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CLINICAL RESEARCH: ACUTE MYOCARDIAL INFARCTION

Association of a pulsatile blood flow pattern on coronary arteriography and short-term clinical outcomes in acute myocardial infarction

C. Michael Gibson, MS, MD^*,*, Juhana Karha, MD^*, Sabina A. Murphy, MPH^*, James A. de Lemos, MD, David A. Morrow, MD^*, Robert P. Giugliano, MD, SM^*, Mathew T. Roe, MD, MHS, Robert A. Harrington, MD, Christopher P. Cannon, MD^*, Elliott M. Antman, MD^*, Robert M. Califf, MD, Eugene Braunwald, MD^* TIMI Study Group

^* TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
Duke Clinical Research Institute, Durham, North Carolina, USA

Manuscript received August 13, 2003; revised manuscript received October 8, 2003, accepted November 13, 2003.

^* Reprint requests and correspondence: Dr. C. Michael Gibson, Director TIMI Data Coordinating Center, 350 Longwood Avenue, 1st Floor, Boston, Massachusetts 02115, USA.
mgibson{at}perfuse.org

OBJECTIVES: We hypothesized that recognition of systolic flow reversal (pulsatile flow) after thrombolytic administration on coronary angiography is associated with angiographic and electrocardiogram findings reflecting impaired myocardial perfusion, as well as poorer clinical outcomes.

BACKGROUND: Reversal of systolic flow on Doppler velocity wire recordings has been associated with impaired tissue perfusion on myocardial contrast echocardiography in the setting of myocardial infarction (MI).

METHODS: Patients (n = 1,062) with a patent infarct-related artery were drawn from the Thrombolysis In Myocardial Infarction (TIMI) 10, TIMI 14, and Integrillin and Tenecteplase acute MI trials.

RESULTS: Pulsatile flow (systolic flow reversal with cessation of antegrade contrast-dye motion or frank reversal of contrast-dye motion during systole) at 60 min after fibrinolytic administration was present in 11.0% of patients. Pulsatile flow was associated with higher corrected TIMI frame counts (slower epicardial flow) (median 40.1 frames, IQ 30 of 63 vs. 30 frames, interquartile 22 of 42, p < 0.0001), a closed microvasculature (TIMI myocardial perfusion grades 0 of 1, 57.1% vs. 37.8%, p = 0.03) and less complete (70%) ST-segment resolution (23.5% vs. 58.9%, p = 0.008). Patients with pulsatile flow had a higher risk of death or reinfarction at 30 days (10.3% vs. 5.0%, p = 0.019). After controlling for age, pulse, blood pressure, anterior MI location, epicardial flow, and creatine kinase, pulsatile flow remained associated with an increased risk of death/MI (odds ratio 3.1, p = 0.006).

CONCLUSIONS: A pulsatile pattern of flow is associated with impaired myocardial perfusion and poorer clinical outcomes independent of the velocity of antegrade flow in the epicardial artery. This simple and easily identifiable angiographic flow pattern may be useful in clinical risk stratification.

Abbreviations and Acronyms   CTFC = corrected TIMI frame count   INTEGRITI = Integrillin and Tenecteplase in Acute Myocardial Infarction trial   LAD = left anterior descending artery   PCI = percutaneous coronary intervention   STEMI = ST-elevation myocardial infarction   TFG = TIMI flow grade   TIMI = Thrombolysis In Myocardial Infarction   TMPG = TIMI myocardial perfusion grade   TNK = tenecteplase

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