CLINICAL STUDIES
Prognostic implications of TIMI flow grade in the infarct related artery compared with continuous 12-lead ST-segment resolution analysis
Reexamining the "gold standard" for myocardial reperfusion assessment
Akbar Shah, MDa,
Galen S. Wagner, MDa,
Christopher B. Granger, MD, FACCa,
Christopher M. O’Connor, MD, FACCa,
Cynthia L. Green, MSa,
Kathleen M. Trollinger, RNa,
Robert M. Califf, MD, FACCa and
Mitchell W. Krucoff, MD, FACCa
a Duke University Medical Center, Durham, North Carolina, USA
Manuscript received August 10, 1998;
revised manuscript received September 21, 1999,
accepted November 15, 1999.
Reprint requests and correspondence: Dr. Akbar Shah, 1380 E. Stroop Road, Cardiology South, Inc., Kettering, Ohio 45429
Shah7865{at}aol.com
OBJECTIVE
To compare the prognostic significance of reperfusion assessment by Thrombolysis in Myocardial Infarction (TIMI) flow grade in the infarct related artery and ST-segment resolution analysis, by correlating with clinical outcomes in patients with acute myocardial infarction (AMI).
BACKGROUND
Angiographic assessment, based on epicardial coronary anatomy, has been considered the "gold standard" for reperfusion. The electrocardiogram (ECG) monitoring provides a noninvasive, real-time physiologic marker of cellular reperfusion and may better predict clinical outcomes.
METHODS
Two hundred fifty-eight AMI patients from the Thrombolytics and Myocardia Infarction phase 7 and Global Utilization of Streptokinase tPA for Occluded coronary arteries phase 1 trials were stratified based on blinded, simultaneous reperfusion assessment on the acute angiogram (divided into TIMI grades 0 & 1, TIMI grade 2 and TIMI grade 3) and ST-segment resolution analysis (divided into: <50% ST-segment elevation resolution or reelevation and  50% ST-segment elevation resolution). In-hospital mortality, congestive heart failure (CHF) and combined mortality or CHF were compared to determine the prognostic significance of reperfusion assessment by each modality using chi-square and Fisher’s Exact tests for univariable correlation and logistic regression analysis for univariable and multivariable prediction models.
RESULTS
By logistic regression analysis, ST-segment resolution patterns were an independent predictor of the combined outcome of mortality or CHF (p = 0.024), whereas TIMI flow grade was not (p = 0.693). Among the patients determined to have failed reperfusion by TIMI flow grade assessment (TIMI flow grade 0 & 1), the ST-segment resolution of 50% identified a subgroup with relatively benign outcomes with the incidence of the combined end point of mortality or CHF 17.2% versus 37.2% in those without ST-segment resolution (p = 0.06).
CONCLUSION
Continuous 12-lead ECG monitoring can be an inexpensive and reliable modality for monitoring nutritive reperfusion status and to obtain prognostic information in patients with AMI.
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Abbreviations and Acronyms
| | AMI | = acute myocardial infarction | | CHF | = congestive heart failure | | CPK | = creatinine phosphokinase | | ECG | = electrocardiogram | | GUSTO-1 | = Global Utilization of Streptokinase tPA for Occluded coronary arteries phase 1 | | IRA | = infarct related artery | | LVEF | = left ventricular ejection fraction | | TAMI-7 | = Thrombolytics and Myocardia Infarction phase 7 | | TIMI | = Thrombolysis in Myocardial Infarction |
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