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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

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

C. Michael Gibson, MS, MD^*,,*, Ajay J. Kirtane, MD^*,, Keith Boundy, BA, Hung Ly, MD, Dimitrios Karmpaliotis, MD^*, Sabina A. Murphy, MPH, Robert P. Giugliano, MD, SM, Christopher P. Cannon, MD, Elliott M. Antman, MD, Eugene Braunwald, MD TIMI Study Group

^* Cardiovascular Division, Beth Israel Deaconess Medical Center
TIMI Study Group, Brigham & Women's Hospital, Departments of Medicine, Harvard Medical School, Boston, Massachusetts

Manuscript received August 4, 2004; revised manuscript received October 14, 2004, accepted October 18, 2004.

^* Reprint requests and correspondence: Dr. C. Michael Gibson, 350 Longwood Avenue, First Floor, Boston, Massachusetts 02115 (Email: mgibson{at}perfuse.org).

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.

Abbreviations and Acronyms   ACC = American College of Cardiology   ACS = acute coronary syndrome   AHA = American Heart Association   CTFC = corrected Thrombolysis In Myocardial Infarction frame count   IVUS = intravascular ultrasound   LAD = left anterior descending coronary artery   MLD = minimum lumen diameter   OR = odds ratio   PCI = percutaneous coronary intervention   REF = normal reference segment   RS = residual stenosis   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