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CLINICAL RESEARCH: MYOCARDIAL INFARCTION

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

C. Michael Gibson, MS, MD, FACC^_*,_*, Yuri B. Pride, MD, Jacqueline L. Buros, BA^_*, Erin Lord, BA^_*, Amy Shui, MA^_*, Sabina A. Murphy, MPH^_*, Duane S. Pinto, MD, FACC, Peter J. Zimetbaum, MD, FACC, Marc S. Sabatine, MD, MPH, FACC, Christopher P. Cannon, MD, FACC, Mark E. Josephson, MD, FACC for the TIMI Study Group

^_* TIMI Study Group, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Brigham & Women’s Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
Division of Cardiology and Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Manuscript received June 18, 2007; revised manuscript received August 24, 2007, accepted August 27, 2007.

^_* Reprint requests and correspondence: Dr. C. Michael Gibson, Director, TIMI Data Coordinating Center, 350 Longwood Avenue, First Floor, Boston, Masschusetts 02115. (Email: mgibson{at}perfuse.org).

Objectives: The goal of this analysis was to evaluate the association of impaired Thrombolysis In Myocardial Infarction myocardial perfusion grade (TMPG) with sustained ventricular tachycardia (VT) or ventricular fibrillation (VF).

Background: Impaired TMPG after successful restoration of epicardial flow among patients treated with fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI) has been associated with adverse clinical outcomes, but its relationship to VT/VF has not been evaluated.

Methods: In the CLARITY-TIMI 28 (Clopidogrel as Adjunctive Reperfusion Therapy–Thrombolysis In Myocardial Infarction 28) study, 3,491 patients underwent angiography a median of 3.5 days after fibrinolytic administration for STEMI; TMPG was assessed, and its association with VT/VF was evaluated.

Results: We observed VT/VF in 4.8% of patients. Impaired myocardial perfusion (TMPG 0/1/2) was associated with an increased incidence of VT/VF (7.1% vs. 2.6% with TMPG 3; log-rank p < 0.001). Among patients with restoration of normal epicardial flow (Thrombolysis In Myocardial Infarction flow grade 3), the incidence of VT/VF was increased among patients with impaired TMPG (4.7% vs. 2.7%; p = 0.02). Among patients with left ventricular ejection fraction 30%, impaired TMPG remained associated with an increased incidence of VT/VF (4.7% vs. 2.5%; p = 0.03). We found that VT/VF was associated with increased mortality (25.2% vs. 3.5%; p < 0.0001). Furthermore, among patients with VT/VF, impaired TMPG was associated with increased mortality (17.1% vs. 2.3%; p = 0.02). All but 1 death among patients who had VT/VF were among patients with impaired myocardial perfusion.

Conclusions: Despite restoration of normal epicardial flow or a left ventricular ejection fraction 30%, impaired myocardial perfusion on angiography 3.5 days after fibrinolytic administration for STEMI is associated with an increased incidence of VT/VF.

Abbreviations and Acronyms   MRI = magnetic resonance imaging   PCI = percutaneous coronary intervention   SCD = sudden cardiac death   STEMI = ST-segment elevation myocardial infarction   TFG = Thrombolysis In Myocardial Infarction flow grade   TMPG = Thrombolysis In Myocardial Infarction myocardial perfusion grade   VF = ventricular fibrillation   VT = ventricular tachycardia