Association of a negative residual stenosis following rescue/adjunctive percutaneous coronary intervention with impaired myocardial perfusion and adverse outcomes among ST-segment elevation myocardial infarction patients

OBJECTIVES: We hypothesized that <0% residual stenosis (RS) after rescue/adjunctive percutaneous coronary intervention (PCI) following fibrinolytic administration in ST-segment elevation myocardial infarction (STEMI) would be associated with improved outcomes. BACKGROUND: Prior studies have associated larger lumen diameters after PCI with reduced rates of restenosis and target vessel revascularization. METHODS: Data were drawn from 748 patients with open epicardial arteries and with optimal luminal results (RS <20%) following rescue/adjunctive PCI after fibrinolytic administration in six STEMI trials. Patients were divided into two groups: 1) <0% RS and 2) 0% to 20% RS. RESULTS: A RS <0% was associated with greater gains in lumen diameter and smaller reference diameters after PCI (p < 0.001 for each), with a trend toward less frequent Thrombolysis In Myocardial Infarction flow grade (TFG) 3. A RS <0% was associated with a greater incidence of abnormal post-PCI Thrombolysis In Myocardial Infarction myocardial perfusion grades (TMPGs) (odds ratio 2.6 [1.2 to 5.9] for TMPG 0/1/2, p = 0.02), even when the analysis was restricted to patients with post-PCI TFG 3. CONCLUSIONS: A RS <0% following rescue/adjunctive PCI after fibrinolytic therapy for STEMI was independently associated with a reduction in the frequency of normal myocardial perfusion. Potential mechanisms of this finding include greater downstream embolization, increased stimulation of arterial stretch receptors with resultant coronary vasoconstriction, and increased vessel-wall injury after PCI. These findings suggest that additional prospective studies are needed to assess optimal RS that minimizes long-term restenosis without adverse effects.     

Sequential risk stratification using TIMI risk score and TIMI flow grade among patients treated with fibrinolytic therapy for ST-segment elevation acute myocardial infarction

In the setting of ST-segment elevation myocardial infarction (STEMI), the Thrombolysis In Myocardial Infarction (TIMI) risk score (TRS) and indexes of epicardial and myocardial perfusion are associated with mortality. The association between TRS at presentation and angiographic indexes of epicardial and myocardial perfusion after reperfusion therapy has not been investigated. We hypothesized that TRS, TIMI flow grade (TFG), and TIMI myocardial perfusion grade (TMPG) would provide independent prognostic information and that angiographic indexes of poor flow and perfusion would be associated with a higher TRS. TRS and angiographic data were evaluated in 3,801 patients from the TIMI 4, 10A, 10B, 14, 20, 23, and 24 trials. Within each TRS stratum (TRS 0 to 2, 3 to 4, >/=5), 30-day mortality increased stepwise among patients with impaired TFG at 60 minutes after fibrinolytic administration. In a multivariate model adjusting for the TRS strata, impaired TMPG (0/1) was independently associated with higher mortality (odds ratio 2.28, p = 0.018). In a multivariate model adjusting for the TFG and infarct location, the likelihood of impaired TMPG (0/1) was greater among intermediate-risk (TRS 3 to 4) and high-risk (TRS >/=5) patients than among low-risk (TRS 0 to 2) patients (odds ratio 1.43, p = 0.019 and 1.50, p = 0.055, respectively). Thus, impaired epicardial flow and myocardial perfusion are independently associated with increased 30-day mortality among patients identified by TRS as high risk, although there is no synergism between either TFG or TMPG and TRS. High TRS at presentation is associated with abnormal myocardial perfusion, even after adjusting for possible confounders.     

Diabetes mellitus, myocardial reperfusion, and outcome in patients with acute ST-elevation myocardial infarction treated with primary angioplasty (from HORIZONS AMI)

Diabetes mellitus (DM) increases mortality in acute ST-segment elevation myocardial infarction (STEMI) but the responsible mechanism is not fully elucidated. We compared the rate of successful myocardial reperfusion measured by tissue myocardial perfusion grade (TMPG) and outcomes in patients with and without DM undergoing primary percutaneous coronary intervention (PCI) for STEMI. Patients enrolled in the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS AMI) trial were analyzed according to presence of DM with respect to TMPG after PCI and outcomes at 30 days and 3 years. Multivariable logistic regression was performed to identify the independent contribution to mortality of DM and TMPG and the interaction between the 2 was assessed. Complete data were available for 3,265 patients, of whom 533 (16.3%) had DM. Diabetic patients were significantly older and heavier and had more risk factors for coronary disease and more previous MI, revascularization, and heart failure. There were no differences in rates of Thrombolysis In Myocardial Infarction grade 3 flow after PCI in the infarct artery or TMPG 2/3 between patients with and without DM. Compared to nondiabetics, mortality was significantly higher at 30 days and at 3 years in the DM group (1.8% vs 4.5%, p = 0.0002 and 5.4% vs 11.0%, p <0.0001, respectively). DM and TMPG were significantly associated with 3-year mortality, but there was no statistical interaction between DM and TMPG (p = 0.70). In conclusion, DM is associated with a significantly higher risk of death but this association is not mediated by impaired epicardial or myocardial reperfusion.     

Association of TIMI Myocardial Perfusion Grade and ST-segment resolution with cardiovascular magnetic resonance measures of microvascular obstruction and infarct size following ST-segment elevation myocardial infarction

Background Impairment of coronary microvascular perfusion is common among patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). Cardiovascular magnetic resonance imaging (CMR) can identify microvascular obstruction (MO) following reperfusion of STEMI. We hypothesized that myocardial perfusion, as assessed by the Thrombolysis in Myocardial Infarction (TIMI) Myocardial Perfusion Grade (TMPG), would be associated with a CMR metric of MO in this population. Methods Twenty-one STEMI patients who underwent successful primary PCI were evaluated. Contrast-enhanced CMR was performed within 7 days of presentation and repeated at three months. TIMI Flow Grade (TFG), corrected TIMI Frame Count (cTFC), TMPG, MO, infarct size, and left ventricular ejection fraction (EF) were assessed. Results The median peak creatine phosphokinase (CPK) was 1,775 IU/l (interquartile range 838–3,321). TFG 3 was present following PCI in 19 (90%) patients. CMR evidence of MO was present in 52% following PCI. Abnormal post-PCI TMPG (0/1/2) was present in 48% of subjects and was associated with MO on CMR (90% MO with TMPG 0/1/2 vs. 18% MO with TMPG 3, P < 0.01). Abnormal post-PCI TMPG was also associated with a greater peak CK (median 3,623 IU/l vs. 838 IU/l, P < 0.001) and greater relative infarct size (17.3% vs. 5.2%, P < 0.01). Conclusion Among STEMI patients undergoing primary PCI, post-PCI TMPG correlates with CMR measures of MO and infarct size. The combined use of both metrics in a comprehensive assessment of microvascular integrity and infarct size following STEMI may aid in the evaluation of future therapeutic strategies.     

Association of peripheral neutrophilia with adverse angiographic outcomes in ST-elevation myocardial infarction

We hypothesized that absolute and relative neutrophilia would be associated with adverse angiographic outcomes in the 394 patient Limitation of Myocardial Infarction Following Thrombolysis in Acute Myocardial Infarction (LIMIT) Acute Myocardial Infarction (AMI) trial of fibrinolysis in ST-elevation myocardial infarction. The mean neutrophil count was 7.9 x 10(9)/L, with a mean neutrophil percentage of 72%. Patients with time from symptom onset to fibrinolytic treatment more than the median (2.7 hours) had a higher neutrophil count and percentage of neutrophils than patients with shorter time to treatment. Patients with a closed infarct-related artery at 90 minutes (Thrombolysis In Myocardial Infarction [TIMI] grade 0/1 flow) had higher neutrophil counts (8.8 +/- 3.8 vs 7.6 +/- 3.0, p = 0.02) but no difference in the percentage of neutrophils than patients with an open artery. Higher neutrophil counts were also mildly correlated with longer corrected TIMI frame counts (CTFC) in the infarct-related artery (r = 0.14, p = 0.02). Patients with impaired myocardial perfusion by TIMI myocardial perfusion grade (TMPG) had a greater percentage of neutrophils (73.2 +/- 10.7% for TMPG 0/1 vs 69.9 +/- 12.6% for TMPG 2/3, p = 0.047) but no detectable difference in neutrophil counts (8.2 +/- 3.3 vs 7.7 +/- 2.9, p = 0.24). There were no significant associations between other indexes in the cell differential and angiographic or clinical outcomes. Higher neutrophil counts remained independently associated with both closed arteries and CTFC in multivariable models controlling for age, left anterior descending artery infarct location, time to treatment, and pulse and blood pressure on admission. A greater percentage of neutrophils remained independently associated with impaired microvascular perfusion in a similar multivariable model. In patients with ST-elevation myocardial infarction, absolute and relative neutrophilia were associated with impaired epicardial and microvascular perfusion.     

冠状动脉内应用维拉帕米对急性心肌梗死急诊介入治疗后冠状动脉灌注、心肌灌注和临床预后的影响

目的探讨急性ST段抬高性心肌梗死（STEMI）急诊经皮冠状动脉介入治疗（PCI）时冠状动脉内应用维拉帕米对冠状动脉灌注、心肌灌注及临床预后的影响。方法本研究为前瞻性、随机、双盲、对照性临床研究。连续性入选99例STEMI拟行急诊PCI的患者,随机分为维拉帕米组与对照组。在支架释放后即刻,维拉帕米组在靶血管内注入维拉帕米200μg,对照组在靶血管内注入肝素生理盐水,比较两组PCI术前、术后和冠状动脉内注药后的冠状动脉灌注和心肌灌注的差别。冠状动脉灌注以心外膜TIMI血流（TFG）和校正的TIMI血流帧数计数（CTFC）来评价。心肌灌注以TIMI心肌灌注分级（TMPG）和心肌灌注显影（MBG）来评价。并比较两组在PCI术后1周心脏彩色超声结果、住院期间以及随访期间主要心脏不良事件（MACE）发生率上的差别。结果最终91例患者有完整资料,其中维拉帕米组47例,对照组44例,两组临床基本特征和造影特征相仿。维拉帕米组和对照组在术前和支架释放后即刻冠状动脉灌注和心肌灌注各指标差异均无统计学意义（P〉0.05）。冠状动脉内注入维拉帕米后,维拉帕米组的CTFC、TFG、MBG、TMPG均较对照组有显著改善,分别为CTFC：27.1±14.2比39.0±23.8,P=0.011;TFG≥2级：100%比90.9%,P=0.035;MBG≥2级：91.5%%比75.5%,P=0.034;TMPG≥2级：89.4%比72.7%,P=0.042。维拉帕米组和对照组PCI术后1周时左室射血分数（63.4%±8.2%比63.5%±10.3%,P=0.578）、院内MACE发生率（4.3%比9.1%,P=0.613）和3个月MACE发生率（23.9%比22.7%,P=0.894）差异均无统计学意义。结论STEMI患者急诊行PCI治疗时,冠状动脉内应用维拉帕米可显著改善冠状动脉灌注和心肌灌注水平,但未观察到其对急诊PCI术后心室重构和短期临床预后的显著影响。     

Angiographic perfusion score: an angiographic variable that integrates both epicardial and tissue level perfusion before and after facilitated percutaneous coronary intervention in acute myocardial infarction

Background

Both epicardial and myocardial perfusion have been associated with clinical outcomes in the setting of ST elevation myocardial infarction (STEMI), and the performance of adjunctive/rescue percutaneous coronary intervention (PCI) may further improve clinical outcomes after fibrinolytic administration.

Methods

The goal was to develop a simple, broadly applicable angiographic metric that takes into account indices of epicardial and myocardial perfusion both before and after PCI to arrive at a single perfusion grade in patients undergoing cardiac catheterization after fibrinolysis. The angiographic perfusion score (APS) is the sum of the Thrombolysis in Myocardial Infarction (TIMI) flow grade (TFG; 0-3) added to the TIMI myocardial perfusion grade (TMPG; 0-3) before and after PCI (total possible grade, 0-12). Failed perfusion was defined as an APS of 0 to 3, partial perfusion was defined as an APS of 4 to 9, and full perfusion was defined as an APS of 10 to 12. The APS was evaluated in patients from the Double-blind, Placebo-contolled, Multicenter Angiographic Trial of Rhumab CD18 in Acute Myocardial Infarction (LIMIT-AMI; n = 394) and Enoxaparin as Adjunctive Antithrombin Therapy for ST-Elevation Myocardial Infarction-Thrombolysis In Myocardial Infarction (ENTIRE-TIMI) 23 trials (n = 483), and infarct size (120-216 hours after AMI SPECT Technetium-99m Sestamibi data) was assessed in the LIMIT-AMI trial.

Results

The APS was associated with the incidence of death or myocardial infarction (failed, 16.7% [n = 18]; partial, 2.5% [n = 155]; full, 2.4% [n = 82]; P = .039 for trend) and larger SPECT infarct sizes (failed, median 39% [n = 10]; partial, 12% [n = 79]; and full, 8% [n = 35]; P = .002). No patient with full APS died, whereas the mortality rate was 11.1% in patients with a failed APS (P = .03).

Conclusions

The APS combines grades of epicardial and tissue level perfusion before and after PCI or at the end of diagnostic cardiac catheterization to arrive at a single angiographic variable that is associated with infarct size and the rates of 30-day death or MI. Partial or full angiographic perfusion scores are associated with a halving of infarct size, and no patients with full angiographic perfusion died.     

Association of Epicardial and Tissue-Level Reperfusion with Left Ventricular End-Diastolic Pressures in ST-Elevation Myocardial Infarction

Unfavorable hemodynamics among patients with ST-elevation myocardial infarction (STEMI) have been associated with adverse clinical outcomes and may be linked to a failure to achieve complete reperfusion. We hypothesized that impaired epicardial and tissue-level perfusion after fibrinolytic therapy would be associated with adverse hemodynamics. The relationship between left ventricular end-diastolic pressure (LVEDP), baseline clinical characteristics, and angiographic findings were examined in 666 patients with STEMI treated with fibrinolytic therapy from the TIMI 14, INTEGRITI (TIMI 20), ENTIRE (TIMI 23), and FASTER (TIMI 24) trials. LVEDP was analyzed as a dichotomous variable with an elevated LVEDP defined as LVEDP >18 mmHg (median value). Higher post-fibrinolytic LVEDP was associated with age > or = 65, female gender, Killip Class II-IV on presentation, and LAD culprit location. Elevated LVEDP was associated with both a closed infarct-related artery (58.8% of TIMI Flow Grade (TFG) 0/1 with elevated LVEDP vs. 46.6% of TFG 2/3, p = 0.03) and impaired myocardial perfusion (55.7% of TIMI Myocardial Perfusion Grade (TMPG) 0/1 with elevated LVEDP vs. 43.8% of TMPG 2/3, p = 0.02). In a multivariate analysis, impaired myocardial perfusion (OR 1.7, p = 0.02), abnormal Killip Class (OR 4.8, p = 0.001), age > or = 65 (OR 1.6, p = 0.04), and female gender (OR 1.9, p = 0.01) were independently associated with elevated LVEDP. Elevated LVEDP was independently associated with a greater incidence of in-hospital (OR 11.8, p = 0.02) and 30-day congestive heart failure (OR 4.4, p = 0.02). In STEMI, angiographic indices of incomplete reperfusion are associated with an elevated LVEDP, and elevated LVEDP is associated with adverse clinical outcomes.     

Effects of glucose-insulin-potassium infusion on myocardial perfusion and left ventricular remodeling in patients treated with primary angioplasty for ST-elevation acute myocardial infarction

The role of glucose-insulin-potassium (GIK) infusion in the management of acute coronary syndrome is controversial. Limited data are available on the effects of adjunctive high-dose GIK (30% glucose, 50 IU of insulin, 80 mEq of potassium chloride infused at 1.5 ml/kg/hour over 24 hours) on myocardial perfusion and left ventricular (LV) remodeling in patients treated with primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction. In this prospective study, 73 patients were randomized to receive GIK infusion (n = 40) or saline (placebo, n = 33) in addition to standard therapy. The primary end points were myocardial perfusion after PCI and LV remodeling at 6 months. Thrombolysis In Myocardial Infarction frame count and myocardial blush grade were evaluated before and after reperfusion treatment. LV end-diastolic and end-systolic volumes, ejection fraction, and wall motion score index were assessed in each patient after PCI and after 6 months. Although no differences in final Thrombolysis In Myocardial Infarction flow were observed between the 2 groups, myocardial blush grade 3 was more frequently achieved in the GIK group (p <0.05). At 6 months, ventricular remodeling was more often observed in the control group (24% vs 3%, p <0.05). In conclusion, GIK infusion in adjunct to primary PCI in patients with ST-segment elevation myocardial infarction was safe, improved myocardial perfusion after revascularization, and was associated with less LV remodeling at follow-up.     

Association of the timing of ST-segment resolution with TIMI myocardial perfusion grade in acute myocardial infarction

Background

More complete ST-segment resolution (ST res) in acute myocardial infarction (MI) has been associated with better epicardial and myocardial reperfusion as assessed with the Thrombolysis in Myocardial Infarction (TIMI) flow grade (TFG) and the TIMI myocardial perfusion grade (TMPG), respectively. However, no data exist comparing the speed of ST resolution on continuous electrocardiogram (ECG) monitoring with the TMPG on coronary angiography. We hypothesized that delayed ST res is associated with impaired TMPGs.

Methods

Continuous 12-lead ECG recordings and 60-minute angiographic data were analyzed in 120 patients with acute MI who received tenectaplase monotherapy or combination therapy with low-dose tenectaplase and eptifibatide in the Integrilin and Tenecteplase in Acute Myocardial Infarction (INTEGRITI) trial.

Results

More rapid ST res on continuous ECG monitoring was associated with improved TMPGs on coronary angiography performed 60 minutes after study drug administration. For TMPG 3, the median time to ST resolution was 53 minutes. For TMPG 2, 1, and 0, the corresponding times were 64 minutes, 80 minutes, and 106 minutes, respectively (P = .01 for trend). Likewise, more rapid ST res was also associated with faster epicardial flow. For TFG 3, the median time to ST resolution was 46 minutes, compared with 109 minutes for TIMI flow grades 0 to 2 (P = .001). The corresponding times for a corrected TIMI frame count ≤40 versus >40 were 52 minutes and 112 minutes, respectively (P <.001).

Conclusions

Although the static ECG has been associated with epicardial and myocardial blood flow in the past, this study extends these observations to demonstrate that more rapid ST res on continuous ECG monitoring is associated with improved myocardial perfusion after thrombolytic administration.     

Relation of hyperemic epicardial flow to outcomes among patients with ST-segment elevation myocardial infarction receiving fibrinolytic therapy

In patients with ST-segment elevation myocardial infarction (STEMI), the restoration of normal epicardial flow following fibrinolytic administration is associated with improved clinical outcomes. The goal of this analysis was to examine the relation between hyperemic flow and outcomes following fibrinolytic administration for STEMI. In Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis In Myocardial Infarction 28 (CLARITY-TIMI 28), patients with STEMI (n=3,491) treated with fibrinolytic therapy were scheduled to undergo angiography 48 to 192 hours after randomization. Corrected TIMI frame count (CTFC) and TIMI myocardial perfusion grade (TMPG) were assessed, and their associations with outcomes at 30 days were evaluated. When evaluating initial angiography of the infarct-related artery, there was a nearly linear relation between CTFC and 30-day mortality, with faster flow (lower CTFC) associated with improved outcomes. Conversely, in patients who underwent percutaneous coronary intervention (PCI), very fast flow (CTFC<14) after intervention was associated with worse outcomes. Post-PCI hyperemic flow (CTFC<14) was associated with a higher incidence of mortality (p=0.056), recurrent myocardial infarction (p=0.011), and a composite of death or myocardial infarction (p<0.001) compared with normal flow (CTFC 14 to 28). When post-PCI CTFC was further stratified by TMPG, there was a U-shaped relation between mortality and CTFC in patients with poor myocardial perfusion (TMPG 0 or 1). This relation appeared to be linear in patients with TMPG 2 or 3. In conclusion, in patients who undergo PCI after fibrinolytic therapy for STEMI, hyperemic flow on coronary angiography is associated with an increased incidence of adverse outcomes. Hyperemic flow with associated impaired myocardial perfusion may be a marker of more extensive downstream microembolization.     

直接经皮冠状动脉介入治疗患者血浆高敏C反应蛋白水平与心肌灌注的相关性研究

目的分析急性心肌梗死患者入院时血浆高敏C反应蛋白(hs-CRP)水平和直接经皮冠状动脉介入治疗(PCI)术后心肌灌注的关系。方法选择2001年10月—2004年12月在我院住院治疗的首发急性心肌梗死患者197例,其中男154例,女43例,平均年龄(60.94±11.62)岁。TIMI心肌灌注分级(TIMImyocardialperfusiongrade,TMPG)0~1级患者为Ⅰ组(n=39,19.8%),TMPG2~3级患者为Ⅱ组(n=158,80.2%)。所有入选患者第一次空腹静脉血检测甘油三酯、总胆固醇、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇、hs-CRP;并在发病后2、6、10、12、16、24、48、72h静脉抽血测定肌酸激酶同工酶;发病48h内超声心动图测定左室射血分数值。结果两组患者之间年龄、性别、病史差异无统计学意义。Ⅰ组与Ⅱ组比较,入院时血浆hs-CRP水平差异有统计学意义[(8.29±4.75)mg/L比(6.38±4.73)mg/L,P=0.026]。肌酸激酶峰值[(3017.85±1901.19)U/L比(2701.41±1992.97)U/L]、肌酸激酶同工酶峰值[(442.37±333.29)U/L比(355.91±287.99)U/L]、发病到球囊扩张的时间两组间差异无统计学意义。结论hs-CRP是炎性反应的标志物,反映了斑块局部的稳定性;直接PCI患者血浆hs-CRP水平是PCI术后心肌再灌注不良的重要影响因素。     

Randomized comparison of upstream tirofiban versus downstream high bolus dose tirofiban or abciximab on tissue-level perfusion and troponin release in high-risk acute coronary syndromes treated with percutaneous coronary interventions: the EVEREST trial.

OBJECTIVES: We aimed to compare the effects of upstream tirofiban versus downstream high-dose bolus (HDB) tirofiban and abciximab on tissue level perfusion and troponin I release in high-risk non-ST-segment elevation acute coronary syndrome (ACS) patients treated with percutaneous coronary intervention (PCI). BACKGROUND: Optimal timing and dosage of glycoprotein IIb/IIIa inhibitors for ACS remain to be explored. METHODS: We randomized 93 high-risk ACS patients undergoing PCI to receive upstream (in the coronary care unit) tirofiban, downstream (just prior to PCI) HDB tirofiban, and downstream abciximab. We evaluated the effects of the three drug regimens on tissue-level perfusion using the corrected Thrombolysis In Myocardial Infarction (TIMI) frame count, the TIMI myocardial perfusion grade (TMPG), and intracoronary myocardial contrast echocardiography (MCE) before and immediately after PCI and after cardiac troponin I (cTnI). RESULTS: The TMPG 0/1 perfusion was significantly less frequent with upstream tirofiban compared with HDB tirofiban and abciximab both before (28.1% vs. 66.7% vs. 71%, respectively; p = 0.0009) and after PCI (6.2% vs. 20% vs. 35.5%, respectively; p = 0.015). Upstream tirofiban was also associated with a significantly higher MCE score index (0.88 +/- 0.18 vs. 0.77 +/- 0.32 vs. 0.71 +/- 0.30, respectively; p < 0.05). Post-procedural cTnI elevation was significantly less frequent among patients in the upstream tirofiban group compared with the HDB tirofiban and abciximab groups (9.4% vs. 30% vs. 38.7%, respectively; p = 0.018). The cTnI levels after PCI were significantly lower with upstream tirofiban compared with HDB tirofiban (3.8 +/- 4.1 vs. 7.2 +/- 12; p = 0.015) and abciximab (3.8 +/- 4.1 vs. 9 +/- 13.8; p = 0.0002) CONCLUSIONS: Among high-risk non-ST-segment-elevation ACS patients treated with an early invasive strategy, upstream tirofiban is associated with improved tissue-level perfusion and attenuated myocardial damage.     

The impact of admission C-reactive protein levels on the development of poor myocardial perfusion after primary percutaneous intervention in patients with acute myocardial infarction

BACKGROUND: Increased preprocedural C-reactive protein (CRP) levels in patients with acute myocardial infarction (MI) undergoing primary percutaneous coronary intervention (PCI) may affect myocardial perfusion. Accordingly, this study was designed to investigate the impact of admission CRP levels on the development of poor myocardial perfusion after PCI in patients with acute MI. METHODS: The study population consisted of 75 patients (62 men, mean age, 61.6+/-6.68 years), who were admitted to our hospital with acute anterior MI and who underwent primary PCI in the left anterior descending coronary artery. All patients underwent stenting following balloon angioplasty. Myocardial perfusion was evaluated by using Thrombolysis In Myocardial Infarction (TIMI) myocardial perfusion grade (TMPG). Patients were divided into two groups according to TMPG after PCI. Group 1 consisted of 25 patients with TMPG 0-1 and group 2 comprised 50 patients with TMPG 2-3. Admission serum high sensitive CRP (hs-CRP) levels were analysed by using nephelometric method. RESULTS: Admission hs-CRP levels, pain to balloon time and white blood cell count (WBC) of patients in group 1 were significantly higher than those of the patients in group 2 (P<0.001; P<0.001; P=0.002, respectively). Univariate analysis identified ejection fraction, pain to balloon time, WBC and hs-CRP levels as the predictors of poor myocardial perfusion. In multivariate logistic regression analysis, hs-CRP levels and pain to balloon time were found to have statistically significant independent association with poor myocardial perfusion. Adjusted odds ratios were calculated as 1.85 for hs-CRP [P=0.003; 95% confidence interval (CI), 1.23-2.80] and 5.49 for pain to balloon time (P=0.04; 95% CI, 1.08-27.84). CONCLUSIONS: On admission, high CRP level in patients with acute MI undergoing primary PCI is likely to be in the causal pathway leading to the development of poor myocardial perfusion, especially when combined with prolonged pain to balloon time.     

替格瑞洛在补救PCI患者中的疗效及安全性

目的 观察替格瑞洛在溶栓失败后补救性经皮冠状动脉介入治疗（PCI）患者中的疗效及安全性。方法 入选2013~2014年因急性ST段抬高型心肌梗死（STEMI）的溶栓失败后12 h内于我院行补救PCI的患者246例。随机将符合条件的患者分为替格瑞洛组（n=121）和氯吡格雷组（n=125）,替格瑞洛组术前给予替格瑞洛180 mg,术后90 mg bid联合阿司匹林100 mg qd;氯吡格雷组术前给予氯吡格雷300 mg,术后75 mg qd联合阿司匹林100 mg qd。采用TIMI血流分级（TFG）、校正的TIMI记帧（CTFC）和TIMI心肌灌注分级（TMPG）评价比较两组术后心肌灌注水平。随访12月比较两组患者的主要不良心脑血管事件（MACCE）的发生率和出血事件及其它不良事件的发生率。结果 两组心肌灌注水平差异无统计学意义。替格瑞洛组与氯吡格雷组相比MACCE复合终点累计发生率降低,差异具有统计学意义（6.6% vs. 15.2% HR=0.395,95%CI:0.166-0.940,P<0.05）。两组总体主要出血、主要致命/危及生命的出血事件发生率差异无统计学意义。结论 替格瑞洛在溶栓失败后补救PCI患者中同样安全有效。     

Prognostic value of Angiographic Perfusion Score (APS) following percutaneous interventions in acute coronary syndromes

IntroductionIdentifying reperfusion and predicting post procedure risk is important following Percutaneous Coronary Interventions (PCI). An Angiographic Perfusion Score (APS) combining TIMI flow (TFG) and myocardial perfusion (TMPG) grades before and after PCI can accurately measure both epicardial and myocardial perfusion and predict Major Adverse Cardiac Events (MACE).Patients and methodsAPS was calculated in 226 (88 ST elevation Myocardial Infarction (STEMI) and 138 Non STEMI) patients. Maximum score being 12, reperfusion was defined as failed: 0–3, partial: 4–9, and full APS: 10–12. Thirty day MACE were observed.ResultsAPS identified reperfusion significantly more than TMPG alone (STEMI: 50.6% vs 11.8% (p < 0.001); Non STEMI, early reperfusion: 69.4% vs 52.8% (p < 0.01) and Non STEMI late reperfusion: 38.2% vs 7.8%; (p ≤ 0.001) respectively. A significantly lower incidence of MACE was observed in the full as compared to the failed APS group (1.8% vs 22.5%) (p < 0.001). No differences were noted between TMPG 0–2 (9.8%, 9.4%, 7.3%, respectively) (p = NS).ConclusionCompared to MPG alone APS detects more low risk reperfused patients, post PCI.     

Restoration of microcirculatory patency after myocardial infarction: results of current coronary interventional strategies and techniques

We sought to evaluate the restoration of microcirculatory patency after primary percutaneous coronary intervention (PCI) in an unselected cohort of patients at a tertiary center.We retrospectively evaluated distributions of the Thrombolysis in Myocardial Infarction (TIMI) myocardial perfusion grade (TMPG) and the myocardial blush grade (MBG) in all primary PCI procedures performed at our institution during 2008. We defined optimal microvascular perfusion as simultaneous TMPG 3 and MBG 3 at procedure's end.Ninety-nine patients (mean age, 61.5 ± 12.7 yr; 64 men) underwent primary PCI. Microvascular perfusion was optimal in 69 patients (69.7%) and was associated with lower peaks of enzymes than those occurring in patients with suboptimal perfusion. When optimal microvascular perfusion was achieved, early spontaneous recanalization was more frequently observed, as expressed by a higher frequency of TIMI-3 flow (34.8% vs 10%; P=0.006), TMPG 3 (26% vs 3.3%; P=0.004), and MBG 3 (24.6% vs 3.3%; P=0.004) on the initial angiogram before primary PCI. A higher frequency of MBG 3 (50% vs 20%; P=0.005) was seen after initial recanalization in patients with optimal microvascular perfusion. Multiple regression analysis showed that MBG after initial recanalization and the use of drug-eluting stents were associated with optimal perfusion.Despite successful recanalization of the culprit coronary artery, optimal microvascular perfusion was achieved in less than 75% of the patients. Restoration of the microvasculature was associated with smaller infarcts. Procedure-related variables associated with suboptimal perfusion were unlikely to be causative.     

Comparative early and late outcomes after primary percutaneous coronary intervention in ST-segment elevation and non-ST-segment elevation acute myocardial infarction (from the CADILLAC trial)

We determined the outcomes of patients with acute ST-segment elevation (STE) myocardial infarction (STEMI) and non-STEMI (NSTEMI) after primary percutaneous coronary intervention (PCI). The prognosis after primary PCI in STEMI has been extensively studied and defined. Outcomes of patients who undergo primary PCI for NSTEMI are less well established. In total, 2,082 patients with ongoing chest pain for > 30 minutes consistent with acute MI were randomized to balloon angioplasty versus stenting, each with/without abciximab. Of 1,964 patients, STEMI was present in 1,725 (87.8%) and NSTEMI in 239 (12.2%). Compared with STEMI, those with NSTEMI were more likely to have delayed time-to-hospital arrival (2.4 vs 1.8 hours, p = 0.0002) and increased door-to-balloon time (3.2 vs 1.9 hours, p < 0.0001). Patients with NSTEMI were more likely to have Thrombolysis In Myocardial Infarction grade 3 flow at baseline (37.3% vs 19.4%, p < 0.0001) and higher ejection fraction (58.7% vs 55.8%, p = 0.001), but similar rates of postprocedural Thrombolysis In Myocardial Infarction grade 3 flow. At 1 year, patients with NTEMI had similar mortality (3.4% vs 4.4%, p = 0.40) but higher rates of major adverse cardiac events (24.0% vs 16.6%, p = 0.007) that was driven by more frequent ischemic target vessel revascularization (21.8% vs 11.9%, p <0.0001). In conclusion, patients with acute MI without STE who are treated with primary PCI have marked delays to treatment, similar late mortality, and increased rates of ischemic target vessel revascularization compared with patients with STEMI, despite more favorable angiographic features at presentation and similar reperfusion success. The adverse prognosis of patients with NSTEMI should be recognized and efforts made to decrease reperfusion times.     

Percutaneous coronary intervention in patients receiving enoxaparin or unfractionated heparin after fibrinolytic therapy for ST-segment elevation myocardial infarction in the ExTRACT-TIMI 25 trial.

OBJECTIVES: We sought to evaluate whether enoxaparin (ENOX) is superior to unfractionated heparin (UFH) as adjunctive therapy for patients with ST-segment elevation myocardial infarction (STEMI) who receive fibrinolytic therapy and subsequently undergo percutaneous coronary intervention (PCI) by analyzing data from the ExTRACT-TIMI 25 (Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment-Thrombolysis In Myocardial Infarction 25) trial. BACKGROUND: Limited data are available on the use of ENOX compared with UFH as adjunctive therapy in STEMI patients treated with fibrinolytic therapy and subsequent PCI. METHODS: A total of 20,479 STEMI patients who received fibrinolytic therapy were randomized to a strategy of ENOX throughout index hospitalization or UFH for at least 48 h, with blinded study drug to continue if PCI was performed. The primary end point of death or recurrent MI through 30 days was compared for ENOX versus UFH among the patients who underwent subsequent PCI (n = 4,676). RESULTS: After initial fibrinolysis, fewer patients underwent PCI through 30 days in the ENOX versus the UFH group (22.8% vs. 24.2%; p = 0.027). Among patients who underwent PCI by 30 days, the primary end point occurred in 10.7% of ENOX and 13.8% of UFH patients (0.77 relative risk; p < 0.001). There were no differences in major bleeding for ENOX versus UFH (1.4% vs. 1.6%; p = NS). Results were similar when PCI was carried out in patients receiving blinded study drug during PCI (n = 2,178). CONCLUSION: Among patients treated with fibrinolytic therapy for STEMI who underwent subsequent PCI, ENOX administration was associated with a reduced risk of death or recurrent MI without difference in the risk of major bleeding. The strategy of ENOX support for fibrinolytic therapy followed by PCI is superior to UFH and provides a seamless transition from the medical management to the interventional management phase of STEMI without the need for introducing a second anticoagulant in the cardiac catheterization laboratory.     

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.