p<0.001) and lower LVEF (49.37±11.06% vs. 56.84±9.72%, p<0.001). Conclusion: Frame counting can improve the accuracy of TMPG for MVD. Moreover, TMP-FC is correlated with the degree of MVD and cardiac detriments, which is useful for risk stratification.
Article
Background: Women with AMI may have worse outcomes than men. However, it is unclear if this is related to differences in treatment, treatment effect or gender specific factors. We sought to determine whether primary percutaneous intervention (PCI) has a differential impact on infarct size, myocardial perfusion and ST segment resolution in men and women with acute myocardial infarction (AMI). Methods: A total of 501 AMI patients were prospectively enrolled in the EMERALD study and underwent PCI with or without distal protection. Post hoc gender subset analysis was performed. Results: 501 patients (108 women, 393 men) with ST-segment elevation AMI presenting within 6h underwent primary (or rescue) PCI with stenting and a distal protection device. Women were older, had more hypertension, less prior AMI, smaller BSA, and smaller vessel size, but had similar rates of diabetes (30% versus 20.2%, p=0.87), LAD infarct, and time-to-reperfusion compared to men. Women more frequently had complete ST-resolution (>70%) at 30days (72.8% versus 59.8%, p=0.02), and smaller infarct size compared to males (12.2±19.6% versus 18.4±18.5%, p=0.006). At 6months, TLR (6.9% versus 5.2%) and MACE (11.4% versus 10.3%) were similar for women and men. Conclusions: Despite worse comorbidities, women with AMI treated with primary PCI with stenting showed similar early and midterm outcomes compared to men.
Article
Background: Abnormal myocardial flow is related to higher in-hospital and late mortality. The prognosis of patients with myocardial infarction is also worsened by the presence of no-reflow. Therefore, the aim of the study was to identify independent predictors of abnormal microvascular flow and flow decrease or no-reflow phenomenon in patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI). Methods: The analysis included consecutive patients with STEMI treated with PCI (direct stenting or stenting after balloon predilatation). The analysis excluded patients with pulmonary edema or cardiogenic shock. Results: Two hundred seventeen out of 300 consecutive patients were included in the analysis. One hundred ten patients underwent direct stenting angioplasty while 107 patients had stenting after balloon predilatation. In the univariate analysis the most relevant factor determining TMPG 0-1 (TIMI Myocardial Perfusion Grade) was the angioplasty of left descending artery (OR=2.15, 95% CI 1.03-4.51) and, subsequently, an anterior infarction (OR=2.12, 95% CI 1.01 -4.43). Moreover, longer pain duration to beginning of the procedure and older age increased TMPG 0-1 occurrence risk by 1.49 per one hour and 1.06 per one year, respectively. The multivariate analysis disclosed that age was the independent predictor of TMPG 0-1 (per 1 year OR=1.04, 95% CI 1.00-1.08). The univariate analysis showed that diabetes was associated with approximately 6-fold higher risk of flow decrease or no-reflow (OR=6.10, 95% CI 2.22-16.80). The risk ratio of flow decrease or no-reflow per 1 mm of lesion or stent length was 1.20 and 1.09, respectively. In addition, patients' age (OR=1.07, 95% CI 1.02-1.12) and percent stenosis after PCI in infarction-related segment (OR=1.04, 95% CI 1.01-1.08) were the independent factors of increased risk. The multivariate analysis showed that the independent predictors of flow decrease or no-reflow were: diabetes (OR=8.09, 95% CI 2.3-28.3), lesion length (per 1 mm OR= 1.26, 95% CI 1.08-1.49) and age (per 1 year OR=1.06, 95% CI 1.00-1.13). Direct stenting was not related to TMPG 0-1, flow decrease or no-reflow. Conclusions: In patients with acute myocardial infarction treated with PCI factors influencing microvascular flow and no-reflow occurrence can be identified.
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Background: Although there is evidence that suboptimal reperfusion has short-term prognostic impact in patients with ST-segment elevation acute coronary syndromes, there is little information about its associated factors. Objectives: The aim of this study was to analyze the factors associated with suboptimal reperfusion in patients with acute ST segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). Methods: Patients from the SCAR (Acute Coronary Syndromes in Argentina) registry diagnosed with acute STEMI undergoing PCI were included in the study. The association of classical clinical and laboratory variables and the leuko-glycemic index with suboptimal reperfusion was analyzed. Suboptimal reperfusion was defined as TIMI III post-PCI angiography with less than 50% ST-segment decrease in the ECG. Results: Overall, 197 patients (76.4%) out of 258 patients with STEMI met the inclusion criteria. Among them, 8.6% (n: 17) had suboptimal reperfusion, with an incidence of in-hospital death of 17.6% (n: 3) versus 1.7% (n: 3) in patients without suboptimal reperfusion (p=0.007). In the univariate analysis, variables associated with suboptimal reperfusion were diabetes [OR: 3.2 (1.09-9.43) p=0.026], previous revascularization [OR: 5.8 (1.74-19.07) p=0.008], leuko-glycemic index (>2159) [OR 3.7 (1.32-10.22) p=0.009], and pain-to-balloon time (>159 minutes) [OR: 6.9 (0.88- 53) p=0.045]. Age >70 years, male sex, high blood pressure, smoking, previous or anterior-wall infarction, and Killip and Kimball 3-4 and TIMI 0-1 flow on admission were not significantly different between patients with or without suboptimal reperfusion. Prior to the analysis, the cutoff point for the leuko-glycemic index associated with suboptimal reperfusion was established at 2159 points by ROC curve analysis (NPV: 94%), and the pain-to-balloon time at 159 min (NPV: 96%). In logistic regression analysis, only previous revascularization [OR: 5.3 (1.53-18.55)] and leuko-glycemic index [OR: 3.2 (1.11-9.28)] were associated with suboptimal reperfusion. Conclusions: Suboptimal reperfusion was significantly associated with a higher incidence of in-hospital death, while previous revascularization and LGI (>2159) were independent factors associated with suboptimal reperfusion. © 2018, Sociedad Argentina de Cardiologia. All rights reserved.
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Early mechanical reperfusion of the epicardial coronary artery by primary percutaneous coronary intervention (PCI) is the guideline-recommended treatment for ST-elevation myocardial infarction (STEMI). Successful restoration of epicardial coronary blood flow can be achieved in over 95% of PCI procedures. However, despite angiographically complete epicardial coronary artery patency, in about half of the patients perfusion to the distal coronary microvasculature is not fully restored, which is associated with increased morbidity and mortality. The exact pathophysiological mechanism of post-ischaemic coronary microvascular dysfunction (CMD) is still debated. Therefore, the current review discusses invasive and non-invasive techniques for the diagnosis and quantification of CMD in STEMI in the clinical setting as well as results from experimental in-vitro and in-vivo models focussing on ischaemic-, reperfusion- and inflammatory damage to the coronary microvascular endothelial cells. Finally, we discuss future opportunities to prevent or treat CMD in STEMI patients.
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Following primary percutaneous coronary intervention (PPCI) for ST segment elevation myocardial infarction, microvascular perfusion is often impaired secondary to thrombotic embolization. Intracoronary (IC) fibrinolytic administration may reduce thrombotic burden and distal embolization. The ICE-T-TIMI-49 study evaluated the feasibility and safety of low-dose IC tenecteplase (TNK) during PPCI. The study randomized 40 PPCI patients to a volume matched bolus of IC TNK (4 mg) (n = 20) or IC saline placebo (n = 20) before and following PPCI. The primary end point was percent diameter stenosis of the culprit lesion following first bolus. The primary end point did not differ between IC placebo (median 100%, interquartile range [IQR] 83.0,100.0) and IC TNK (median 100% stenosis, IQR 91.0,100.0; p = 0.522). However, the proportion of patients with reduction in thrombus following first bolus tended to be greater with IC TNK (placebo: 12.5% vs IC TNK: 40.0%, p = 0.133). Following PPCI, the corrected Thrombolysis In Myocardial Infarction (TIMI) frame count (cTFC) was lower (faster) with placebo (16.0 frames [IQR 12.0,24.0] vs 24.0 frames [22.0,32.0], p = 0.045) due to a trend towards greater frequency of hyperemia (cTFC <14), a marker of distal embolization (50.0% vs 8.3%, p = 0.056). There was no difference in TIMI major bleeds and no intracranial hemorrhage. In conclusion, treatment with low-dose IC TNK appears safe and well tolerated during PPCI. Although IC TNK administration did not improve percent stenosis, a trend towards reduced thrombus burden was demonstrated with less hyperemia (a marker of distal embolization). Our findings provide support for a large randomized study.
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Corrected thrombolysis in myocardial infarction frame count (cTFC) is an objective, simple, and reproducible method to assess coronary blood flow which is a surrogate for cardiovascular outcomes. It is important to learn which factors are associated with cTFC. The goal of this study was to determine predictive models for epicardial blood flow assessed by cTFC and develop a diagnostic predictive model that indicates the individualized assessment of epicardial blood flow prior to primary percutaneous coronary intervention. This is a retrospective study including 3205 patients with ST-segment elevation myocardial infarction who underwent pPCI. The primary outcome was cTFC. Multivariable linear regression analysis was performed. Subsequently, a nomogram was developed to predict cTFC according to the candidate predictors. Median age was 58; the number of male patients was 2381 (74.3%). Median value of cTFC was 22 and interquartile range (IQR): 16.5–28.0). Age, diabetes mellitus (DM), total ischemic time, systolic blood pressure (SBP), heart rate (HR), and history of statin use remained in both full and reduced models. Our model may potentially allow clinicians to identify patients at high risk for impaired epicardial perfusion.
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In acute ST-segment elevation myocardial infarction (STEMI), improvement in reperfusion strategies has contributed to improvement in mortality. Nonetheless up to 40-50% of patients who achieve satisfactory epicardial patency do not necessarily achieve patency at the coronary microvascular level, a condition referred to as the 'no-reflow' phenomenon. The 'no-reflow' phenomenon is associated with a worse prognosis at follow up. The pathogenic mechanisms underlying the 'no-reflow' phenomenon is complex and dynamic. This includes a variable combination of mechanisms including distal atherothrombotic embolisation, ischaemic injury, reperfusion injury and heightened susceptibility of coronary microcirculation to injury. Accurate detection of 'no-reflow' is crucial because it is independently associated with adverse ventricular remodelling and patient prognosis. The diagnosis of 'no-reflow' can be made using angiography, electrocardiography, nuclear scintigraphy, myocardial contrast echocardiography or cardiovascular magnetic resonance (CMR). Despite our improved understanding on the pathogenesis and diagnosis of 'no-reflow', the treatment of 'no-reflow' remains the 'Achilles heel' in the treatment of patients with acute myocardial infarction. Several therapeutic strategies have been tested for the prevention and treatment of 'no-reflow', however none have been associated with improvement in clinical outcomes. Therefore there exists a need for 'in-lab' tools that will be able to aid early identification of patients at increased risk of 'no-reflow'. This may enable patients at heightened risk of 'no-reflow' to be treated with the most appropriate individualised treatment early. We review the pathogenic mechanisms and diagnostic techniques of the 'no-reflow' phenomenon as well as the prevention and treatment strategies of the candidate mechanisms.
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Coronary-stent implantation is frequently performed for treatment of acute myocardial infarction. However, few studies have compared stent implantation with primary angioplasty alone. We designed a multicenter study to compare primary angioplasty with angioplasty accompanied by implantation of a heparin-coated Palmaz-Schatz stent. Patients with acute myocardial infarction underwent emergency catheterization and angioplasty. Those with vessels suitable for stenting were randomly assigned to undergo angioplasty with stenting (452 patients) or angioplasty alone (448 patients). The mean (+/-SD) minimal luminal diameter was larger after stenting than after angioplasty alone (2.56+/-0.44 mm vs. 2.12+/-0.45 mm, P<0.001), although fewer patients assigned to stenting had grade 3 blood flow (according to the classification of the Thrombolysis in Myocardial Infarction trial) (89.4 percent, vs. 92.7 percent in the angioplasty group; P=0.10). After six months, fewer patients in the stent group than in the angioplasty group had angina (11.3 percent vs. 16.9 percent, P=0.02) or needed target-vessel revascularization because of ischemia (7.7 percent vs. 17.0 percent, P<0.001). In addition, the combined primary end point of death, reinfarction, disabling stroke, or target-vessel revascularization because of ischemia occurred in fewer patients in the stent group than in the angioplasty group (12.6 percent vs. 20.1 percent, P<0.01). The decrease in the combined end point was due entirely to the decreased need for target-vessel revascularization. The six-month mortality rates were 4.2 percent in the stent group and 2.7 percent in the angioplasty group (P=0.27). Angiographic follow-up at 6.5 months demonstrated a lower incidence of restenosis in the stent group than in the angioplasty group (20.3 percent vs. 33.5 percent, P<0.001). In patients with acute myocardial infarction, routine implantation of a stent has clinical benefits beyond those of primary coronary angioplasty alone.
Article
Background —The corrected TIMI frame count (CTFC) is the number of cine frames required for dye to first reach standardized distal coronary landmarks, and it is an objective and quantitative index of coronary blood flow. Methods and Results —The CTFC was measured in 1248 patients in the TIMI 4, 10A, and 10B trials, and its relationship to clinical outcomes was examined. Patients who died in the hospital had a higher CTFC (ie, slower flow) than survivors (69.6±35.4 [n=53] versus 49.5±32.3 [n=1195]; P =0.0003). Likewise, patients who died by 30 to 42 days had higher CTFCs than survivors (66.2±36.4 [n=57] versus 49.9±32.1 [n=1059]; P =0.006). In a multivariate model that excluded TIMI flow grades, the 90-minute CTFC was an independent predictor of in-hospital mortality (OR=1.21 per 10-frame rise [95% CI, 1.1 to 1.3], an ≈0.7% increase in absolute mortality for every 10-frame rise; P 40 ( P =0.003). Although the risk of death, recurrent myocardial infarction, shock, congestive heart failure, or left ventricular ejection fraction ≤40% was 13.0% among patients with TIMI grade 3 flow (CTFC ≤40), the CTFC tended to segregate patients into lower-risk (CTFC ≤20, risk of adverse outcome of 7.9%) and higher-risk subgroups (CTFC >20 to ≤40, risk of adverse outcome of 15.5%; P =0.17). Conclusions —Faster (lower) 90-minute CTFCs are related to improved in-hospital and 1-month clinical outcomes after thrombolytic administration in both univariate and multivariate models. Even among those patients classified as having normal flow (TIMI grade 3 flow, CTFC ≤40), there may be lower- and higher-risk subgroups.
Article
Objectives: This study proposed to verify the prognostic power of early ST segment elevation resolution in patients with acute myocardial infarction from the Intravenous Streptokinase in Acute Myocardial Infarction study data base. Background: Data from a small prospective study suggested that use of two cutoff points for three different levels of ST segment resolution 3 h after the start of thrombolysis may be an efficient way to predict outcome in an individual patient. Methods: The three groups of ST segment resolution were defined as 1) complete resolution (> or = 70% [552 patients]) or only slight ST segment elevation (127 patients); 2) partial resolution (< 70% to 30% [475 patients]); 3) no resolution (< 30% to > 0% [362 patients]). Infarct size was measured from creatine kinase isoenzyme, MB fraction, release and from the number of Q waves. Left ventricular function was assessed in 818 patients 1 month after infarction. Results: For complete, partial and no ST segment resolution 3 h after the start of streptokinase or placebo infusion, enzyme release was 1.2, 1.8 and 2.1 IU/ml x h; number of Q waves 1.7, 2.5 and 3.0; and ejection fraction 60%, 53% and 49%, respectively (all adjusted p = 0.0000). Mortality rate at 21 days was 2.2%, 3.4% and 8.6%, respectively. No ST segment resolution was the most powerful independent predictor of early mortality (p = 0.0001). Survival rate curves at 6-year follow-up showed significant mortality differences with increasing divergence (p = 0.0003 anterior infarction; p = 0.005 inferior infarction). In subgroups with an overall higher risk of dying, mortality was strongly determined by the extent of early ST segment resolution. Conclusions: The extent of ST segment elevation resolution conveys useful early information about outcome in an individual patient after acute myocardial infarction.
Article
The extent of microvascular obstruction during acute coronary occlusion may determine the eventual magnitude of myocardial damage and thus, patient prognosis after infarction. By contrast-enhanced MRI, regions of profound microvascular obstruction at the infarct core are hypoenhanced and correspond to greater myocardial damage acutely. We investigated whether profound microvascular obstruction after infarction predicts 2-year cardiovascular morbidity and mortality. Forty-four patients underwent MRI 10 +/- 6 days after infarction. Microvascular obstruction was defined as hypoenhancement seen 1 to 2 minutes after contrast injection. Infarct size was assessed as percent left ventricular mass hyperenhanced 5 to 10 minutes after contrast. Patients were followed clinically for 16 +/- 5 months. Seventeen patients returned 6 months after infarction for repeat MRI. Patients with microvascular obstruction (n = 11) had more cardiovascular events than those without (45% versus 9%; P=.016). In fact, microvascular status predicted occurrence of cardiovascular complications (chi2 = 6.46, P<.01). The risk of adverse events increased with infarct extent (30%, 43%, and 71% for small [n = 10], midsized [n = 14], and large [n = 14] infarcts, P<.05). Even after infarct size was controlled for, the presence of microvascular obstruction remained a prognostic marker of postinfarction complications (chi2 = 5.17, P<.05). Among those returning for follow-up imaging, the presence of microvascular obstruction was associated with fibrous scar formation (chi2 = 10.0, P<.01) and left ventricular remodeling (P<.05). After infarction, MRI-determined microvascular obstruction predicts more frequent cardiovascular complications. In addition, infarct size determined by MRI also relates directly to long-term prognosis in patients with acute myocardial infarction. Moreover, microvascular status remains a strong prognostic marker even after control for infarct size.
Article
We investigated myocardial perfusion dynamics after thrombolysis and its clinical implications. We studied 39 patients with acute anterior myocardial infarction (AMI). Myocardial contrast echocardiography (MCE) was performed before and immediately after successful reflow with intracoronary injection of sonicated Ioxaglate. The average segmental score by two-dimensional echocardiography (graded 0, normal, to 3, akinetic/dyskinetic) and global ejection fraction (left ventricular ejection fraction, LVEF%) by left ventriculography were measured at 1 day and at 4 weeks after reflow. Hypokinesis in the infarct region was assessed by the centerline method and expressed in terms of standard deviations (regional wall motion [RWM]: SD/chord) of normal. Immediately after reflow, 30 of 39 patients (group A) showed significant contrast enhancement within the risk area. The other nine patients (23%, group B), however, showed the residual contrast defect in the risk area (myocardial no reflow). There were no significant differences in the elapsed time, angiographic collateral grade, and degree of residual stenosis between group A and group B. Before reflow, both groups exhibited similar levels of global and regional left ventricular function. Improvement in global (LVEF, average segmental score) and regional left ventricular function was greater in group A than in group B (average segmental score, 0.44 +/- 0.41 versus 0.97 +/- 0.36, p less than 0.01; LVEF, 56.4 +/- 13.4 versus 42.7 +/- 8.9, p less than 0.05; RWM, -1.87 +/- 0.85 versus -3.18 +/- 0.52, p less than 0.005). MCE demonstrates that angiographically successful reflow cannot be used as an indicator of successful myocardial reperfusion in AMI patients. The residual contrast defect in the risk area demonstrated immediately after reflow is a predictor of poor functional recovery of the postischemic myocardium.
Article
The objective of the study was to determine the coronary vasodilatory reserve in reperfused myocardium in patients with acute myocardial infarction and its relation to regional myocardial function. The study population consisted of 22 patients with acute myocardial infarction who underwent successful coronary angioplasty. The vasodilatory reserve in the reperfused myocardium was assessed quantitatively using computer-assisted digital subtraction cine-angiography immediately after angioplasty and at follow-up angiography before hospital discharge. Myocardial contrast medium appearance time and density were determined before and after pharmacological hyperemia induced by an intracoronary injection of 12.5 mg papaverine. Global and regional left ventricular functions were determined from contrast angiography. After papaverine, the mean contrast medium appearance time decreased significantly from 3.5 +/- 0.7 to 2.7 +/- 0.7 cardiac cycles (P < .000005) immediately after successful coronary angioplasty and from 3.8 +/- 0.7 to 2.7 +/- 0.9 cardiac cycles (P < .000005) at angiography before hospital discharge. The mean contrast medium density increased significantly from 48.7 +/- 13.8 to 61.0 +/- 19.0 pixels (P < .003) and from 49.6 +/- 19.7 to 80.3 +/- 29.6 pixels (P < .000005), respectively. As a consequence, the calculated coronary flow reserve increased significantly from 1.8 +/- 0.7 to 2.6 +/- 1.0 (P < .0008). The global ejection fraction increased significantly from 52 +/- 12% to 58 +/- 14% (P < .03), primarily because of a significant improvement in the regional myocardial function of the infarct zone from 20.8 +/- 9.0% to 26.0 +/- 10.5% (P < .001). Coronary flow reserve correlated well with regional myocardial function both during the acute phase (R = .79, P < .002) and at follow-up angiography (R = .82, P < .000004). Interestingly, coronary flow reserve measurement on reperfusion, immediately after angioplasty, correlated significantly with regional myocardial function at follow-up angiography (R = .81, P < .00003). The results indicate that there is a pharmacologically inducible vasodilatory reserve in reperfused ischemic myocardium after successful coronary angioplasty in patients with acute myocardial infarction and that this is increased at 10-day follow-up angiography. More important, the degree of reactive hyperemic response on reperfusion has a predictive value regarding the ultimate degree of recovery of regional myocardial function. Quantitative assessment of reperfusion may be useful in investigating the role of coronary reperfusion and salvage of myocardial function.
Article
Recent studies demonstrated that the "no reflow" phenomenon after coronary reflow implies the presence of advanced myocardial damage. In this study, we verified the prognostic value of the detection of this phenomenon by studying complications, left ventricular morphology, and in-hospital survival after acute myocardial infarction (AMI). The study population consisted of 126 patients with a first anterior AMI. All patients received coronary reflow within 24 hours of onset of symptoms and underwent myocardial contrast echocardiography (MCE) before and shortly after coronary reflow with an intracoronary injection of sonicated microbubbles. From contrast reperfusion patterns, patients were divided into two subsets: those with MCE no reflow (47 patients, 37%) and those with MCE reflow (79 patients). There was no difference in the frequency of arrhythmia or coronary events between the two subsets. Pericardial effusion and early congestive heart failure were observed more frequently in patients with MCE no reflow than in those with MCE reflow (26% versus 4%, P < .05; 45% versus 15%, P < .05, respectively). Congestive heart failure tended to be prolonged in those with MCE no reflow, and 3 patients (7%) of this subset died of pump failure. Left ventricular end-diastolic volume progressively increased in the convalescent stage in patients with MCE no reflow (early versus late, 145 +/- 43 versus 169 +/- 60 mL, P < .001), whereas it decreased in those with MCE reflow (154 +/- 42 versus 144 +/- 44 mL, P < .01). The substantial size of the MCE no reflow phenomenon at coronary reflow conveys useful information about an outcome of coronary intervention and left ventricular remodeling in individual patients with anterior wall AMI, although these are suggestive results in a limited number of patients.
Article
Although the Thrombolysis in Myocardial Infarction (TIMI) flow grade is valuable and widely used qualitative measure in angiographic trials, it is limited by its subjective and categorical nature. In normal patients and patients with acute myocardial infarction (MI) (TIMI 4), the number of cineframes needed for dye to reach standardized distal landmarks was counted to objectively assess an index of coronary blood flow as a continuous variable. The TIMI frame-counting method was reproducible (mean absolute difference between two injections, 4.7 +/- 3.9 frames, n=85). In 78 consecutive normal arteries, the left anterior descending coronary artery (LAD) TIMI frame count (36.2 +/- 2.6 frames) was 1.7 times longer than the mean of the right coronary artery (20.4 +/- 3.0) and circumflex counts (22.2 +/- 4.1, P < .001 for either versus LAD). Therefore, the longer LAD frame counts were corrected by dividing by 1.7 to derive the corrected TIMI frame count (CTFC). The mean CTFC in culprit arteries 90 minutes after thrombolytic administration followed a continuous unimodal distribution (there were not subpopulations of slow and fast flow) with a mean value of 39.2 +/- 20.0 frames, which improved to 31.7 +/- 12.9 frames by 18 to 36 hours (P < .001). No correlation existed between improvements in CTFCs and changes in minimum lumen diameter (r=-.05, P=.59). The mean 90-minute CTFC among nonculprit arteries (25.5 +/- 9.8) was significantly higher (flow was slower) compared with arteries with normal flow in the absence of acute MI (21.0 +/- 3.1, P < .001) but improved to that of normal arteries by 1 day after thrombolysis (21.7 +/- 7.1, P=NS). The CTFC is a simple, reproducible, objective and quantitative index of coronary flow that allows standardization of TIMI flow grades and facilitates comparisons of angiographic end points between trials. Disordered resistance vessel function may account in part for reductions in flow in the early hours after thrombolysis.
Article
A simple clinical method to stratify risk for patients who have had successful reperfusion therapy after myocardial infarction is attractive since it facilitates the tailoring of therapy. We investigated the clinical value of the 12-lead electrocardiogram (ECG), in 403 patients after successful reperfusion therapy by primary coronary angioplasty, in relation to infarct size measured by enzyme activity, left-ventricular function, and clinical outcome. ECGs were analysed to find the extent of the ST-segment-elevation resolution 1 h after reperfusion therapy. A normalised ST segment was seen in 51% of patients, a partly normalised ST segment in 34%, and 15% had no ST-segment-elevation resolution. Enzymatic infarct size and ejection fraction were related to the extent of the early resolution of the ST segment. The relative risk of death among patients with no resolution compared with patients with a normalised ST segment was 8.7 (95% CI 3.7-20.1), and that among patients with partial resolution compared with patients with a normalised ST segment was 3.6 (1.6-8.3). Our findings suggest that ECG patterns reflect the effectiveness of myocardial reperfusion. Patients for whom reperfusion therapy by primary angioplasty was successful and who had normalised ST segments had limited damage to the myocardium and an excellent outlook during follow-up. Patients with persistent ST elevation after reperfusion therapy may need additional interventions since they have more extensive myocardial damage and have a higher mortality rate.
Article
To determine whether there are sex differences in the demographics, treatment, and outcome of patients with acute myocardial infarction in the United States, data from the National Registry of Myocardial Infarction-I from September 1990 to September 1994 were examined. The National Registry of Myocardial Infarction-I is a national observational database consisting of 1234 US hospitals in which each hospital submits data from each patient with acute myocardial infarction to a central data collection center. For these analyses, the following variables were examined in 354 435 patients with acute myocardial infarction: demographics; use of medical therapy including thrombolytic agents; use of procedures including cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass surgery; length of hospital stay; adverse events (stroke, major bleeding, or recurrent myocardial infarction); and causes of death. In comparison with men, women experiencing acute myocardial infarction in the United States are older, with 55.7% older than 70 years. Women have a higher mortality rate than men even when controlled for age and die less often from arrhythmia but more often from cardiac rupture whether or not thrombolytic therapy is used. Treatment with aspirin, heparin, or beta-blockers is less frequent in women. When thrombolytic therapy is used, women are treated an average of almost 14 minutes later than men and experience a greater incidence of major bleeding. Cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass surgery are used less often in women. Observations from the National Registry of Myocardial Infarction-I document important sex differences in demographics, treatment, and outcome of patients with acute myocardial infarction in the United States.
Article
The primary objective of reperfusion therapies for acute myocardial infarction is not only restoration of blood flow in the epicardial coronary artery but also complete and sustained reperfusion of the infarcted part of the myocardium. We studied 777 patients who underwent primary coronary angioplasty during a 6-year period and investigated the value of angiographic evidence of myocardial reperfusion (myocardial blush grade) in relation to the extent of ST-segment elevation resolution, enzymatic infarct size, left ventricular function, and long-term mortality. The myocardial blush immediately after the angioplasty procedure was graded by two experienced investigators, who were otherwise blinded to all clinical data: 0, no myocardial blush; 1, minimal myocardial blush; 2, moderate myocardial blush; and 3, normal myocardial blush. The myocardial blush was related to the extent of the early ST-segment elevation resolution on the 12-lead ECG. Patients with blush grades 3, 2, and 0/1 had enzymatic infarct sizes of 757, 1143, and 1623 (P<0.0001), respectively, and ejection fractions of 50%, 46%, and 39%, respectively (P<0.0001). After a mean+/-SD follow-up of 1.9+/-1.7 years, mortality rates of patients with myocardial blush grades 3, 2, and 0/1 were 3%, 6%, and 23% (P<0.0001), respectively. Multivariate analysis showed that the myocardial blush grade was a predictor of long-term mortality, independent of Killip class, Thrombolysis In Myocardial Infarction grade flow, left ventricular ejection fraction (LVEF), and other clinical variables. In patients after reperfusion therapy, the myocardial blush grade as seen on the coronary angiogram can be used to describe the effectiveness of myocardial reperfusion and is an independent predictor of long-term mortality.
Article
The aim of this study was to evaluate the relation between myocardial perfusion and ST-segment changes in patients with acute myocardial infarction treated with successful direct angioplasty. Thirty-seven patients, successfully treated with direct angioplasty, underwent myocardial contrast echocardiography before and after angioplasty. The sum of ST-segment elevation divided by the number of the leads involved (ST-segment elevation index) was calculated at 1, 5, 10, 20, and 30 minutes after restoration of a Thrombolysis In Myocardial Infarction trial grade 3 flow. After recanalization, myocardial reperfusion within the risk area was observed in 26 patients, whereas a no-reflow phenomenon occurred in 11. In patients with myocardial reperfusion, the ST-segment elevation index progressively declined, whereas in patients with no reflow, no significant change was observed. Reduction of > or = 50% in the ST-segment elevation index occurred in 20 of the 26 patients with reflow and in 1 of the 11 with no reflow (p = 0.0002). An additional increase of > or = 30% in the ST-segment elevation index occurred in 3 patients with reflow and in 7 with no reflow (p = 0.003). Sensitivity, specificity, positive and negative predictive values, and accuracy of the reduction in the ST-segment elevation index for predicting microvascular reflow were 77%, 91%, 95%, 62%, and 81%, respectively. The corresponding values of the increase in ST-segment elevation index for predicting no reflow were 64%, 88%, 70%, 85%, and 81%, respectively. In conclusion, after successful angioplasty, different patterns of myocardial perfusion are associated with different ST-segment changes. Analysis of ST-segment changes predicts the degree of myocardial reperfusion.
Article
Apart from its established effects on vessel patency after percutaneous coronary revascularization, glycoprotein IIb/IIIa receptor blockade by abciximab may improve myocardial perfusion by inhibition of the interaction of platelets and platelet aggregates with the microvasculature. We investigated the effect of abciximab with stent placement in acute myocardial infarction. In a prospective randomized trial, patients undergoing stenting in acute myocardial infarction within 48 hours after onset of symptoms were randomly assigned to receive either standard-dose heparin or abciximab plus low-dose heparin. Immediately after the procedure and at 14-day angiographic follow-up, we assessed flow velocity in the recanalized vessel with the Doppler wire and regional wall motion by the centerline method. End points were changes in papaverine-induced peak flow velocities and in wall motion indices. We assigned 98 patients to standard heparin and 102 to abciximab. We obtained 152 paired flow measurements and 151 paired left ventricular function studies. Residual stenoses of the treated lesions did not differ between the 2 groups. Improvement of peak flow velocity (mean [95% CI]: 18.1 cm/s [13.6 to 22.6 cm/s], n=80, versus 10.4 cm/s [5.4 to 15.4 cm/s], n=72, P=0.024) and wall motion index (0.44 SD/chord [0.29 to 0.59 SD/chord], n=79 versus 0. 15 SD/chord [0.00 to 0.30 SD/chord], n=72, P=0.007) was significantly greater in patients assigned to abciximab than in those on heparin alone. At follow-up, the abciximab group had a higher global left ventricular ejection fraction than the heparin group (62% [59% to 65%] versus 56% [53% to 59%], P=0.003). Abciximab had important effects beyond the maintenance of large-vessel patency. It improved the recovery of microvascular perfusion and concomitantly enhanced the recovery of contractile function in the area at risk.
Article
AMI reperfusion by thrombolysis does not improve TIMI flow and LV function. The role of infarct-related artery (IRA) stenosis and superimposed changes in coronary vasomotor tone in maintaining LV dysfunction must be elucidated. Forty patients underwent diagnostic angiography 24 hours after thrombolysis. Seventy-two hours after thrombolysis, the culprit lesion was dilated with coronary stenting. During angioplasty, LV function was monitored by transesophageal echocardiography. Percent regional systolic thickening was quantitatively assessed before PTCA, soon after stenting, 15 minutes after stenting, and after phentolamine 12 microg/kg IC (n=10), the alpha1-blocker urapidil 600 microg/kg IV (n=10), or saline (n=10). Ten patients pretreated with beta-blockers received urapidil 10 mg IC. Coronary stenting significantly improved thickening in IRA-dependent and in non-IRA-dependent myocardium (from 27+/-15% to 38+/-16% and from 40+/-15% to 45+/-15%, respectively). Simultaneously, TIMI frame count decreased from 39+/-11 and 40+/-11 in the IRA and non-IRA, respectively, to 23+/-10 and 25+/-7 (P<0.05). Fifteen minutes after stenting, thickening worsened in both IRA- and non-IRA-dependent myocardium (to 19+/-14% and 28+/-14%, P<0.05), and TIMI frame count returned, in both the IRA and non-IRA, to the values obtained before stenting. Phentolamine and urapidil increased thickening to 36+/-17% and 41+/-14% in IRA and to 48+/-11% and 49+/-17% in non-IRA myocardium respectively, and TIMI frame count decreased to 16+/-6 and to 17+/-5, respectively. Changes were attenuated with beta-blocker pretreatment. Our finding that alpha-adrenergic blockade attenuates vasoconstriction and postischemic LV dysfunction supports the hypothesis of an important role of neural mechanisms in this phenomenon.
Article
Despite early recanalization of an occluded infarct artery, reperfusion at the level of the microcirculation may remain impaired owing to a process of microvascular reperfusion injury. Microvascular reperfusion injury was studied in 91 patients with acute myocardial infarction (AMI) by evaluation of the resolution of ST-segment elevation after successful PTCA. Impaired microvascular reperfusion, defined as the presence of persistent (>/=50% of initial value) ST-segment elevation (ST >/=50%) at the end of coronary intervention, was observed in 33 patients (36%) and was independently correlated with low systolic pressure on admission and high age. Patients >/=55 years of age with systolic pressures </=120 mm Hg were at high risk for development of impaired reperfusion compared with patients not meeting these criteria (72% versus 14%, P<0.001). Impaired microvascular reperfusion was associated with a more extensive infarction and worse clinical outcome at the 1-year follow-up: cardiac death rate, 15% versus 2% (ST >/=50% versus ST <50%, P=0.01); nonfatal MI rate, 9% versus 2% (P=0.1); and total major adverse cardiac event (MACE) rate, 45% versus 15% (P<0.005). ST >/=50% was the most important independent determinant of MACE with an adjusted risk ratio of 3.4. Impaired microvascular reperfusion, as evidenced by ST >/=50% after successful recanalization, occurs in more than one third of our AMI patients, especially in older patients with low systolic pressure. Its detrimental implications on clinical outcome reinforce the need to develop adjunctive agents that attenuate the process of reperfusion injury.
Article
The corrected TIMI frame count (CTFC) is the number of cine frames required for dye to first reach standardized distal coronary landmarks, and it is an objective and quantitative index of coronary blood flow. The CTFC was measured in 1248 patients in the TIMI 4, 10A, and 10B trials, and its relationship to clinical outcomes was examined. Patients who died in the hospital had a higher CTFC (ie, slower flow) than survivors (69. 6+/-35.4 [n=53] versus 49.5+/-32.3 [n=1195]; P=0.0003). Likewise, patients who died by 30 to 42 days had higher CTFCs than survivors (66.2+/-36.4 [n=57] versus 49.9+/-32.1 [n=1059]; P=0.006). In a multivariate model that excluded TIMI flow grades, the 90-minute CTFC was an independent predictor of in-hospital mortality (OR=1.21 per 10-frame rise [95% CI, 1.1 to 1.3], an approximately 0.7% increase in absolute mortality for every 10-frame rise; P<0.001) even when other significant correlates of mortality (age, heart rate, anterior myocardial infarction, and female sex) were adjusted for in the model. The CTFC identified a subgroup of patients with TIMI grade 3 flow who were at a particularly low risk of adverse outcomes. The risk of in-hospital mortality increased in a stepwise fashion from 0.0% (n=41) in patients with a 90-minute CTFC that was faster than the 95% CI for normal flow (0 to 13 frames, hyperemia, TIMI grade 4 flow), to 2.7% (n=18 of 658 patients) in patients with a CTFC of 14 to 40 (a CTFC of 40 has previously been identified as the cutpoint for distinguishing TIMI grade 3 flow), to 6.4% (35/549) in patients with a CTFC >40 (P=0.003). Although the risk of death, recurrent myocardial infarction, shock, congestive heart failure, or left ventricular ejection fraction </=40% was 13.0% among patients with TIMI grade 3 flow (CTFC </=40), the CTFC tended to segregate patients into lower-risk (CTFC </=20, risk of adverse outcome of 7. 9%) and higher-risk subgroups (CTFC >20 to </=40, risk of adverse outcome of 15.5%; P=0.17). Faster (lower) 90-minute CTFCs are related to improved in-hospital and 1-month clinical outcomes after thrombolytic administration in both univariate and multivariate models. Even among those patients classified as having normal flow (TIMI grade 3 flow, CTFC </=40), there may be lower- and higher-risk subgroups.
Article
Although improved epicardial blood flow (as assessed with either TIMI flow grades or TIMI frame count) has been related to reduced mortality after administration of thrombolytic drugs, the relationship of myocardial perfusion (as assessed on the coronary arteriogram) to mortality has not been examined. A new, simple angiographic method, the TIMI myocardial perfusion (TMP) grade, was used to assess the filling and clearance of contrast in the myocardium in 762 patients in the TIMI (Thrombolysis In Myocardial Infarction) 10B trial, and its relationship to mortality was examined. TMP grade 0 was defined as no apparent tissue-level perfusion (no ground-glass appearance of blush or opacification of the myocardium) in the distribution of the culprit artery; TMP grade 1 indicates presence of myocardial blush but no clearance from the microvasculature (blush or a stain was present on the next injection); TMP grade 2 blush clears slowly (blush is strongly persistent and diminishes minimally or not at all during 3 cardiac cycles of the washout phase); and TMP grade 3 indicates that blush begins to clear during washout (blush is minimally persistent after 3 cardiac cycles of washout). There was a mortality gradient across the TMP grades, with mortality lowest in those patients with TMP grade 3 (2.0%), intermediate in TMP grade 2 (4.4%), and highest in TMP grades 0 and 1 (6.0%; 3-way P=0.05). Even among patients with TIMI grade 3 flow in the epicardial artery, the TMP grades allowed further risk stratification of 30-day mortality: 0.73% for TMP grade 3; 2.9% for TMP grade 2; 5.0% for TMP grade 0 or 1 (P=0.03 for TMP grade 3 versus grades 0, 1, and 2; 3-way P=0.066). TMP grade 3 flow was a multivariate correlate of 30-day mortality (OR 0.35, 95% CI 0.12 to 1.02, P=0.054) in a multivariate model that adjusted for the presence of TIMI 3 flow (P=NS), the corrected TIMI frame count (OR 1.02, P=0.06), the presence of an anterior myocardial infarction (OR 2.3, P=0.03), pulse rate on admission (P=NS), female sex (P=NS), and age (OR 1.1, P<0.001). Impaired perfusion of the myocardium on coronary arteriography by use of the TMP grade is related to a higher risk of mortality after administration of thrombolytic drugs that is independent of flow in the epicardial artery. Patients with both normal epicardial flow (TIMI grade 3 flow) and normal tissue level perfusion (TMP grade 3) have an extremely low risk of mortality.
Article
This study investigated whether the extent of perfusion defect determined by intravenous myocardial contrast echocardiography (MCE) in patients with acute myocardial infarction (AMI) treated by primary percutaneous transluminal coronary angioplasty (PTCA) relates to coronary flow reserve (CRF) for assessment of myocardial reperfusion and is predictive for left ventricular recovery. Twenty-five patients with first AMI underwent intravenous MCE with NC100100 with intermittent harmonic imaging before PTCA and after 24 hours. MCE before PTCA defined the risk region and MCE at 24 hours the "no-reflow" region. The no-reflow region divided by the risk region determined the ratio to the risk region. CFR was assessed immediately after PTCA and 24 hours later. Left ventricular wall motion score indexes were calculated before PTCA and after 4 weeks. CFR at 24 hours defined a recovery (CFR >/=1.6; n=17) and a nonrecovery group (CFR <1.6; n=8). Baseline CFR did not differ between groups. MCE ratio to the risk region was smaller in the recovery group compared with the nonrecovery group (34+/-49% vs 81+/-46%, P=0.009). A ratio to the risk region of </=50% defined an MCE reperfusion group. It was associated with improvement of CFR from 1.67+/-0.47 at baseline to 2. 15+/-0.53 at 24 hours (P<0.001) and of regional wall motion score index from 2.6+/-0.5 to 1.9+/-0.5 at 4 weeks (P<0.001). Intravenous MCE can be used to define perfusion defects after AMI. Assessment of microcirculation by MCE corresponds to evaluation by CFR. Serial intravenous MCE has the potential to identify patients likely to have improved left ventricular function after AMI.
Article
Successful reperfusion after acute myocardial infarction (MI) has traditionally been considered to be restoration of epicardial patency, but increasing evidence suggests that disordered microvascular function and inadequate myocardial tissue perfusion are often present despite infarct vessel patency. Thus, optimal reperfusion is being redefined to include intact microvascular flow and restored myocardial perfusion, as well as sustained epicardial patency. Coronary angiography has been used as the gold standard to define failed reperfusion, according to the Thrombolysis In Myocardial Infarction (TIMI) flow grades. However, new angiographic techniques, including the corrected TIMI frame count and myocardial blush grade, have been used to show that epicardial TIMI flow grade 3 may be an incomplete measure of reperfusion success. Furthermore, evolving noninvasive diagnostic techniques, including measurement of infarct size with cardiac marker release patterns or technetium-99m-sestamibi single-photon emission computed tomographic imaging and analysis of ST segment resolution appear to be useful complements to angiography for the assessment of myocardial tissue reperfusion. Promising adjunctive therapies that target microvascular dysfunction, including platelet glycoprotein IIb/IIIa inhibitors, and agents designed to improve tissue perfusion and attenuate reperfusion injury are being evaluated to further improve clinical outcomes after acute MI. To accelerate development of these new reperfusion regimens, an integrated approach to phase II clinical trials that incorporates multiple efficacy variables, including angiography and noninvasive biomarkers of microvascular dysfunction, should be considered. Thus, as the reperfusion era moves into the next millennium, the open-artery hypothesis is expected to shift downstream and guide efforts to further improve myocardial salvage and clinical outcomes after acute MI.
Article
Background: The TIMI myocardial perfusion grade (TMPG) and ST-segment resolution both reflect perfusion and are associated with mortality after thrombolysis for acute myocardial infarction. We hypothesized that these measures would also be associated with infarct size by single photon emission computed tomography (SPECT). Methods and Results- In the LIMIT AMI trial (Limitation of Myocardial Injury following Thrombolysis in Acute Myocardial Infarction) of lytic monotherapy versus lytic plus rhuMAb CD18, early 90-minute TMPG (n=221) and ST segment resolution (n=242) were compared with subsequent SPECT Technetium-99 m Sestamibi, measuring the percentage of the left ventricle with no Sestamibi uptake. Infarct sizes were larger with TMPG 0 or 1 (a closed or stained myocardium) than with TMPG 2 or 3 (open myocardium, median 13% versus 7%, P=0.004). Infarcts were also larger in patients with no ST segment resolution (median 15%) or incomplete resolution (11%) than in those with complete resolution (6%, overall P=0.0001). The difference in infarct size by TMPG persisted when stratified by category of ST resolution. Conclusions: There may be a pathophysiological link between early restoration of tissue-level perfusion and reduced subsequent infarct size that may partially explain why these early angiographic and electrocardiographic measures are associated with long-term survival.
Article
We sought to evaluate and validate the ability of the angiographic myocardial blush grade to risk stratify patients after successful angioplasty in acute myocardial infarction (AMI). Although epicardial Thrombolysis In Myocardial Infarction (TIMI)-3 flow is restored in >90% of patients undergoing primary percutaneous coronary intervention (PCI), normal myocardial perfusion may be present less frequently and may detrimentally impact survival. A cohort of 173 consecutive patients undergoing intervention within 24 h of AMI onset were studied. High-risk features of this population included failed thrombolysis in 39%, cardiogenic shock in 17% and saphenous vein graft culprit in 11% of patients. Despite the restoration of TIMI-3 flow in 163 (94.2%) patients, myocardial perfusion, as evidenced by normal contrast opacification of the myocardial bed subtended by the infarct artery (myocardial blush), was normal in only 29.4% of patients with TIMI-3 flow following PCI, and in no patient with TIMI 0 to 2 flow. In patients in whom TIMI-3 flow was restored, survival was strongly dependent on the myocardial perfusion grade; one-year cumulative mortality was 6.8% with normal myocardial blush, 13.2% with reduced myocardial blush and 18.3% in patients with absent myocardial blush (p = 0.004). Abnormal myocardial perfusion is present in most patients following primary or rescue PCI in AMI, despite restoration of brisk epicardial coronary flow. In high risk patients achieving TIMI-3 flow after intervention, the myocardial blush score may be used to stratify prognosis into excellent, intermediate and poor survival. Further study is warranted to examine whether adjunctive mechanical or pharmacologic strategies can further improve myocardial perfusion and survival of patients with acute myocardial infarction undergoing intervention.
Article
Although 90-minute TIMI flow grades (TFGs), corrected TIMI frame counts (CTFCs), and TIMI myocardial perfusion grades (TMPGs) have been associated with 30-day outcomes, we hypothesized that these indices would be related to long-term outcomes after thrombolytic administration. As a substudy of the TIMI 10B trial (tissue plasminogen activator versus tenecteplase), 49 centers carried out 2-year follow-up. TIMI grade 2/3 flow (Cox hazard ratio [HR] 0.41, P=0.001), reduced CTFCs (faster flow, P=0.02), and an open microvasculature (TMPG 2/3) (HR 0.51, P=0.038) were all associated with improved 2-year survival. Rescue percutaneous coronary intervention (PCI) of closed arteries (TFG 0/1) at 90 minutes was associated with reduced mortality (P=0.03), and mortality trended lower with adjunctive PCI of open (TFG 2/3) arteries (P=0.11). In a multivariate model correcting for previously identified correlates of mortality (age, sex, pulse, left anterior descending coronary artery infarction, and any PCI during initial hospitalization), patency (TFG 2/3) (HR 0.32, P<0.001), CTFC (P=0.01), and TMPG 2/3 remained associated with reduced mortality (HR 0.46, P=0.02). Both improved epicardial flow (TFG 2/3 and low CTFCs) and tissue-level perfusion (TMPG 2/3) at 90 minutes after thrombolytic administration are independently associated with improved 2-year survival, suggesting complementary mechanisms of improved long-term survival. Although rescue PCI reduced long-term mortality, improved microvascular perfusion (TMPG 2/3) before PCI was also related to improved mortality independently of epicardial blood flow and the performance of rescue or adjunctive PCI. Further prospective trials are warranted to re-examine the benefit of early PCI with thrombolysis.
The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction
The GUSTO Angiographic Investigators. The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. N Engl J Med 1993;329:1615-22.
A randomized trial of primary angioplasty compared to heparin-coated stent implantation for acute myocardial infarction
  • C L Grines
  • D Cox
  • G W Stone
Grines CL, Cox D, Stone GW, et al. A randomized trial of primary angioplasty compared to heparin-coated stent implantation for acute myocardial infarction. N Engl J Med 1999;341:1949 -56.
A randomized trial of primary angioplasty compared to heparin-coated stent implantation for acute myocardial infarction
  • Grines
Extent of early ST segment elevation resolution
  • Schröder
TIMI myocardial perfusion grade and ST segment resolution
  • Angeja