ST segment resolution as a tool for assessing the efficacy of reperfusion therapy
James A. de Lemos, MD*,* and
Eugene Braunwald, MD, FACC
* Donald W. Reynolds Cardiovascular Clinical Research Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Figure 2 ST segment resolution 180 min after administration of therapy and mortality (at time points between 21 to 35 days) in four trials of thrombolytic therapy in acute myocardial infarction. All studies found statistically significant mortality differences between the three groups of ST resolution. GUSTO-III = Global Use of Strategies to Open Occluded Coronary Arteries study; HIT-4 = Hirudin for Improvement of Thrombolysis (HIT)-4 study; INJECT = International Joint Efficacy Comparison of Thrombolytics study; ISAM = Intravenous Streptokinase in Acute Myocardial Infarction. Data abstracted from references 12, 13 and 40. The GUSTO-III data are abstracted from Anderson R, White H, Ohmann E, et al. Resolution of ST segment elevation 90 minutes after thrombolysis for acute myocardial infarction predicts outcome: a GUSTO III substudy (abstr). J Am Coll Cardiol 1998;31 Suppl A:371A.
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Figure 3 ST resolution versus Thrombolysis In Myocardial Infarction (TIMI) flow grade. The reperfusion regimens used in the TIMI-14 substudy were tissue plasminogen activator (tPA) and combinations of abciximab plus reduced-dose tPA, whereas the fibrinolytic agent used in Hirudin for Improvement of Thrombolysis study (HIT-4) was streptokinase. p < 0.001 for the correlation between ST resolution and TIMI 3 flow; p < 0.001 for correlation between ST resolution and infarct-related artery patency (TIMI 2 + 3 flow). Adapted from references 37 and 38.
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Figure 4 Differences in ST resolution between patients with Thrombolysis In Myocardial Infarction (TIMI) grade 2 and TIMI grade 3 epicardial blood flow. Adapted from de Lemos JA, Antman EM, McCabe CH, et al. ST segment resolution and infarct related artery patency and flow after thrombolytic therapy. Am J Cardiol 2000;85:299–304.
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Figure 5 Correlation between noninvasive predictors of failed epicardial reperfusion and infarct artery patency, flow and mortality. The three noninvasive criteria for failed reperfusion are: ST resolution <50% at 90 min, 60 min/baseline ratio of serum myoglobin <4 and persistent chest pain at the time of coronary angiography. IRA = infarct-related artery; TIMI = Thrombolysis In Myocardial Infarction. Reproduced with permission from de Lemos JA, Morrow DA, Gibson CM, et al. Early noninvasive detection of failed epicardial reperfusion after fibrinolytic therapy. Am J Cardiol 2001;88:353–8.
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Figure 6 Proposed algorithm for the noninvasive detection of failed epicardial reperfusion. Percentages shown are the expected proportion of patients with an occluded infarct artery (Thrombolysis In Myocardial Infarction [TIMI] 0/1 flow). IRA = infarct-related artery; MYO = myoglobin; ST RES = ST resolution.
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Figure 7 Stratified analyses of 30-day mortality based on the status of a bedside myoglobin assay performed immediately before fibrinolysis, and ST resolution, measured 60 to 90 min after fibrinolysis. ST RES = ST resolution. Adapted with permission from de Lemos JA, Antman EM, Giugliano RP, et al. Very early risk stratification after thrombolytic therapy with a bedside myoglobin assay and the 12-lead electrocardiogram. Am Heart J 2000;140:373–8.
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Figure 8 Overview of studies using ST resolution (ST RES) to compare standard fibrinolytic therapy with reperfusion regimens containing glycoprotein IIb/IIIa inhibitors and reduced doses of fibrinolytics (combination therapy). In the Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis-Acute Myocardial Infarction (IMPACT-AMI) and Platelet Aggregation Receptor Antagonist Dose Investigation and Reperfusion Gain in Myocardial Infarction (PARADIGM) studies, where continuous ST monitoring was performed, combination therapy was associated with more rapid ST recovery than was standard fibrinolytic therapy. In the Thrombolysis In Myocardial Infarction (TIMI) 14 study, where static ST monitoring was performed, combination therapy was associated with a greater likelihood of achieving complete ( 70%) ST resolution, even after limiting the analysis to patients with normal (TIMI grade 3) epicardial blood flow. Pts = patients; TFG3 = TIMI grade 3 flow. Adapted from references 16, 20 and 83.
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Figure 9 Subset of patients from the Thrombolysis In Myocardial Infarction (TIMI) 14 trial with TIMI grade 3 flow in the infarct artery at 90 min. Comparison of mean percent ST resolution from 90 to 180 min between patients who did and did not undergo early adjunctive percutaneous coronary intervention (PCI) between 90 to 180 min after fibrinolysis. Patients are further separated into those who received and did not receive abciximab (Abx) as part of the reperfusion regimen. In the presence of Abx pretreatment, early adjunctive PCI was associated with greater ST resolution, whereas in the absence of Abx pretreatment, ST resolution tended to be worse in patients who underwent PCI. Reproduced with permission from de Lemos JA, Gibson CM, Antman EM, et al. Abciximab and early adjunctive percutaneous coronary intervention are associated with improved ST segment resolution after thrombolysis: observations from the TIMI 14 trial. Am Heart J 2001;141:592–8.
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ST) from epicardial leads and the