Effect of preinfarction angina pectoris on myocardial blush grade after reperfusion in first anterior wall acute myocardial infarction.

BACKGROUND: The aim of the present study was to clarify the effect of preinfarction angina pectoris (PIA) on myocardial blush grade (MBG), a simple marker of myocardial tissue-level reperfusion, in acute myocardial infarction (AMI). METHODS AND RESULTS: One hundred forty-two patients with first anterior wall AMI who were admitted within 6 h after onset of symptoms were examined. PIA was defined as typical chest pain within 48 h before onset of symptoms. MBG was evaluated by coronary angiography after reperfusion. Patients with MBG 2 or 3 (n=103) had a higher frequency of PIA and a lower frequency of diabetes mellitus than those with MBG 0 or 1 (n=39) (57% vs 28%, p=0.004, and 23% vs 44%, p=0.03, respectively). The former had a lower peak creatine kinase level and a greater left ventricular ejection fraction at predischarge than the latter (3,652+/-2,440 vs 5,507+/-3,058 IU/L, p=0.0002, and 57+/-12% vs 45+/-11%, p<0.0001, respectively). Multivariate logistic regression analysis showed that PIA (p=0.004) and diabetes mellitus (p=0.03) were independently associated with MBG 2 or 3 after reperfusion. CONCLUSIONS: PIA has beneficial effects on myocardial tissue-level reperfusion evaluated by MBG in first anterior wall AMI.     

Myocardial perfusion grade and survival after percutaneous transluminal coronary angioplasty in patients with cardiogenic shock

We sought to evaluate myocardial reperfusion and its prognostic value after percutaneous transluminal coronary angioplasty (PTCA) in patients admitted for cardiogenic shock. Lack of myocardial reperfusion despite restored coronary flow affects the survival of patients with acute myocardial infarction (AMI). Myocardial blush grade (MBG) is an angiographic measure of myocardial perfusion. We assessed MBG in 41 consecutive patients admitted to our department within 12 hours from the onset of AMI and in cardiogenic shock. PTCA was successful in 83% of patients. Thrombolysis In Mycardial Infarction (TIMI) grade 3 flow was demonstrated in 22 patients (53%). MBG 2/3 was found in 14 patients (34%); among them, 12 had TIMI 3 flow. Compared with patients with MBG 2/3, those with MBG 0/1 were older (71 +/- 11 vs 57 +/- 13 years, p = 0.001), had a higher prevalence of diabetes (48% vs 14%, p = 0.04) and hypertension (63% vs 29%, p = 0.04), showed a trend toward longer ischemic time (6.1 +/- 2.4 vs 4.9 +/- 1.1), and had larger enzymatic infarct size (peak creatine kinase 7,690 +/- 3,516 vs 5,500 +/- 2,977 IU/L). Mortality was higher in patients with MBG 0/1 both in the hospital (81% vs 14%, p <0.001) and at follow-up (81% vs 29%, p = 0.001). After adjustment by multivariate analysis, MBG 0/1 (odds ratio 16, p = 0.01) and age (odds ratio 3.8/10 years, p = 0.04) were correlated with in-hospital mortality. MBG 2/3 was achieved in a few patients in cardiogenic shock after AMI who were treated with PTCA; this was a strong predictor of in-hospital survival. Also, risk stratification after mechanical revascularization should include assessment of restoration of myocardial reperfusion.     

Usefulness of myocardial blush grade early and late after primary coronary angioplasty for acute myocardial infarction in predicting left ventricular function

This study sought to analyze the evolution of myocardial perfusion during follow-up after primary angioplasty for acute myocardial infarction (AMI) and relate it to final left ventricular (LV) function. In 101 patients with a first AMI, angiographic myocardial blush grade (MBG) was analyzed immediately after intervention and at follow-up 7.5 +/- 5.6 months later. Cine ventriculography was performed at follow-up angiography to define LV function. Five patients had occluded stents or flow-limiting restenosis. In the remaining patients, myocardial perfusion at follow-up, as defined by MBG, was persistently abnormal in 19 patients (20%), had become normalized from previously abnormal MBG in 30 patients (31%), remained normal in 40 patients (42%), and deteriorated from normal to abnormal in 7 patients (7%). Patients with improvement of abnormal blush determined immediately after intervention to normal blush at follow-up (n = 30) compared with patients with persistently abnormal blush (n = 19) had a better LV ejection fraction at follow-up (53.7 +/- 11.1 vs. 37.4 +/- 9.7%, p <0.001). Evolution of MBG had a better predictive value for LV ejection fraction at follow-up than acute MBG only. Multivariate analysis proved evolution of MBG from AMI to follow-up to be an independent predictor of LV function (R(2) = 0.177, p <0.001) in addition to the initial size of jeopardized myocardium as defined by the sum of ST-segment elevation (R(2) = 0.138, p = 0.001) and infarct location (R(2) = 0.044, p = 0.033). In conclusion, tissue reperfusion after angioplasty for AMI is characterized by frequent improvement over time, as indicated by repeated MBG analysis. Patients with recovery of perfusion have better, final LV function.     

Association of C-reactive protein and myocardial perfusion in patients with ST-elevation acute myocardial infarction

This study sought to evaluate the relation between C-reactive protein (CRP) on admission of patients with acute myocardial infarction (AMI) and myocardial perfusion as defined by postintervention angiographic myocardial blush grade (MBG) and their impact on subsequent mortality. The patient population comprised 191 consecutive patients with AMI undergoing PTCA within 12h of symptom onset on a native vessel. Patients were divided based on the CRP level on admission (Rolf Greiner BioChemica, Germany, cutpoint for the assay CRP: 5mg/l) into a group with elevated CRP (>or=5mg/l) and a group with normal CRP. Angiographic myocardial blush grade (MBG) after revascularization of the infarct-related artery was determined to evaluate myocardial reperfusion. Revascularization of the infarct-related artery was successful in 176 (92.6%) patients. The frequency of impaired perfusion (MBG 0-2) was higher in the elevated CRP group than in the normal CRP group (74.5% versus 59.7%, respectively, p=0.046). Elevated CRP on admission was an independent predictor of impaired myocardial perfusion (MBG 0-2, OR 1.92, 95% CI 1.02-4.01, p=0.042) in addition to age >70 years. Elevated CRP (OR 2.64, 95% CI 1.26-5.53, p=0.009) and MBG 0-2 (OR 4.58; 95% 1.73-12.20, p=0.002) were independent predictors of mortality during a 22.4+/-15.3 months follow-up in addition to heart rate on admission >100 beats/min (OR 3.07; 95% CI 1.30-7.25, p=0.009). In sequential Cox models, the predictive power of clinical data and MBG for mortality (model chi-squared 18.3) was strengthened by the inclusion of CRP levels (model chi-squared 24.3). In conclusion, there is a relation between elevated admission CRP and impaired reperfusion in the myocardium subtended to the infarct-related artery. The combination of clinical data, myocardial reperfusion levels after primary angioplasty for AMI and admission CRP increases the predictive value for subsequent survival.     

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

OBJECTIVES: 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. BACKGROUND: Abnormal myocardial perfusion has a detrimental impact on survival. Several parameters of reperfusion have been evaluated in controlled study populations for risk stratification. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.     

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.     

Impact of prodromal angina pectoris and white blood cell count on outcome of patients with acute myocardial infarction

BACKGROUND: Elevation of white blood cell (WBC) count at admission is associated with adverse outcome after acute myocardial infarction (AMI). Prodromal angina, by the mechanism of ischemic preconditioning, improves left ventricular (LV) function and survival after reperfusion therapy in patients with AMI. Recent experimental studies have reported that preconditioning has anti-inflammatory effect. METHODS: This study consisted of 598 patients with first anterior wall AMI who underwent coronary angiography within 12 h after symptom onset. WBC count was measured at the time of hospital admission. Prodromal angina was defined as angina occurring within 24 h before the onset of AMI. Serial measurements of LV ejection fraction (EF) were obtained before reperfusion therapy and before discharge in 421 patients (71%). RESULTS: High WBC count (>10.2 x 103/mm3, n=297) was associated with higher 30-day mortality (8% vs. 4%, p=0.02) and lower predischarge LVEF (51+/-15% vs. 57+/-14%, p<0.001), although there was no significant difference in acute LVEF (47+/-10% vs. 49+/-11%, p=0.07). High WBC count was an independent predictor of 30-day mortality (p=0.009) and predischarge LVEF (p=0.002). Prodromal angina was associated with lower 30-day mortality (3% vs. 7%, p=0.02) and preserved predischarge LVEF (57+/-15% vs. 53+/-14%, p=0.006). Patients with prodromal angina had lower WBC count (10.0+/-3.3 x 10(3)/mm3 vs. 11.0+/-3.9 x 10(3)/mm3, p=0.001) and prodromal angina was an independent predictor of WBC count (p<0.001). CONCLUSIONS: Elevation of WBC count and lack of prodromal angina were associated with impaired LV function and mortality after reperfusion in patients with AMI. Prodromal angina might have contributed to favorable outcome after AMI through its anti-inflammatory effect.     

Convalescent stage coronary flow reserve and late myocardial morphologic outcomes in patients with first anterior acute myocardial infarction.

BACKGROUND: Microvascular damage immediately after reperfusion therapy is an independent predictor of left ventricular function in patients with acute myocardial infarction (AMI). However, its recovery may vary among individuals and the relationship between convalescent stage microvasculature and late myocardial morphologic change is unclear. METHODS AND RESULTS: Patients treated with coronary angioplasty within 12 h of their first anterior AMI were enrolled in this study. Coronary flow reserve (CFR) was measured 3 weeks post AMI, in both branches of the left coronary artery: culprit (left anterior descending artery: LAD) and non-culprit (left circumflex artery: LCX). Left ventriculography was performed at 3 weeks and 6 months post AMI and compared. Seventeen patients showed abnormal CFR in the LAD (Group 1: CFR<2), whereas 20 patients showed normal CFR (Group 2: CFR >/=2). Percent changes of end-diastolic volume tended to be higher in Group 1 than in Group 2 (11.8+/-21.6% vs -1.3+/-14.4%, p=0.056), and %changes of end-systolic volume was significantly smaller in Group 2 (11.8+/-22.1% vs -8.7+/-25.1%, p<0.05). A statistically significant correlation was found between absolute and relative CFR in the LAD and %change of end-systolic volume (r=-0.58: p<0.001, and r=0.40: p<0.05, respectively). CONCLUSIONS: Microvascular function in the convalescent stage may be related to these favorable changes.     

Coronary angioplasty reduces free wall rupture and improves mortality and morbidity of acute myocardial infarction

BACKGROUND: Free wall rupture (FWR) is one of the major causes of mortality in acute myocardial infarction (AMI). To what extent coronary angioplasty for AMI would modify the predictors of FWR is not clear. METHODS: In prospective database of consecutive 3,138 AMI patients seen between May 1985 to May 2002, 3,096 patients (98.7%) who underwent emergent coronary angiography were analyzed retrospectively. The incidence of FWR was determined by univariate and multivariate analyses. RESULTS: FWR after admission occurred in 40 (1.3%) patients. A higher rate of FWR was associated with: 1) not having coronary angioplasty (3.2% vs. 0.9%, p< 0.0001); 2) thrombolytic agents usage (2.4% vs. 1.0%, p = 0.004); 3) female gender (2.5% vs. 1.1%, p = 0.0004); 4) failed reperfusion (5.4% vs. 0.9%, p< 0.0001); and 5) LMT-related infarct (4.7% vs. 1.2%, p = 0.02) in univariate analysis. Five conditions were identified as significant protective or predictive factors of FWR in multivariate logistic regression analysis: having coronary angioplasty (odds ratio [OR]: 0.45, 95% confidence interval [95% CI] 0.22-0.94, p = 0.03), failed reperfusion (OR: 4.57, 95% CI: 2.31-9.05, p< 0.0001), LMT-related infarct (OR: 4.96, 95% CI: 1.42-17.34, p = 0.01), female gender (OR: 2.17, 95% CI: 1.11-4.25, p = 0.02) and age (OR: 1.04, 95% CI: 1.00-1.07, p = 0.03). Coronary angioplasty alone resulted in a lower incidence of FWR (0.5%) than thrombolysis alone (1.6%, p = 0.02), coronary angioplasty with thrombolysis (3.3%, p< 0.0001) and without either treatment (6.3%, p< 0.0001). CONCLUSIONS: Angiographic reperfusion success was the most significant protective factor from FWR. Coronary angioplasty reduced FWR complicating AMI and its concomitant fatality.     

The effect of ST resolution on QT dispersion after interventional treatment in acute myocardial infarction

BACKGROUND: It has been reported that reperfusion treatment reduces QT dispersion (QTD) in cases of acute myocardial infarction (AMI). Successful myocardial perfusion is not synonymous with Thrombolysis in Myocardial Infarction (TIMI) III flow. It has been demonstrated that in AMI, the grade of ST-resolution correlates strongly with left ventricular (LV) function, enzyme elevation, and mortality after primary angioplasty. HYPOTHESIS: This study investigated the relation between ST-resolution grade and QTD and the feasibility of using QTD as a determinant of successful myocardial tissue perfusion in patients in whom TIMI III flow in the infarct-related artery (IRA) is restored by interventional treatment for AMI. METHODS: The study included 57 patients (38 men, 19 women, average age 54.4 +/- 11.6 years), whose IRA was perfused by primary angioplasty after the diagnosis of anterior AMI with ST elevation. Electrocardiograms of patients were taken 45 +/- 12 min post procedure, and patients were divided into three groups depending on the grade of ST resolution: Group 1, full ST resolution; Group 2, partial ST resolution; and Group 3, unsuccessful ST resolution. RESULTS: Full ST resolution was seen in 19 cases (33%), partial resolution in 26 cases (47%), and unsuccessful resolution in 12 cases (20%). There were no differences among groups in terms of risk factors, stent diameters, symptom onset-balloon time, LV function, and preprocedure corrected QTD (QTcD) (p = 0.274). After the procedure, a significant reduction in QTcD was found within the groups (p = 0.0001 in Group 1, p = 0.004 in Group 2, and p = 0.011 in Group 3). Reductions in QTcD post procedure were 24.21 +/- 14.27, 11.85 +/- 16.18, and 12.50 +/- 11.58 ms in Groups 1, 2, and 3, respectively. There was a statistically significant difference of p = 0.015 between Groups 1 and 2 and a difference of p = 0.028 between Groups 1 and 3. There was no statistically significant difference between Groups 2 and 3 (p = 0.916). CONCLUSION: In acute MI, TIMI III flow led to a reduction in QTcD, and full myocardial perfusion made an additional contribution to the electrical stability of the myocardium.     

Randomized early versus late abciximab in acute myocardial infarction treated with primary coronary intervention (RELAx-AMI Trial).

OBJECTIVES: This prospective randomized trial evaluates the impact of early abciximab administration on angiographic and left ventricular function parameters. BACKGROUND: Glycoprotein IIb/IIIa inhibitors improve myocardial reperfusion in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI), but optimal timing of administration remains unclear. METHODS: Two-hundred ten consecutive patients with first AMI undergoing primary PCI were randomized to abciximab administration either in the emergency room (early group: 105 patients) or in the catheterization laboratory, after coronary angiography (late group: 105 patients). Primary end points were initial Thrombolysis In Myocardial Infarction (TIMI) flow grade, corrected TIMI frame count (cTFC), and myocardial blush grade (MBG), as well as left ventricular function recovery as assessed by serial echocardiographic evaluations. RESULTS: Angiographic pre-PCI analysis showed a significantly better initial TIMI flow grade 3 (24% vs. 10%; p = 0.01), cTFC (78 +/- 30 frames vs. 92 +/- 21 frames; p = 0.001), and MBG 2 or 3 (15% vs. 6%; p = 0.02) favoring the early group. Consistently, post-PCI tissue perfusion parameters were significantly improved in the early group, as assessed by 60-min ST-segment reduction > or =70% (50% vs. 35%; p = 0.03) and MBG 2 or 3 (79% vs. 58%; p = 0.001). Left ventricular function recovery at 1 month was significantly greater in the early group (mean gain ejection fraction 8 +/- 7% vs. 6 +/- 7%, p = 0.02; mean gain wall motion score index 0.4 +/- 0.3 vs. 0.3 +/- 0.3, p = 0.03). CONCLUSIONS: In patients with AMI treated with primary PCI, early abciximab administration improves pre-PCI angiographic findings, post-PCI tissue perfusion, and 1-month left ventricular function recovery, possibly by starting early recanalization of the infarct-related artery.     

Primary angioplasty of unprotected left main coronary artery for acute anterolateral myocardial infarction

BACKGROUND: Mortality of acute unprotected left main coronary artery (LMCA) occlusion is very high. The objectives of this analysis were to determine the effect of primary angioplasty and the impact of cardiogenic shock on unprotected LMCA occlusion-induced acute anterolateral myocardial infarction (AAMI). METHODS: Of 1,736 consecutive patients with acute myocardial infarction (AMI), 38 (2.2%) had LMCA occlusion-induced AAMI with Thrombolysis in Myocardial Infarction (TIMI) flow less than or equal to 2. All were given primary angioplasty. RESULTS: Of these 38 patients, 17 (45%) were discharged, and 21 (55%) died in-hospital. Cardiogenic shock was overt in 28 patients; 47.1% of the survival group and 95.2% of the mortality group (p=0.0008). On arrival, the survival-group had higher pH (7.40+/-0.10 vs. 7.30+/-0.14; p=0.013) and base excess (-4.5+/-3.9 vs. -10.4+/-6.0 mEq/L; p=0.0013). In the survival group reperfusion was successful in 100% of patients, as opposed to 57.1% in the mortality group (p=0.0020), and the incident of stenting was not different between the two groups (64.7% vs. 71.4%, p=0.66). Shock patients had lower successful angioplasty rate (67.9% vs. 100%, p=0.040), higher in-hospital mortality (71.4% vs. 10.0%, p=0.0008), and higher 1-year mortality rates (p=0.0064), than stable patients. All shock patients with failed angioplasty died, but the mortality rate was 57.9% (p=0.021) when angioplasty was successful. CONCLUSIONS: Patients presenting with AAMI, LMCA occlusion, and cardiogenic shock have poor survival regardless of primary angioplasty in conjunction with coronary stents. Nevertheless, primary angioplasty is a feasible and effective procedure, and it may save lives in this clinical setting.     

Thrombolysis in myocardial infarction myocardial perfusion grade in angiography correlates with myocardial salvage in patients with acute myocardial infarction treated with stenting or thrombolysis

OBJECTIVES: We sought to assess the relationship between the Thrombolysis In Myocardial Infarction (TIMI) myocardial perfusion (TMP) grade and myocardial salvage as well as the usefulness of TMP grade in comparing two different reperfusion strategies. BACKGROUND: The angiographic index of TMP grade correlates with infarct size and mortality after thrombolysis for acute myocardial infarction (AMI). Its relationship to myocardial salvage and its usefulness in comparing different reperfusion strategies are not known. METHODS: We analyzed the TMP grade on angiograms obtained at one to two weeks after treatment in 267 patients enrolled in two randomized trials that compared stenting with thrombolysis in AMI. Patients were classified into two groups: 159 patients with TMP grade 2/3 and 108 patients with TMP grade 0/1. Two scintigraphic studies were performed: before and one to two weeks after reperfusion. The salvage index was calculated as the proportion of the area at risk salvaged by reperfusion. RESULTS: Patients with TMP grade 2/3 had a higher salvage index (0.49 +/- 0.42 vs. 0.34 +/- 0.49, p = 0.01), a smaller final infarct size (15.4 +/- 15.5% vs. 22.1 +/- 16.2% of the left ventricle, p = 0.001), and a trend toward lower one-year mortality (3.8% vs. 8.3%, p = 0.11) than patients with TMP grade 0/1. The relationship between TMP and salvage index was independent of the form of reperfusion therapy. The proportion of patients with TMP grade 2/3 was significantly higher after stenting than after thrombolysis (70.9% vs. 48.1%, p = 0.001). CONCLUSIONS: These findings show that the TMP grade is a useful marker of the degree of myocardial salvage achieved with reperfusion and a sensitive indicator of the efficacy of reperfusion strategies in patients with AMI.     

The distinction between coronary and myocardial reperfusion after thrombolytic therapy by clinical markers of reperfusion

Objectives. We sought to examine the hypothesis that rapid resolution of ST-segment elevation in acute myocardial infarction (AMI) patients with early peak creatine kinase (CK) after thrombolytic therapy differentiates among patients with early recanalization between those with and those without adequate tissue (myocardial) reperfusion.Background. Early recanalization of the epicardial infarct-related artery (IRA) during AMI does not ensure adequate reperfusion on the myocardial level. While early peak CK after thrombolysis results from early and abrupt restoration of the coronary flow to the infarcted area, rapid ST-segment resolution, which is another clinical marker of successful reperfusion, reflects changes of the myocardial tissue itself.Methods. We compared the clinical and the angiographic results of 162 AMI patients with early peak CK (≤12 h) after thrombolytic therapy with (group A) and without (group B) concomitant rapid resolution of ST-segment elevation.Results. Patients in groups A and B had similar patency rates of the IRA on angiography (anterior infarction: 93% vs. 93%; inferior infarction: 89% vs. 77%). Nevertheless, group A versus B patients had lower peak CK (anterior infarction: 1,083 ± 585 IU/ml vs. 1,950 ± 1,216, p < 0.01; and inferior infarction: 940 ± 750 IU/ml vs. 1,350 ± 820, p = 0.18) and better left ventricular ejection fraction (anterior infarction: 49 ± 8, vs. 44 ± 8, p < 0.01; inferior infarction: 56 ± 12 vs. 51 ± 10, p = 0.1). In a 2-year follow-up, group A as compared with group B patients had a lower rate of congestive heart failure (1% vs. 13%, p < 0.01) and mortality (2% vs. 13%, p < 0.01).Conclusions. Among patients in whom reperfusion appears to have taken place using an early peak CK as a marker, the coexistence of rapid resolution of ST-segment elevation further differentiates among patients with an opened culprit artery between the ones with and without adequate myocardial reperfusion.     

Effect of prodromal angina pectoris on altering the relation between time to reperfusion and outcomes after a first anterior wall acute myocardial infarction

To test the hypothesis that prodromal angina may favorably alter the relation between time to reperfusion and outcomes after acute myocardial infarction (AMI), we studied 658 patients with a first anterior AMI: 200 patients with early reperfusion (time to reperfusion 相似文献   

Primary coronary angioplasty in patients with ST segment elevation acute myocardial infarction and diabetes

BACKGROUND: Subjects with diabetes constitute 13-25% of patients with ST segment elevation acute myocardial infarction (STEMI). In spite of the introduction of thrombolytic therapy, patients with STEMI and diabetes continue to have worse prognosis than those without diabetes. Primary percutaneous coronary intervention (PCI) has been shown in recent years to be the most effective therapy in patients with STEMI. AIM: To compare the outcome of STEMI patients with or without diabetes who underwent primary PCI. METHODS: The study group consisted of 500 consecutive patients with STEMI. The occurrence of major adverse cardiac events (MACE) which included death, reinfarction or repeated PCI of the target vessel, was analysed peri-operatively and during a six-month follow-up period.Results. Diabetes was diagnosed in 68 (13.6%) patients. The mean time duration from the onset of STEMI symptoms to treatment was similar in patients with or without diabetes (230+/-97 min vs 231+/-139 min, NS). Patients with diabetes were older (61.9+/-8.9 vs 57.9+/-10.8 years, p=0.004), had higher body mass index (29+/-4 vs 27+/-5, p=0.002), more frequent history of coronary artery disease (57.4% vs 37.9%, p=0.002), higher prevalence of arterial hypertension (71.6% vs 56.8%, p=0.02) and more frequently the left anterior descending artery as the infarct-related artery (58.8% vs 42.1%, p=0.01). Immediately after PCI, epicardial and myocardial reperfusion rates were lower in patients with rather than without diabetes (TIMI 3: 84.9% vs 91.3%, p=NS, cTFC: 32+/-26 vs 22+/-16, p<0.0001, and MPG3: 25% vs 41.9% p=0.008). Diabetes increased the risk of MACE during in-hospital period by 2.7 times. The rate of MACE during a six-month follow-up period was almost two times higher in patients with rather than without diabetes (death: 8.8% vs 5.1%, reinfarction: 1.5% vs 1.2%, repeated PCI: 11.8% vs 6.9%). CONCLUSIONS: Primary PCI-achieved epicardial and myocardial reperfusion rate is lower in STEMI patients with rather than without diabetes. The presence of diabetes almost doubles the risk of MACE during a six-month follow-up.     

Frequency, correlates, and clinical implications of myocardial perfusion after primary angioplasty and stenting, with and without glycoprotein IIb/IIIa inhibition, in acute myocardial infarction

OBJECTIVES: We sought to determine the prognostic importance of myocardial reperfusion after various contemporary interventional strategies in patients with acute myocardial infarction (AMI). BACKGROUND: The frequency, correlates, and clinical implications of myocardial perfusion after primary angioplasty in AMI have not been examined in a large-scale prospective study. Similarly, whether glycoprotein (GP) IIb/IIIa inhibitors and/or stents improve myocardial perfusion beyond balloon angioplasty has not been investigated. METHODS: Tissue-level perfusion assessed by the myocardial blush grade was evaluated in 1,301 patients with AMI randomized to balloon angioplasty versus stenting, each with or without abciximab. RESULTS: Despite Thrombolysis In Myocardial Infarction flow grade 3 restoration in 96.1% of patients, myocardial perfusion was normal in only 17.4% of patients, reduced in 33.9%, and absent in 48.7%. Myocardial perfusion status post-coronary intervention stratified patients into three distinct risk categories, with 1-year mortality rates of 1.4% (normal blush), 4.1% (reduced blush), and 6.2% (absent blush) (p = 0.01). Among patients randomized to angioplasty, angioplasty + abciximab, stenting, and stenting + abciximab, normal myocardial perfusion was restored in 17.7%, 17.0%, 17.5%, and 17.6%, respectively (p = 0.95), which was associated with similar 1-year rates of mortality in patients randomized to stenting versus angioplasty (4.5% vs. 4.8%, p = 0.91) and abciximab versus no abciximab (4.3% vs. 5.0%, p = 0.63). CONCLUSIONS: Restoration of normal tissue-level perfusion is a powerful determinate of survival after primary PCI in AMI and is achieved in a minority of patients. Neither stents nor GP IIb/IIIa inhibitors significantly enhance myocardial perfusion compared to balloon angioplasty alone, underlying the similar long-term mortality with these different mechanical reperfusion strategies.     

Effect of impaired myocardial reperfusion on left ventricular remodeling in patients with anterior wall acute myocardial infarction treated with primary coronary intervention

We assessed the effect of impaired myocardial blush after primary coronary intervention (PCI) on left ventricular remodeling in patients with ST-segment elevation myocardial infarction (STEMI). The study population consisted of 145 patients with first anterior STEMI that was treated successfully (Thrombolysis In Myocardial Infarction grade 3 flow) with PCI. Left ventricular remodeling was defined as an increase of > or =20% in end-diastolic volume based on repeated echocardiographic measurements in patients. The study population was divided into 2 groups according to the presence (myocardial blush grade [MBG] 2 to 3, n = 86) or absence (MBG 0 to 1, n = 59) of myocardial reperfusion. Left ventricular remodeling appeared in 21% of the entire study group. Poor myocardial blush after PCI was associated with an increased rate of remodeling compared with good myocardial reperfusion (32% vs 14%, hazard ratio 2.308, 95% confidence interval [CI] 1.21 to 4.39, p=0.014). Symptoms of heart failure were observed significantly more often in patients with MBG 0 to 1 (35.6% vs 18.6%, p = 0.032) than in patients with MBG 2 to 3. In multivariate analysis, only age (odds ratio 0.96, 95% CI 0.92 to 0.99, p = 0.02) and MBG 0 to 1 (odds ratio 3.15, 95% CI 1.35 to 7.31, p = 0.008) were associated with left ventricular dilation. In conclusion, impaired microvascular reperfusion is associated with left ventricular remodeling and development of congestive heart failure in patients with anterior STEMI that is treated with primary coronary angioplasty.     

急性心肌梗死再灌注心律失常不增加心肌损伤

目的探讨急性心肌梗死（AMI）患者PCI再灌注心律失常的临床意义。方法回顾性分析近年在我院接受直接PCI且成功开通梗死相关血管（IRA）的AMI患者228例。将其中开通IRA后数分钟内发生心肌缺血再灌注损伤（MIRI）的119例患者（MIRI组）分为3个亚组,即严重心动过缓和低血压（缓慢性心律失常组）、需电复律的严重室性心律失常（快速性心律失常组）和IRA前向血流≤TIMI2级且除外急性闭塞（无复流组）。结果（1）临床和造影资料：与无MIRI组相比,MIRI组缺血时间短,梗死前心绞痛所占比例低,多支血管病变、下壁梗死、右冠状动脉IRA、PCI前IRA血流TIM10级和肾功能不全所占比例高,住院病死率较高（13．4％比4．6％,P=0．021）。（2）血清心肌酶水平：缓慢性心律失常组肌酸激酶（OK）峰值中位数显著低于无MIRI组（20LOIU／L比2521IU／L,P=0．039）,肌酸激酶同工酶（CK．MB）峰值中位数有低于无MIRI组的趋势（98IU／L比142IU／L,P=0．091）;快速性心律失常组CK峰值中位数（2317IU／L）和CK-MB峰值中位数（134IU／L）与无MIRI组相比差异无统计学意义（P=0．627,0．500）;无复流组CK峰值中位数（4573IU／L）和CK-MB峰值中位数（338IU／L）均显著高于无MIRI组（P均=0．000）。（3）超声心功能：无复流组左心室射血分数显著低于无MIRI组（38．7％±8．3％比51．2％±8．1％,P=0．000）,左心室舒张末期容积显著大于快速性心律失常组[（135±32）ml比（105±19）ml,P=0．029],左心室收缩末期容积显著大于无MIRI组[（82±33）ml比（54±24）ml,P=0．008]和缓慢性心律失常组[（56±19）ml,P=0．025]。结论再灌注心律失常可能提示梗死区存活心肌多,而且不增加心肌损伤;无复流增加心肌损伤,导致永久的心功能障碍。     

Intraaortic balloon pumping as the postangioplasty strategy in acute myocardial infarction.

To assess the usefulness of intraaortic balloon pumping (IABP) in acute myocardial infarction (AMI), 114 patients with anterior AMI undergoing emergency percutaneous transluminal coronary angioplasty (PTCA) for total occlusion of the left anterior descending artery were studied. After successful PTCA 66 patients were treated with conventional therapy (group I), and 48 patients were treated with IABP for 25 +/- 8 hours (group II). The reocclusion rate was significantly lower in group II (2.4% vs 17.7% p less than 0.05). An increase in ejection fraction in group II compared with group I was marginally significant (4.5 +/- 12.2% vs 9.2 +/- 13.0%, p = 0.08). Vascular complications occurred in two patients, but there were no deaths from IABP. These results suggest that after successful PTCA for acute myocardial infarction, IABP prevents reocclusion and may add strength to reperfusion in the improvement of left ventricular function.