CLINICAL STUDY: MYOCARDIAL INFARCTION
Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction
Gregg W. Stone, MD, FACC*,*,
Michael A. Peterson, MD ,
Alexandra J. Lansky, MD, FACC*,
George Dangas, MD, FACC*,
Roxana Mehran, MD, FACC* and
Martin B. Leon, MD, FACC*
* Cardiovascular Research Foundation, Lenox Hill Heart and Vascular Institute, New York, New York, USA
The Washington Hospital Center, Washington, DC, USA
Manuscript received June 22, 2001;
revised manuscript received October 31, 2001,
accepted November 13, 2001.
* Reprint requests and correspondence: Dr. Gregg W. Stone, The Cardiovascular Research Foundation, 55 E. 59th St., 6th Floor, New York, NY 10022, USA.
gstone{at}crf.org
OBJECTIVES: We sought to evaluate and validate the ability of the angiographic myocardial blush grade to risk stratify patients after successful angioplasty in acute myocardial infarction (AMI).
BACKGROUND: Although epicardial Thrombolysis In Myocardial Infarction (TIMI)-3 flow is restored in >90% of patients undergoing primary percutaneous coronary intervention (PCI), normal myocardial perfusion may be present less frequently and may detrimentally impact survival.
METHODS: A cohort of 173 consecutive patients undergoing intervention within 24 h of AMI onset were studied. High-risk features of this population included failed thrombolysis in 39%, cardiogenic shock in 17% and saphenous vein graft culprit in 11% of patients.
RESULTS: Despite the restoration of TIMI-3 flow in 163 (94.2%) patients, myocardial perfusion, as evidenced by normal contrast opacification of the myocardial bed subtended by the infarct artery (myocardial blush), was normal in only 29.4% of patients with TIMI-3 flow following PCI, and in no patient with TIMI 0 to 2 flow. In patients in whom TIMI-3 flow was restored, survival was strongly dependent on the myocardial perfusion grade; one-year cumulative mortality was 6.8% with normal myocardial blush, 13.2% with reduced myocardial blush and 18.3% in patients with absent myocardial blush (p = 0.004).
CONCLUSIONS: Abnormal myocardial perfusion is present in most patients following primary or rescue PCI in AMI, despite restoration of brisk epicardial coronary flow. In high risk patients achieving TIMI-3 flow after intervention, the myocardial blush score may be used to stratify prognosis into excellent, intermediate and poor survival. Further study is warranted to examine whether adjunctive mechanical or pharmacologic strategies can further improve myocardial perfusion and survival of patients with acute myocardial infarction undergoing intervention.
|
Abbreviations and Acronyms
| | CPK-MB | | AMI | | acute myocardial infarction | | CABG | | coronary artery prior bypass grafting | | CPK-MB | | creatine phosphokinase-MB isozyme | | LAD | | left anterior descending artery | | LCX | | left circumflex artery | | PCI | | percutaneous coronary intervention | | RAO | | right anterior oblique | | RCA | | right coronary artery | | TIMI | | Thrombolysis In Myocardial Infarction |
|
This article has been cited by other articles:
|
|
|
|
 
F. Liistro, S. Grotti, P. Angioli, G. Falsini, K. Ducci, S. Baldassarre, A. Sabini, R. Brandini, E. Capati, and L. Bolognese
Impact of Thrombus Aspiration on Myocardial Tissue Reperfusion and Left Ventricular Functional Recovery and Remodeling After Primary Angioplasty
Circ Cardiovasc Interv,
October 1, 2009;
2(5):
376 - 383.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Srinivasan, C. Rihal, D. R. Holmes, and A. Prasad
Adjunctive Thrombectomy and Distal Protection in Primary Percutaneous Coronary Intervention: Impact on Microvascular Perfusion and Outcomes
Circulation,
March 10, 2009;
119(9):
1311 - 1319.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. A. Bavry, D. J. Kumbhani, and D. L. Bhatt
Role of adjunctive thrombectomy and embolic protection devices in acute myocardial infarction: a comprehensive meta-analysis of randomized trials
Eur. Heart J.,
December 2, 2008;
29(24):
2989 - 3001.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. De Luca
Adjunctive antithrombotic therapy during primary percutaneous coronary intervention
Eur. Heart J. Suppl.,
December 1, 2008;
10(suppl_J):
J2 - J14.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Albertal, F. Cura, A. G. Escudero, L. T. Padilla, J. Thierer, M. Trivi, J. A Belardi, and PREMIAR InvestigatorsBelardi
Relationship Between Collateral Circulation and Successful Myocardial Reperfusion in Acute Myocardial Infarction: A Subanalysis of the PREMIAR Trial
Angiology,
October 1, 2008;
59(5):
587 - 592.
[Abstract]
[PDF]
|
|
|
|
|
|
|
Y. Ikari, M. Sakurada, K. Kozuma, S. Kawano, T. Katsuki, K. Kimura, T. Suzuki, T. Yamashita, A. Takizawa, K. Misumi, et al.
Upfront Thrombus Aspiration in Primary Coronary Intervention for Patients With ST-Segment Elevation Acute Myocardial Infarction: Report of the VAMPIRE (VAcuuM asPIration thrombus REmoval) Trial
J. Am. Coll. Cardiol. Intv.,
August 1, 2008;
1(4):
424 - 431.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Majidi, A. S. Kosinski, S. M. Al-Khatib, M. E. Lemmert, L. Smolders, A. van Weert, J. H.C. Reiber, D. Tzivoni, F. W.H.M. Bar, H. J.J. Wellens, et al.
Reperfusion ventricular arrhythmia 'bursts' in TIMI 3 flow restoration with primary angioplasty for anterior ST-elevation myocardial infarction: a more precise definition of reperfusion arrhythmias
Europace,
August 1, 2008;
10(8):
988 - 997.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. A. Leopold
Does Thrombolytic Therapy Facilitate or Foil Primary PCI?
N. Engl. J. Med.,
May 22, 2008;
358(21):
2277 - 2279.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Svilaas, P. J. Vlaar, I. C. van der Horst, G. F.H. Diercks, B. J.G.L. de Smet, A. F.M. van den Heuvel, R. L. Anthonio, G. A. Jessurun, E.-S. Tan, A. J.H. Suurmeijer, et al.
Thrombus Aspiration during Primary Percutaneous Coronary Intervention
N. Engl. J. Med.,
February 7, 2008;
358(6):
557 - 567.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. M. Gibson, Y. B. Pride, J. L. Buros, E. Lord, A. Shui, S. A. Murphy, D. S. Pinto, P. J. Zimetbaum, M. S. Sabatine, C. P. Cannon, et al.
Association of impaired thrombolysis in myocardial infarction myocardial perfusion grade with ventricular tachycardia and ventricular fibrillation following fibrinolytic therapy for ST-segment elevation myocardial infarction.
J. Am. Coll. Cardiol.,
February 5, 2008;
51(5):
546 - 551.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Seyfeli, A. Abaci, M. Kula, R. Topsakal, N. K. Eryol, H. Arinc, I. Ozdogru, and A. Ergin
Myocardial Blush Grade: To Evaluate Myocardial Viability in Patients With Acute Myocardial Infarction
Angiology,
November 1, 2007;
58(5):
556 - 560.
[Abstract]
[PDF]
|
|
|
|
|
|
|
X. Liu, Y. Huang, P. Pokreisz, P. Vermeersch, G. Marsboom, M. Swinnen, E. Verbeken, J. Santos, M. Pellens, H. Gillijns, et al.
Nitric Oxide Inhalation Improves Microvascular Flow and Decreases Infarction Size After Myocardial Ischemia and Reperfusion
J. Am. Coll. Cardiol.,
August 21, 2007;
50(8):
808 - 817.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. C. Keeley and L. D. Hillis
Primary PCI for Myocardial Infarction with ST-Segment Elevation
N. Engl. J. Med.,
January 4, 2007;
356(1):
47 - 54.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. J. Kirtane, J. J. Vafai, S. A. Murphy, J. M. Aroesty, M. S. Sabatine, C. P. Cannon, C. M. Gibson, and for the TIMI Study Group
Angiographically evident thrombus following fibrinolytic therapy is associated with impaired myocardial perfusion in STEMI: a CLARITY-TIMI 28 substudy
Eur. Heart J.,
September 1, 2006;
27(17):
2040 - 2045.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Kaltoft, M. Bottcher, S. S. Nielsen, H.-H. T. Hansen, C. Terkelsen, M. Maeng, J. Kristensen, L. Thuesen, L. R. Krusell, S. D. Kristensen, et al.
Routine Thrombectomy in Percutaneous Coronary Intervention for Acute ST-Segment-Elevation Myocardial Infarction: A Randomized, Controlled Trial
Circulation,
July 4, 2006;
114(1):
40 - 47.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L De Luca, G Sardella, C J Davidson, G De Persio, M Beraldi, T Tommasone, M Mancone, B L Nguyen, L Agati, M Gheorghiade, et al.
Impact of intracoronary aspiration thrombectomy during primary angioplasty on left ventricular remodelling in patients with anterior ST elevation myocardial infarction
Heart,
July 1, 2006;
92(7):
951 - 957.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G De Luca, H Suryapranata, and M Chiariello
Aspiration thrombectomy and primary percutaneous coronary intervention
Heart,
July 1, 2006;
92(7):
867 - 869.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
U. Limbruno and R. De Caterina
EMERALD, AIMI, and PROMISE: is there still a potential for embolic protection in primary PCI?
Eur. Heart J.,
May 2, 2006;
27(10):
1139 - 1145.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. Iwakura, H. Ito, S. Kawano, A. Okamura, T. Kurotobi, M. Date, K. Inoue, and K. Fujii
Chronic pre-treatment of statins is associated with the reduction of the no-reflow phenomenon in the patients with reperfused acute myocardial infarction
Eur. Heart J.,
March 1, 2006;
27(5):
534 - 539.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Dudek, W. Mielecki, A. Dziewierz, J. Legutko, and J. S. Dubiel
The role of thrombectomy and embolic protection devices
Eur. Heart J. Suppl.,
October 1, 2005;
7(suppl_I):
I15 - I20.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Kosuge, K. Kimura, T. Ishikawa, T. Ebina, K. Hibi, N. Toda, and S. Umemura
ST-Segment Depression in Lead aVR: A Useful Predictor of Impaired Myocardial Reperfusion in Patients With Inferior Acute Myocardial Infarction
Chest,
August 1, 2005;
128(2):
780 - 786.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Lefevre, E. Garcia, B. Reimers, I. Lang, C. di Mario, A. Colombo, F.-J. Neumann, M. V. Chavarri, P. Brunel, E. Grube, et al.
X-Sizer for Thrombectomy in Acute Myocardial Infarction Improves ST-Segment Resolution: Results of the X-Sizer in AMI for Negligible Embolization and Optimal ST Resolution (X AMINE ST) Trial
J. Am. Coll. Cardiol.,
July 19, 2005;
46(2):
246 - 252.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Ilkay, I. Karaca, M. Yavuzkir, M. Akbulut, and M. Pekdemir
The Effect of Interventional Treatment in Acute Myocardial Infarction on ST Resolution: A Comparison of Coronary Angioplasty with Excimer Laser Angioplasty
Angiology,
July 1, 2005;
56(4):
377 - 384.
[Abstract]
[PDF]
|
|
|
|
|
|
|
H S Gurm and E J Topol
The ECG in acute coronary syndromes: new tricks from an old dog
Heart,
July 1, 2005;
91(7):
851 - 853.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Sorajja, B. J. Gersh, C. Costantini, M. G. McLaughlin, P. Zimetbaum, D. A. Cox, E. Garcia, J. E. Tcheng, R. Mehran, A. J. Lansky, et al.
Combined prognostic utility of ST-segment recovery and myocardial blush after primary percutaneous coronary intervention in acute myocardial infarction
Eur. Heart J.,
April 1, 2005;
26(7):
667 - 674.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Agewall
How should we evaluate an open artery in STEMI patients?
Eur. Heart J.,
April 1, 2005;
26(7):
634 - 636.
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. W. Stone, J. Webb, D. A. Cox, B. R. Brodie, M. Qureshi, A. Kalynych, M. Turco, H. P. Schultheiss, D. Dulas, B. D. Rutherford, et al.
Distal Microcirculatory Protection During Percutaneous Coronary Intervention in Acute ST-Segment Elevation Myocardial Infarction: A Randomized Controlled Trial
JAMA,
March 2, 2005;
293(9):
1063 - 1072.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Prasad, G. W. Stone, T. D. Stuckey, C. O. Costantini, P. J. Zimetbaum, M. McLaughlin, R. Mehran, E. Garcia, J. E. Tcheng, D. A. Cox, et al.
Impact of diabetes mellitus on myocardial perfusion after primary angioplasty in patients with acute myocardial infarction
J. Am. Coll. Cardiol.,
February 15, 2005;
45(4):
508 - 514.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. M. Gibson, A. J. Kirtane, K. Boundy, H. Ly, D. Karmpaliotis, S. A. Murphy, R. P. Giugliano, C. P. Cannon, E. M. Antman, E. Braunwald, et al.
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
J. Am. Coll. Cardiol.,
February 1, 2005;
45(3):
357 - 362.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Ilkay, I. Karaca, M. Akbulut, A E. Kilicoglu, M. Yavuzkir, and N. Arslan
Excimer Laser Coronary Angioplasty in Acute Myocardial Infarction
Asian Cardiovasc Thorac Ann,
December 1, 2004;
12(4):
291 - 295.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K P Balachandran, C Berry, J Norrie, B D Vallance, M Malekianpour, T J Gilbert, A C H Pell, and K G Oldroyd
Relation between coronary pressure derived collateral flow, myocardial perfusion grade, and outcome in left ventricular function after rescue percutaneous coronary intervention
Heart,
December 1, 2004;
90(12):
1450 - 1454.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. G. McLaughlin, G. W. Stone, E. Aymong, G. Gardner, R. Mehran, A. J. Lansky, C. L. Grines, J. E. Tcheng, D. A. Cox, T. Stuckey, et al.
Prognostic utility of comparative methods for assessment of ST-segment resolution after primary angioplasty for acute myocardial infarction: The controlled abciximab and device investigation to lower late angioplasty complications (CADILLAC) trial
J. Am. Coll. Cardiol.,
September 15, 2004;
44(6):
1215 - 1223.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. O. Costantini, G. W. Stone, R. Mehran, E. Aymong, C. L. Grines, D. A. Cox, T. Stuckey, M. Turco, B. J. Gersh, J. E. Tcheng, et al.
Frequency, correlates, and clinical implications of myocardial perfusion after primary angioplasty and stenting, with and without glycoprotein IIb/IIIa inhibition, in acute myocardial infarction
J. Am. Coll. Cardiol.,
July 21, 2004;
44(2):
305 - 312.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Napodano, G. Pasquetto, S. Sacca, C. Cernetti, V. Scarabeo, P. Pascotto, and B. Reimers
Intracoronary thrombectomy improves myocardial reperfusion in patients undergoing direct angioplasty for acute myocardial infarction
J. Am. Coll. Cardiol.,
October 15, 2003;
42(8):
1395 - 1402.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Dangas
Interventional therapy for acute myocardial infarction: respect the microvasculature
J. Am. Coll. Cardiol.,
October 15, 2003;
42(8):
1403 - 1405.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R Hoffmann, P Haager, W Lepper, A Franke, and P Hanrath
Relation of coronary flow pattern to myocardial blush grade in patients with first acute myocardial infarction
Heart,
October 1, 2003;
89(10):
1147 - 1151.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
U. Limbruno, A. Micheli, M. De Carlo, G. Amoroso, R. Rossini, C. Palagi, V. Di Bello, A. S. Petronio, G. Fontanini, and M. Mariani
Mechanical Prevention of Distal Embolization During Primary Angioplasty: Safety, Feasibility, and Impact on Myocardial Reperfusion
Circulation,
July 15, 2003;
108(2):
171 - 176.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. P.S. Henriques, F. Zijlstra, A. W.J. van 't Hof, M.-J. de Boer, J.-H. E. Dambrink, M. Gosselink, J. C.A. Hoorntje, and H. Suryapranata
Angiographic Assessment of Reperfusion in Acute Myocardial Infarction by Myocardial Blush Grade
Circulation,
April 29, 2003;
107(16):
2115 - 2119.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D V Cokkinos, A Manginas, and V Voudris
Coronary flow: clinical considerations
Heart,
April 1, 2003;
89(4):
361 - 363.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. K. Haager, P. Christott, N. Heussen, W. Lepper, P. Hanrath, and R. Hoffmann
Prediction of clinical outcome after mechanical revascularization in acute myocardial infarction by markers of myocardial reperfusion
J. Am. Coll. Cardiol.,
February 19, 2003;
41(4):
532 - 538.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
