ACUTE MYOCARDIAL ISCHEMIA/INFARCTION
Association of duration of symptoms at presentation with angiographic and clinical outcomes after fibrinolytic therapy in patients with st-segment elevation myocardial infarction
C. Michael Gibson, MS, MD*,*,
Sabina A. Murphy, MPH*,
Ajay J. Kirtane, MD*, ,
Robert P. Giugliano, MD, SM*,
Christopher P. Cannon, MD*,
Elliott M. Antman, MD*,
Eugene Braunwald, MD* TIMI Study Group
* TIMI Study Group, Cardiovascular Division, Brigham & Women's Hospital
Cardiovascular Division, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MassachusettsUSA
Manuscript received March 12, 2004;
revised manuscript received May 6, 2004,
accepted May 11, 2004.
* Reprint requests and correspondence: Dr. C. Michael Gibson, 350 Longwood Avenue, First Floor, Boston, Massachusetts 02115 (Email: mgibson{at}timi.org).
OBJECTIVES: We sought to determine if an underlying mechanism of the association between prolonged symptom-to-treatment times and adverse outcomes may be an association of symptom-to-treatment times with impaired Thrombolysis In Myocardial Infarction myocardial perfusion grades (TMPGs).
BACKGROUND: Prolonged symptom duration among ST-segment elevation myocardial infarction (STEMI) patients undergoing fibrinolytic therapy is associated with adverse outcomes.
METHODS: Angiography was performed 60 min after fibrinolytic administration in 3,845 Thrombolysis In Myocardial Infarction (TIMI) trial patients.
RESULTS: The median time from symptom onset to treatment was longer among patients with impaired myocardial perfusion (3.0 h for TMPG 0/1 vs. 2.7 h for TMPG 2/3; p = 0.001). In a multivariate model, impaired tissue perfusion (TMPG 0/1) remained associated with increased time to treatment (odds ratio1.14 per hour of delay; p = 0.007) even after adjusting for Thrombolysis In Myocardial Infarction flow grade (TFG) 3, left anterior descending infarct location, and baseline clinical characteristics. Impaired myocardial perfusion after rescue/adjunctive percutaneous coronary intervention (PCI) was associated with longer median times to treatment (3.0 h for TMPG 2/3 vs. 2.7 h for TMPG 0/1; p = 0.017), as was abnormal epicardial flow after rescue/adjunctive PCI (3.3 h for TFG 0/1/2 vs. 2.8 h for TFG 3; p = 0.005). Thirty-day mortality was associated with longer time from onset of symptoms to treatment (6.6% mortality for time to treatment >4 h vs. 3.3%; p < 0.001), even among patients undergoing rescue PCI.
CONCLUSIONS: A prolonged symptom to treatment time among STEMI patients is associated with impaired myocardial perfusion independent of epicardial flow both immediately after fibrinolytic administration and after rescue/adjunctive PCI. These data provide a pathophysiologic link between prolonged symptoms due to vessel occlusion, impaired myocardial perfusion, and poor clinical outcomes.
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Abbreviations and Acronyms
| | CHF = congestive heart failure | | CTFC = corrected Thrombolysis In Myocardial Infarction frame count | | LAD = left anterior descending | | PCI = percutaneous coronary intervention | | OR = odds ratio | | rt-PA = recombinant tissue-type plasminogen activator | | STEMI = ST-segment elevation myocardial infarction | | TFG = Thrombolysis In Myocardial Infarction flow grade | | TIMI = Thrombolysis In Myocardial Infarction | | TMPG = Thrombolysis In Myocardial Infarction myocardial perfusion grade | | TNK = tenecteplase | | t-PA = tissue-type plasminogen activator |
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