Relation between neutrophil counts on admission, microvascular injury, and left ventricular functional recovery in patients with an anterior wall first acute myocardial infarction treated with primary coronary angioplasty

Increased neutrophil counts have been associated with an increased risk of adverse clinical events after acute myocardial infarction (AMI). We examined the association of neutrophil counts on admission with degree of microvascular injury and left ventricular functional recovery after primary coronary angioplasty in AMI. We studied 116 patients with a first anterior wall AMI who underwent primary coronary angioplasty within 12 hours of onset. Patients were categorized into 3 groups based on initial neutrophil count: low (<5,000/mm(3)), intermediate (5,000 to 10,000/mm(3)), and high (>10,000/mm(3)). Coronary flow velocity parameters were assessed immediately after reperfusion using a Doppler guidewire. We defined severe microvascular injury as the presence of systolic flow reversal and a diastolic deceleration time <600 ms. Echocardiographic wall motion was analyzed before revascularization and 4 weeks after revascularization. In patients with a high neutrophil count, systolic flow reversal was more frequently observed, diastolic deceleration time was shorter, and coronary flow reserve was lower. By regression analysis, neutrophil count significantly correlated with diastolic deceleration time (r = -0.38, p <0.0001), coronary flow reserve (r = -0.33, p = 0.0004), and score for change in wall motion (r = -0.36, p = 0.0004). Multivariate analysis showed that neutrophil count on admission was an independent predictor of severe microvascular injury (odds ratio 2.94, p = 0.02). In conclusion, neutrophilia on admission is associated with impaired microvascular reperfusion and poor functional recovery after primary coronary angioplasty.     

Preinfarction angina limits myocardial infarction size in nondiabetic patients treated with primary coronary angioplasty

OBJECTIVE: To evaluate myocardial necrosis extent after myocardial infarction (MI) and reperfusion with primary coronary angioplasty in nondiabetic patients and the relationship with unstable preinfarction angina (PA). DESIGN: Prospective cohort study. SETTING: Studies suggest PA limits infarct size. This effect is questioned in patients treated with primary coronary angioplasty. PATIENTS: Seventy-eight, nondiabetic, consecutive MI patients. INTERVENTIONS: Primary coronary angioplasty and scintigraphic study to assess the myocardial infarct size. MAIN OUTCOME MEASURES: Scintigraphic myocardial infarct size. RESULTS: There were 32 patients with PA (PA +) and 46 without PA (PA -) in the 24-h period prior to MI onset. There were no significant differences in the baseline characteristics between the two groups. The scintigraphy indicated myocardial infarct size significantly smaller in PA + patients: mean, 18.0% (SD, 14.7) vs 27.0% (SD, 20.1) [p = 0.033]. This occurs even though Thrombolysis in Myocardial Infarction grade 3 flow achieved in both groups was similar (84.8% vs 84.4%, p = 1.000). We found a higher percentage of ST-segment resolution (>/= 70%) in PA + patients (65.6% vs 45.7%, p = 0.082) together with a lower incidence of left ventricular systolic dysfunction (3.2% vs 18.6%, p = 0.071). CONCLUSIONS: PA exerts a beneficial effect in nondiabetic patients with ST-segment elevation acute MI even when treated with primary PCI. The infarct size is limited, and left ventricular systolic function is preserved. The effects may be related to a better preservation of tissue reperfusion in patients with PA.     

Impaired coronary flow reserve immediately after coronary angioplasty in patients with acute myocardial infarction.

OBJECTIVE--To examine coronary flow reserve immediately after emergency coronary angioplasty in patients with acute myocardial infarction. DESIGN--A 3 F coronary Doppler catheter was used to measure coronary blood flow velocity in the infarct artery and in the non-infarct artery. Maximal hyperaemia was produced by 10 mg of intracoronary papaverine and coronary flow reserve was calculated. PATIENTS--11 patients with acute myocardial infarction undergoing both emergency coronary angioplasty (4.7 (3.6) h after the onset of chest pain (mean (SD))) and at follow up catheterisation 16 (4) days after angioplasty. SETTING--Hiroshima City Hospital. RESULTS--There was no stenosis of > or = 50% in the coronary artery of interest. Immediately after coronary angioplasty the mean (1 SD) coronary flow reserve of the infarct artery was significantly less than that of the non-infarct artery (1.4 (0.4) v 2.8 (0.8), p < 0.001). At follow up catheterisation the coronary flow reserve of the infarct artery increased almost to the value of the non-infarct artery (2.8 (1.2) v 3.1 (0.8) p = NS). CONCLUSION--The coronary flow reserve in the infarct region was severely impaired immediately after reperfusion, even with a widely patent infarct artery. This could restrict the beneficial effects of reperfusion therapy, especially when there is a severe residual stenosis.     

Catheter reperfusion for failed emergency coronary angioplasty without subsequent bypass surgery

A transluminal intracoronary reperfusion catheter was used in eight patients, seven with acute myocardial infarction and one with unstable angina after failed emergency coronary angioplasty. After placement of the reperfusion catheter across the occlusion, symptoms of ischemia resolved in each patient. Chest pain recurred 3 hr later in a single patient who underwent successful repeat angioplasty. The catheter was withdrawn within 6 hr after introduction. Control coronary angiography showed a patent vessel in all but one. Repeat angioplasty or bypass surgery was unnecessary. During 1 year mean follow-up time all patients remained free of symptoms. The reperfusion catheter is a safe and effective means of perfusing a coronary artery after failure of thrombolytic therapy and coronary angioplasty in cases where emergency bypass surgery is not performed because operative morbidity is expected to outweigh the benefit of myocardial salvage, or when it cannot be immediately organized.     

Usefulness of coronary flow reserve immediately after primary coronary angioplasty for acute myocardial infarction in predicting long-term adverse cardiac events

Coronary flow reserve (CFR) evaluated immediately after reperfusion is thought to reflect the degree of microvascular injury and predict left ventricular (LV) functional recovery after acute myocardial infarction. It was hypothesized that CFR immediately after reperfusion would be predictive of the occurrence of long-term adverse cardiac events. Using a Doppler guidewire, CFR was evaluated immediately after primary coronary angioplasty in 118 consecutive patients with first anterior acute myocardial infarctions. Adverse cardiac events combining cardiac death, recurrent myocardial infarction, and congestive heart failure were recorded during an average follow-up period of 62 +/- 32 months. Using receiver-operating characteristic analysis, CFR 1.3 (n = 68). Patients with CFR 1.3. CFR was significantly correlated with the LV ejection fraction at 4 weeks (r = 0.50, p <0.0001) and LV end-diastolic volume at 4 weeks (r = -0.43, p <0.0001). Kaplan-Meier survival analysis showed a higher incidence of adverse cardiac events in patients with CFR 相似文献   

Variations of coronary blood flow measured by intracoronary doppler in the acute phase of myocardial infarction before and after revascularization by angioplasty]

The authors studied the changes in coronary blood flow before, during and after reperfusion by angioplasty of the disease coronary vessel responsible for myocardial infarction using intracoronary Doppler. Forty patients aged 60.2 +/- 15.4 years, admitted for primary myocardial infarction (inferior: 22, anterior: 18) were included. Before reperfusion, the peak velocity of the collateral coronary circulation was 14.8 +/- 8.1 cm/s. The flow was bidirectional, mainly retrograde (N = 32), negative (N = 1) or positive (N = 5). The five Rentrop 0 patients had velocities similar to Rentrop 1, 2 or 3 patients (Rentrop 0: 14.9 +/- 6.4 cm/s; Rentrop 1: 12.3 +/- 9.9 cm/s; Rentrop 2: 15.2 +/- 8.2 cm/s; Rentrop 3: 17.5 +/- 6.3 cm/s). Patients with TIMI 3 reperfusion flow had the highest APV Doppler velocities (average peak velocities during the cardiac cycle) (APV TIMI 3 = 20.2 cm/s versus APV TIMI 1 and 2 = 10.9 cm/s, p = 0.05). After angioplasty, the APV was 18.7 +/- 10.4 cm/s (p < 0.001). Diastolic flow was dominant. Seventeen patients had retrograde systolic flow, 12 had minimal systolic flow and 17 had a steep diastolic deceleration slope. Intracoronary Doppler demonstrates the wide range of coronary flow in TIMI 3 flow patients, both from the morphological and the quantitative points of view, which seems to be independent of the presence of residual stenosis and could be related to abnormalities of the microcirculation. This could allow identification of a subgroup of patients at high risk and candidates for a complementary therapeutic intervention (intra-aortic balloon pumping...).     

Myocardial salvage after failed coronary angioplasty

Patients undergoing coronary angioplasty have a 2% to 7% risk of requiring emergency coronary artery bypass graft surgery for impending infarction. These patients provide a unique model of early reperfusion because the exact time of compromise to blood flow and the composition of the reperfusion solution are known. However, the amount of myocardium salvaged is unknown. Between December 1981 and September 1985, 859 patients underwent coronary angioplasty. Forty-two patients had emergency surgery for objective evidence of impending infarction. Five patients died. Thirty-six patients were contacted for follow-up; 21 (58%) of 36 had a radionuclide ventriculogram performed at a mean of 39 +/- 13 months after surgery. These radionuclide studies were compared with the patient's preangioplasty contrast ventriculogram. One patient had a myocardial infarction 3 years after surgery. Eleven (55%) of the remaining 20 patients had a normal radionuclide ventriculogram at follow-up study (ejection fraction 65 +/- 9%). Five (25%) of the 20 patients had a depressed ejection fraction (46 +/- 4%) with wall motion abnormalities, but these were unchanged from the preangioplasty studies. Four patients (20%) had a significant decrease in ejection fraction over baseline (37 +/- 10%) with new wall motion abnormalities. In conclusion: 1) there is an 80% chance that left ventricular function will be unchanged at 3 year follow-up study in patients surviving emergency bypass grafting for failed angioplasty; 2) these data suggest that early revascularization for impending infarction in this setting is associated with a good late outcome; and 3) this patient group offers a unique opportunity to study the effects of early reperfusion in a human model.     

How long can a coronary reperfusion catheter be placed in acute coronary occlusion following failed transluminal coronary angioplasty? A case report

A coronary reperfusion catheter (CRC) is designed to preserve antegrade coronary flow when abrupt coronary closure occurs during percutaneous transluminal coronary angioplasty (PTCA). Insertion of the catheter to an occluded coronary artery for a few hours has been reported to be effective for myocardial salvage: however, it is unknown how long the catheter can be kept in place without causing extension of myocardial ischemia. The authors experienced a case in which the CRC was kept in place for twenty-four hours for anticoagulant therapy of an occluded coronary artery following failure of PTCA. This case suggests that adequate anticoagulant therapy can prolong the period during which a CRC can be kept in place if emergency coronary bypass surgery cannot be performed immediately after failure of coronary angioplasty.     

A randomized trial of coronary stenting versus balloon angioplasty as a rescue intervention after failed thrombolysis in patients with acute myocardial infarction

OBJECTIVES: This study was conducted to assess whether coronary stenting produces better results compared with balloon angioplasty in patients with acute myocardial infarction (AMI) after failed thrombolysis. BACKGROUND: Little evidence exists on the value of rescue mechanical reperfusion after failed thrombolysis. METHODS: This open-label, randomized study enrolled 181 patients with AMI referred for failed thrombolysis performed within the previous 24 h. The patients had to have a Thrombolysis In Myocardial Infarction (TIMI) flow grade of 相似文献   

Repeated assessment of coronary flow velocity pattern in patients with first acute myocardial infarction

OBJECTIVES: The aim of this study was to evaluate the coronary blood flow velocity pattern immediately and 24 h after percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) in relation to myocardial reperfusion and follow-up left ventricular (LV) function. BACKGROUND: Analysis of coronary blood flow velocity pattern after AMI may provide information about microvascular damage and the occurrence of a reperfusion injury. METHODS: Measurement of coronary blood flow velocity pattern was performed immediately after PTCA and after 24 h in 25 patients with first AMI using a Doppler guidewire. Measurements were related to reperfusion determined by intravenous myocardial contrast echocardiography (MCE) performed before PTCA and at 24 h and to LV function at four weeks. RESULTS: Using MCE, 13 patients showed reperfusion and 12 patients showed nonreperfusion. Compared with patients with reperfusion, patients with MCE nonreperfusion had a lower systolic peak flow velocity immediately after PTCA (10.0 +/- 0.3 cm/s vs. 19.3 +/- 0.8 cm/s, respectively) and after 24 h (12.3 +/- 0.4 cm/s vs. 21.3 +/- 0.1 cm/s, respectively, p = 0.0022), more frequent early systolic retrograde flow (6/12 vs. 0/13, p = 0.0052 immediately after PTCA and 24 h later) and a shorter diastolic deceleration time immediately after PTCA (483 +/- 6 ms vs. 737 +/- 0 ms, respectively) and after 24 h (551 +/- 9 ms vs. 823 +/- 2 ms, respectively, p = 0.0091). Similarly, patients with impaired LV function at four weeks had altered coronary flow pattern compared with patients with preserved function. The coronary flow velocity pattern showed a tendency for improvement after 24 h in the reperfusion and the nonreperfusion groups. CONCLUSIONS: The coronary flow velocity pattern immediately and 24 h after PTCA for AMI relates to myocardial perfusion determined by MCE and LV function at four weeks. The flow velocity pattern shows slight improvement during the first 24 h after revascularization, indicating the absence of a major reperfusion injury.     

Relationship between tissue reperfusion and postinfarction left ventricular remodelling in patients with anterior wall myocardial infarction treated with primary coronary angioplasty

INTRODUCTION: Pathological left ventricular remodelling is considered the main cause of heart failure in patients after myocardial infarction. AIM: The purpose of this study was to evaluate correlations between the degree of coronary microvascular reperfusion assessed by means of the angiographic myocardial blush grade (MBG) scale and adverse left ventricular remodelling in patients with acute myocardial infarction treated with primary coronary angioplasty. METHODS: This study involved 92 consecutive patients, hospitalised because of their first anterior wall myocardial infarction, who underwent successful (TIMI-3 grade flow) primary coronary angioplasty. Angiographic myocardial reperfusion parameters (MBG, corrected TIMI Frame Count) were assessed. Three days and 6 months after the index PCI all patients underwent an echocardiographic examination and such parameters as end-diastolic volume (EDV), left ventricular ejection fraction (EF) and contractility index (WMSI) were calculated. RESULTS: The patients were divided into two groups: group 1 with impaired myocardial reperfusion (MBG 0-1) (n=32) and group 2 with adequate tissue reperfusion (MBG 2-3) (n=60). Negative left ventricular remodelling was observed more frequently in group 1 than in group 2 (28.1% vs 10%, p=0.029). More patients in group 1 presented heart failure symptoms (56.3% vs 25%, p=0.013). CONCLUSIONS: Failure of tissue reperfusion assessed by means of angiographic indices (MBG 0-1) in patients with myocardial infarction treated with primary coronary angioplasty is associated with a higher rate of adverse myocardial remodelling and heart failure at 6 months after myocardial infarction.     

Benefit of coronary reperfusion before intervention on outcomes after primary angioplasty for acute myocardial infarction

Primary percutaneous transluminal coronary angioplasty has become the preferred reperfusion strategy for acute myocardial infarction in most institutions with interventional facilities and experienced operators. The benefit of establishing coronary reperfusion, with or without pharmacologic therapy, before primary angioplasty has not been established. Consecutive patients (n = 1,490) with acute myocardial infarction treated with aspirin and heparin followed by primary percutaneous transluminal coronary angioplasty were followed for 13 years. Follow-up angiography was obtained in 737 patients at 7.7 months. Thrombolysis In Myocardial Infarction (TIMI) 2 to 3 flow in the infarct artery at initial angiography was present in 18.3% of patients, and TIMI 0 to 1 flow in 81.7% of patients. Baseline variables were similar between the 2 groups, except patients with initial TIMI 2 to 3 flow had significantly less cardiogenic shock (1.7% vs 9.4%, p <0.0001) and a lower incidence of depressed ejection fraction <40% (12.6% vs 19.9%, p = 0.007). Procedural success was better in patients with initial TIMI 2 to 3 flow (97.4% vs 93.8%, p = 0.02), and catheterization laboratory events were less frequent. Patients with initial TIMI 2 to 3 flow had lower peak creatine kinase values (1,328 vs 2,790 IU/L, p <0.0001), higher acute ejection fraction (54.3% vs 51.6%, p = 0.05), higher late ejection fraction (59.2% vs 54.9%, p = 0.004), and lower 30-day mortality (4.8% vs 8.9%, p = 0.02). These data indicate that when reperfusion occurs before primary angioplasty, outcomes are strikingly better with less cardiogenic shock, improved procedural outcomes, smaller infarct size, better preservation of left ventricular function, and reduced mortality. This should encourage new strategies to establish reperfusion before "primary" angioplasty with "catheterization laboratory friendly" platelet inhibitors and/or low-dose thrombolytic drugs.     

Status of the myocardium and infarct-related coronary artery in 19 necropsy patients with acute recanalization using pharmacologic (streptokinase, r-tissue plasminogen activator), mechanical (percutaneous transluminal coronary angioplasty) or combined types of reperfusion therapy

In acute myocardial infarction, myocardial salvage is dependent on rapid restoration of blood flow. Pharmacologic (streptokinase, recombinant tissue-type plasminogen activator), mechanical (percutaneous transluminal coronary angioplasty, guide wire perforation) or combined forms of reperfusion therapy can accomplish this goal, but their effects on infarcted myocardium and vessel occlusion site have not been compared at necropsy. The heart of 19 necropsy patients who had received various forms of acute reperfusion therapy was studied: 14 had pharmacologic or combined forms of reperfusion therapy (13 streptokinase and 1 tissue-type plasminogen activator, including 4 with combined balloon angioplasty) and 5 had had purely mechanical (balloon angioplasty) reperfusion therapy. Reperfusion was initially clinically successful in all 19 patients with the average time from onset of symptoms to reperfusion being 3.7 hours. Necropsy observations separated the 19 patients into distinct subgroups based on changes in the myocardium and infarct-related coronary arteries. Of the 19 patients, 14 (74%) had hemorrhagic myocardial infarction and they all received pharmacologic or combined forms of reperfusion therapy. The remaining five patients (26%) had nonhemorrhagic (anemic) infarction and were treated with balloon angioplasty therapy alone. Increased luminal cross-sectional area was present in 8 of 9 patients with acute balloon angioplasty but severe coronary atherosclerotic plaque remained in 9 of 10 patients without acute balloon angioplasty. Severe hemorrhage surrounded angioplasty sites in all four patients who also received streptokinase or tissue-type plasminogen activator. Severe bleeding at the angioplasty site compromised the dilated coronary lumen in one patient. No patient with angioplasty alone had intraplaque bleeding. Thus, acute coronary balloon angioplasty reperfusion therapy alone appears to avoid the potentially adverse effects of myocardial and intraplaque hemorrhage while simultaneously increasing luminal cross-sectional area at the site of acute occlusion.     

Angiographic findings and catheterization laboratory events in patients with primary coronary angioplasty or streptokinase therapy for acute myocardial infarction

Background: The purpose of this study was to evaluate catheterizationlaboratory events and angiographic findings in patients randomlyassigned to undergo primary coronary angioplasty or to receiveintravenous streptokinase for acute myocardial infarction. Methods: We analysed angiographic data in 301 patients withacute myocardial infarction, randomly assigned to undergo primarycoronary angioplasty without antecedent thrombolytic therapyor to receive intravenous streptokinase therapy. Follow-up coronaryangiography was preferably performed after 3 months. AII angiogramswere analysed with a quantitative coronary analysis system. Results: Of the 152 patients assigned to angioplasty treatment,140 underwent this procedure with a success rate of 97%. Theresidual diameter stenosis of the infarct-related vessel immediatelyafter angioplasty was 27 ± 15% and there were major eventsin 14% of the patients in the catheterization laboratory. Atfollow-up angiography after a mean interval of 92 days in theangioplasty assigned patients, a diameter stenosis of 35 ±22% was observed in this group. The restenosis rate was 28%and the reocclusion rate 5%. A Thrombolysis in Myocardial Infarction(TIMI) grade 2 flow immediately after angioplasty was predictivefor reocclusion at follow-up (P= 0.001). In the streptokinaseassigned patients (149) the infarct-related vessel was patentat follow-up angiography after a mean of 22 days in 66% of thepatients with a mean residual diameter stenosis of 77 ±20%. Conclusion: Primary coronary angioplasty is a highly effectiveand safe reperfusion modality for patients with acute myocardialinfarction. However, TIMI grade 2 flow through the infarct-relatedvessel immediately after angioplasty is a predictor of reocclusion.     

Coronary flow velocity immediately after primary coronary stenting as a predictor of ventricular wall motion recovery in acute myocardial infarction

OBJECTIVES

The purpose of this study was to examine the relationship between the pattern of coronary blood flow velocity immediately after successful primary stenting and the recovery of left ventricular (LV) wall motion in patients with acute myocardial infarction (AMI).

BACKGROUND

It is difficult to predict the recovery of LV wall motion immediately after direct angioplasty in AMI. Recent reports indicate that dysfunctional coronary microcirculation is an important determinant of prognosis for AMI patients after successful reperfusion.

METHODS

We measured left anterior descending coronary flow velocity variables using a Doppler guide wire immediately after successful primary stenting in 31 patients with their first anterior AMI. The patients were divided into two groups: those with and those without early systolic reverse flow (ESRF). Changes in LV regional wall motion (RWM) and ejection fraction (EF) at admission and at discharge were compared between the two groups. Coronary flow velocity variables immediately after primary stenting were compared with changes in left ventriculographic indexes.

RESULTS

The change in RWM was significantly greater in the non-ESRF group than it was in the ESRF group (0.9 ± 0.7 vs. −0.1 ± 0.3 standard deviation/chord, respectively, p < 0.001). The change in EF was also significantly greater in the non-ESRF group than it was in the ESRF group (10 ± 10 vs. 1 ± 6%, respectively, p < 0.05). In the non-ESRF group (diastolic to systolic velocity ratio [DSVR] <3.0), the DSVR correlated positively with the change in RWM (r = 0.60, p < 0.005, n = 24) and the change in EF (r = 0.52, p < 0.01).

CONCLUSIONS

The coronary flow velocity pattern measured immediately after successful primary stenting is predictive of the recovery of regional and global LV function in patients with AMI.     

急性心肌梗死直接冠状动脉成形术后再灌注心律失常分析

目的 分析急性心肌梗死直接冠脉成形术后严重再灌注心律失常发生的状况，探讨其预防和紧急治疗方法。方法 行直接经皮冠状动脉成形术的急性心肌梗死患者245例，根据梗死相关动脉分成三组，LAD组：126例；RCA组：97例；LCX组：22例。统计各组经皮冠状动脉成形术后再灌注心律失常发生的状况。结果 共151例患者发生严重的再灌注心律失常，发生率为61．6％；加速性室性自主心律发生率最高(22．0％)，与梗死相关动脉无关；其次是室性早搏(19．2％)，以LAD组最高(27．8％)。RCA组缓慢性心律失常(窦缓、窦性停搏、高度房室传导阻滞)发生率(35．1％)显著高于LAD组(3．9％)和ICX组(22．7％)：LCX组各种再灌注心律失常发生率界于LAD组和RCA组之间。结论 急性心肌梗死直接冠脉成形术后严重心律失常总的发生率较高，心律失常的类型与梗死相关动脉有明确的相关性。     

Efficacy of combined therapy using coronary reperfusion and elective percutaneous transluminal coronary angioplasty for acute myocardial infarction

The effects of elective percutaneous transluminal coronary angioplasty (PTCA) performed one month after coronary reperfusion therapy in patients with acute myocardial infarction (AMI) were observed using exercise Tl-201 myocardial scintigraphy performed before and after PTCA. Myocardial perfusion in Tl-201 scintigraphy was significantly greater in the early (less than 4 hours) and late (4-9 hours) reperfusion groups than in the total occlusion group one month after the onset of AMI. Both reperfusion groups showed significant improvement in myocardial perfusion after elective PTCA; whereas, the total occlusion group showed no significant improvement. In the early reperfusion group, there were no significant differences in myocardial perfusion between those with well developed and those with poorly developed collateral circulations one month after the onset of AMI. However, in the late reperfusion group, myocardial perfusion was greater in those with well developed collateral circulations compared to those with poorly developed collateral circulations. The grade of myocardial perfusion in the late reperfusion group with poorly developed collateral circulations did not differ significantly from that of the total occlusion group. There was significant improvement of myocardial perfusion in the early and late reperfusion groups with well developed collateral circulations after elective PTCA; whereas, no significant improvement was observed in the late reperfusion group with poorly developed collateral circulations. These findings indicate that the time interval from the onset of AMI to reperfusion and the grade of development of collateral circulations are the major determinants of myocardial perfusion after elective PTCA and after reperfusion therapy.     

Management of multivessel coronary disease after ST elevation myocardial infarction treated by primary angioplasty

BACKGROUND: Optimal treatment strategy of patients with ST elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) undergoing primary angioplasty is still unclear. Percutaneous coronary intervention (PCI) of non-culprit vessels simultaneously or soon after primary angioplasty is feasible and safe, but available data failed to consistently show a benefit in long-term clinical outcomes. METHODS: We retrospectively compared in-hospital and long-term outcomes for patients with STEMI and multivessel CAD treated by primary angioplasty with (Group 1, n=64) or without (Group 2, n=46) early, staged PCI of other angiographically significant coronary lesions. In-hospital major adverse cardiovascular events (MACE) were defined as a composite of death, periprocedural myocardial infarction after staged, elective PCI, stroke, stent thrombosis, major bleeding, and vascular complications. MACE at follow-up were defined as a composite of death, stroke, stent thrombosis, any coronary revascularization, and re-hospitalization for acute coronary syndrome. RESULTS: Group 1 patients underwent staged PCI 5.9 +/- 3.5 days after primary angioplasty. The mean length of follow-up was 13 months (392 +/- 236 days). The incidence of in-hospital MACE was 20.3% in Group 1 and 10.8% in Group 2 (P=0.186); the incidence of out of hospital MACE was 9.3% in Group 1 and 23.9% in Group 2 (P=0.037). In Group 1 in-hospital MACE were driven by periprocedural myocardial infarction after the elective procedure, which occurred in 15.6% of patients. CONCLUSIONS: Our data show that multivessel, staged PCI in STEMI patients is associated with a low incidence of adverse events at follow-up but with a higher incidence of in-hospital MACE, mainly driven by periprocedural myocardial infarction during the elective procedure.     

Alterations of phasic coronary artery flow velocity in humans during percutaneous coronary angioplasty.

BACKGROUND AND OBJECTIVES. Studies using Doppler catheters to assess blood flow velocity and vasodilator reserve in proximal coronary arteries have failed to demonstrate significant improvement immediately after coronary angioplasty. Measurement of blood flow velocity, flow reserve and phasic diastolic/systolic velocity ratio performed distal to a coronary stenosis may provide important information concerning the physiologic significance of coronary artery stenosis. This study was designed to measure these blood flow velocity variables both proximal and distal to a significant coronary artery stenosis in patients undergoing coronary angioplasty. METHODS. A low profile (0.018-in.) (0.046-cm) Doppler angioplasty guide wire capable of providing spectral flow velocity data was used to measure blood flow velocity, flow reserve and diastolic/systolic velocity ratio both proximal and distal to left anterior descending or left circumflex coronary artery stenosis. These measurements were made in 38 patients undergoing coronary angioplasty and in 12 patients without significant coronary artery disease. RESULTS. Significant improvement in mean time average peak velocity was noted in distal coronary arteries after angioplasty (before 19 +/- 12 cm/s; after 35 +/- 16 cm/s; p less than 0.01). Increases in proximal average peak velocity after angioplasty were less remarkable (before 34 +/- 18 cm/s; after 41 +/- 14 cm/s; p = 0.04). Mean flow reserve remained unchanged after angioplasty both proximal (1.5 +/- 0.5 vs. 1.6 +/- 1; p greater than 0.10) and distal (1.6 +/- 1 vs. 1.5 +/- 0.8; p greater than 0.10) to a coronary stenosis. Before angioplasty, mean diastolic/systolic velocity ratio measured distal to a significant stenosis was decreased compared with that in normal vessels (1.3 +/- 0.5 vs. 1.8 +/- 0.5; p less than 0.01). After angioplasty, distal abnormal phasic velocity patterns generally returned to normal, with a significant increase in mean diastolic/systolic velocity ratio (1.3 +/- 0.5 vs. 1.9 +/- 0.6; p less than 0.01). Phasic velocity patterns and mean diastolic/systolic velocity ratio measured proximal to a coronary stenosis were not statistically different from values in normal vessels (1.8 +/- 0.8 vs. 1.8 +/- 0.5; p greater than 0.10) and did not change significantly after angioplasty (1.8 +/- 0.8 vs. 2.13 +/- 0.9; p greater than 0.10). CONCLUSIONS. Flow velocity measurements may be performed distal to a coronary stenosis with the Doppler guide wire. Phasic velocity measurements made proximal to a coronary stenosis differed from those in the distal coronary artery. Both proximal and distal flow reserve measurements made immediately after angioplasty were of limited utility. Changes in distal flow velocity patterns and diastolic/systolic velocity ratio appeared to be more relevant than the hyperemic response in assessing the immediate physiologic outcome of coronary angioplasty.     

Administration of atrial natriuretic peptide attenuates reperfusion phenomena and preserves left ventricular regional wall motion after direct coronary angioplasty for acute myocardial infarction.

To evaluate the effects of synthetic human atrial natriuretic peptide (hANP) on myocardial reperfusion injury and left ventricular remodeling, 19 patients within 12 h of a first attack of anterior myocardial infarction (AMI) underwent intracoronary injection of 25 microg of hANP immediately after coronary angioplasty, combined with intravenous infusion of 0.025 microg x kg(-1) x min(-1) of hANP initiated on admission for 1 week (hANP group); 18 similar patients had saline administered (control group). The incidences of premature ventricular contraction, ventricular tachycardia and/or fibrillation in the hANP group were significantly less than in the control group after coronary angioplasty. Left ventricular ejection fraction was significantly greater and left ventricular end-diastolic volume index was significantly smaller 6 months after coronary angioplasty. Left ventricular regional wall motion of the infarcted segments significantly increased. Thus, hANP remarkably suppressed reperfusion phenomena and preserved left ventricular function through improvement of regional wall motion of the infarcted segments after coronary angioplasty.